Is wax equivalent to tissue in electron conformal therapy planning? A Monte Carlo study of material approximation introduced dose difference

With CT-based Monte Carlo (MC) dose calculations, material composition is often assigned based on the standard Hounsfield unit ranges. This is known as the density threshold method. In bolus electron conformal therapy (BolusECT), the bolus material, machineable wax, would be assigned as soft tissue and the electron density is assumed equivalent to soft tissue based on its Hounsfield unit. This study investigates the dose errors introduced by this material assignment. BEAMnrc was used to simulate electron beams from a Trilogy accelerator. SPRRZnrc was used to calculate stopping power ratios (SPR) of tissue to wax, SPRwaxtissue, and tissue to water, SPRwatertissue, for 6, 9, 12, 15, and 18 MeV electron beams, of which 12 and 15MeV beams are the most commonly used energies in BolusECT. DOSXYZnrc was applied in dose distribution calculations in a tissue phantom with either flat wax slabs of various thicknesses or a wedge-shaped bolus on top. Dose distribution for two clinical cases, a chest wall and a head and neck, were compared with the bolus material treated as wax or tissue. The SPRwaxtissue values for 12 and 15MeV beams are between 0.935 and 0.945, while the SPRwatertissue values are between 0.990 and 0.991. For a 12 MeV beam, the dose in tissue immediately under the bolus is overestimated by 2.5% for a 3 cm bolus thickness if the wax bolus is treated as tissue. For 15 MeV beams, the error is 1.4%. However, in both clinical cases the differences in the PTV DVH is negligible. Due to stopping power differences, dose differences of up to 2.5% are observed in MC simulations if the bolus material is misassigned as tissue in BolusECT dose calculations. However, for boluses thinner than 2 cm that are more likely encountered in practice, the error is within clinical tolerance.