{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T04:03:31Z","timestamp":1783742611166,"version":"3.55.0"},"reference-count":23,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2020,12,24]],"date-time":"2020-12-24T00:00:00Z","timestamp":1608768000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["aapm.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Applied Clin Med Phys"],"published-print":{"date-parts":[[2021,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Purpose<\/jats:title><jats:p>A unique mantle cell lymphoma case with bilateral periorbital disease unresponsive to chemotherapy and with dosimetry not conducive to electron therapy was treated with pencil beam scanning (PBS) proton therapy. This patient presented treatment planning challenges due to the thin target, immediately adjacent organs at risk (OAR), and nonconformal orbital surface anatomy. Therefore, we developed a patient\u2010specific bolus and hypothesized that it would provide superior setup robustness, dose uniformity and dose conformity.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials\/Methods<\/jats:title><jats:p>A blue\u2010wax patient\u2010specific bolus was generated from the patient's face contour to conform to his face and eliminate air gaps. A relative stopping power ratio (RSP) of 0.972 was measured for the blue\u2010wax, and the HUs were overridden accordingly in the treatment planning system (TPS). Orthogonal kV images were used for bony alignment and then to ensure positioning of the bolus through fiducial markers attached to the bolus and their contours in TPS. Daily CBCT was used to confirm the position of the bolus in relation to the patient's surface. Dosimetric characteristics were compared between (a) nonbolus, (b) conventional gel bolus and (c) patient\u2010specific bolus plans. An in\u2010house developed workflow for assessment of daily treatment dose based on CBCT images was used to evaluate inter\u2010fraction dose accumulation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The patient was treated to 24 cobalt gray equivalent (CGE) in 2 CGE daily fractions to the bilateral periorbital skin, constraining at least 50% of each lacrimal gland to under 20\u00a0Gy. The bolus increased proton beam range by adding 2\u20133 energy layers of different fields to help achieve better dose uniformity and adequate dose coverage. In contrast to the plan with conventional gel bolus, dose uniformity was significantly improved with patient\u2010specific bolus. The global maximum dose was reduced by 7% (from 116% to 109%). The max and mean doses were reduced by 6.0% and 7.7%, respectively, for bilateral retinas, and 3.0% and 13.9% for bilateral lacrimal glands. The max dose of the lens was reduced by 2.1%. The rigid shape, along with lightweight, and smooth fit to the patient face was well tolerated and reported as \u201cvery comfortable\u201d by the patient. The daily position accuracy of the bolus was within 1\u00a0mm based on IGRT marker alignment. The daily dose accumulation indicates that the target coverage and OAR doses were highly consistent with the planning intention.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Our patient\u2010specific blue\u2010wax bolus significantly increased dose uniformity, reduced OAR doses, and maintained consistent setup accuracy compared to conventional bolus. Quality PBS proton treatment for periorbital tumors and similar challenging thin and shallow targets can be achieved using such patient\u2010specific bolus with robustness on both setup and dosimetry.<\/jats:p><\/jats:sec>","DOI":"10.1002\/acm2.13134","type":"journal-article","created":{"date-parts":[[2020,12,25]],"date-time":"2020-12-25T08:13:23Z","timestamp":1608884003000},"page":"203-209","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Using patient\u2010specific bolus for pencil beam scanning proton treatment of periorbital disease"],"prefix":"10.1002","volume":"22","author":[{"given":"Minglei","family":"Kang","sequence":"first","affiliation":[{"name":"New York Proton Center New York NY USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shaakir","family":"Hasan","sequence":"additional","affiliation":[{"name":"New York Proton Center New York NY 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