Monte Carlo investigation on the effect of air gap under bolus in post-mastectomy radiotherapy

•Studies the effect of air gaps the under bolus for VMAT breast treatments.•The surface dose reduction was more pronounced for VMAT treatments than for FinF.•AAA was seen to underestimate the surface dose. To investigate the dosimetric effect of air gaps under bolus on skin dose for left-sided post-mastectomy radiotherapy with loco regional involvement. Eight patients were planned retrospectively with volume modulated arc therapy (VMAT) and conventional static Field-in-Field (FinF) methods. Three different setups were applied for the 5-mm bolus over the chest wall having 0, 5 or 10 mm air gap under the bolus. The dose calculation was performed using Monte Carlo (MC) simulation. In addition, Analytic Anisotropic Algorithm (AAA) was used to demonstrate the differences observed in clinical setting. The investigated air gaps under the bolus had minimal effect on surface dose for FinF plans (relative difference ≤ 2.6%), whereas for VMAT plans the surface dose decreased 13.6% when compared to the case with no air gap. In both FinF and VMAT, the largest differences between AAA and MC were seen at the surface where AAA underestimated the dose by 1.5 Gy (p 0.05) larger with AAA than with MC calculations. The surface dose was significantly lower with VMAT technique than with FinF technique. Possible air gaps under the bolus reduced the surface dose significantly further for VMAT but not for FinF treatments, which may have clinical impact on recurrence rate. AAA was shown to underestimate the surface dose when compared to MC calculation.