Dosimetric effects of supine immobilization devices on the skin in intensity-modulated radiation therapy for breast cancer: a retrospective study

The dose perturbation effect of immobilization devices is often overlooked in intensity-modulated radiation therapy (IMRT) for breast cancer (BC). This retrospective study assessed the dosimetric effects of supine immobilization devices on the skin using a commercial treatment planning system. Forty women with BC were divided into four groups according to the type of primary surgery: groups A and B included patients with left and right BC, respectively, who received 50 Gy radiotherapy in 25 fractions after radical mastectomy, while groups C and D included patients with left and right BC, respectively, who received breast-conservation surgery (BCS) and 40.05 Gy in 15 fractions as well as a tumor bed simultaneous integrated boost to 45 Gy. A 0.2-cm thick skin contour and two sets of body contours were outlined for each patient. Dose calculations were conducted for the two sets of contours using the same plan. The dose differences were assessed by comparing the dose-volume histogram parameter results and by plan subtraction. The supine immobilization devices for BC resulted in significantly increased skin doses, which may ultimately lead to skin toxicity. The mean dose increased by approximately 0.5 and 0.45 Gy in groups A and B after radical mastectomy and by 2.7 and 3.25 Gy in groups C and D after BCS; in groups A-D, the percentages of total normal skin volume receiving equal to or greater than 5 Gy (V ) increased by 0.54, 1.15, 2.67, and 1.94%, respectively, while the V increased by 1.27, 1.83, 1.36, and 2.88%; the V by 0.85, 1.87, 2.76, and 4.86%; the V by 1.3, 1.24, 10.58, and 11.91%; and the V by 1.29, 0.65, 10, and 10.51%. The dose encompassing the planning target volume and other organs at risk, showed little distinction between IMRT plans without and with consideration of immobilization devices. The supine immobilization devices significantly increased the dose to the skin, especially for patients with BCS. Thus, immobilization devices should be included in the external contour to account for dose attenuation and skin dose increment. This study does not report on interventions in human health care.