A novel approach to embed eye shields in customized bolus on nasal dorsum treatment for electron radiotherapy

We aim to demonstrate the unique use of embedded lead eye shields in an electron wax bolus when treating the nasal dorsum. A patient presented to the clinic with squamous cell carcinoma of the nasal dorsum requiring treatment with en face electrons. A 3D customized wax bolus was designed and imported into the treatment planning system (TPS) to calculate the dose distribution. Due to high lens dose, the bolus was customized further to create 2 milled open slots in the wax, over the lens of eye, to allow lead sheets totaling 4 mm to be slid into the wax. The patient was brought back to the clinic to be scanned with the wax bolus fitting snugly over the nose, eyes, and cheek regions. The 3D milled insert holes were contoured on the CT in the TPS, assigned HU of 2758, to mimic the lead insertion. The lens dose with lead inserts was compared to the plan without lead insert. To further confirm the lens dose, EBT3 films were placed on the right and left eye under the bolus, and nose dorsum on the first day of treatment. The maximum dose of right lens, as calculated in the TPS with the simulated lead shields in place, decreased from 989.5cGy to 457cGy. The maximum dose of left lens decreased from 1085.4cGy to 501cGy. The dose readings from EBT3 films were in good agreement with the TPS, with deviation of 3.32%, 0.26%, and 3.44% for right lens, left lens, and nose, respectively. Daily positioning deviations compared to the plan were 0.65 ± 0.16cm and 0.63 ± 0.29cm for right eye and left eye, respectively. This novel device demonstrated the feasibility, in terms of dose calculation accuracy in the TPS and fabrication, of using customized bolus with lead inserts to conveniently shield the lens of the eyes in an electron treatment for the nose, enabling a streamlined daily setup.