Evaluation of superficial dosimetry between treatment planning system and measurement for several breast cancer treatment techniques

Dosimetric accuracy in radiation treatment of breast cancer is critical for the evaluation of cosmetic outcomes and survival. It is often considered that treatment planning systems (TPS) may not be able to provide accurate dosimetry in the buildup region. This was investigated in various treatment techniques such as tangential wedges, field-in-field (FF), electronic compensator (eComp), and intensity-modulated radiotherapy (IMRT).

Under Institutional Review Board (IRB) exemption, radiotherapy treatment plans of 111 cases were retrospectively analyzed. The distance between skin surface and 95% isodose line was measured. For measurements, Gafchromic EBT2 films were used on a humanoid unsliced phantom. Multiple layers of variable thickness of superflab bolus were placed on the breast phantom and CT scanned for planning. Treatment plans were generated using four techniques with two different grid sizes (1 × 1 and 2.5 × 2.5 mm(2)) to provide optimum dose distribution. Films were placed at different depths and exposed with the selected techniques. A calibration curve for dose versus pixel values was also generated on the same day as the phantom measurement was conducted. The DICOM RT image, dose, and plan data were imported to the in-house software. On axial plane of CT slices, curves were drawn at the position where EBT2 films were placed, and the dose profiles on the lines were acquired. The calculated and measured dose profiles were separated by check points which were marked on the films before irradiation. The segments of calculated profiles were stretched to match their resolutions to that of film dosimetry.

On review of treatment plans, the distance between skin and 95% prescribed dose was up to 8 mm for plans of 27 patients. The film measurement revealed that the medial region of phantom surface received a mere 45%-50% of prescribed dose. For wedges, FF, and eComp techniques, region around the nipple received approximately 80% of prescribed dose, although only IMRT showed inhomogeneous dose profile. At deeper depths mainly (6-11 mm depths), film dosimetry showed good agreement with the TPS calculation. In contrast, the measured dose at a 3-mm depth was higher than TPS calculation by 15%-30% for all techniques. For the tangential and IMRT techniques, 1 × 1 mm(2) grid size showed a smaller difference than that with a 2.5 × 2.5 mm(2) grid size compared to the measurements.

In general, TPS even with advanced algorithms do not provide accurate dosimetry in the buildup region, as verified by EBT2 film for all treatment techniques. For all cases, TPS and measured doses were in agreement from 6 mm in depth but differed at shallower depths. Grid size plays an important role in dose calculation. For accurate dosimetry small grid size should be used where differences are lower between TPS and measurements.