making customized bolus with a 3d printer
TRANSCRIPT
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MAKING CUSTOMIZED BOLUS WITH A
3D PRINTER
Alex Markovic, PhD
Banner Health, North Colorado Medical Center, Greeley, CO
RMAAPM Annual Meeting
May 20, 2017
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OUTLINE
�Advantages of 3Dprinted bolus
�Equipment and software
�Clinical cases
�Test case on a phantom
�Dosimetry data
�Other uses of 3d printing in radiation oncology
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Greeley In the News
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DISADVANTAGE OF TRADITIONAL BOLUS
�Air gaps
�Poor conformity
�In many cases, the delivery does not reflect the plan
Narrow bolus covering scar
Axial
Coronal
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ADVANTAGES OF 3D PRINTED BOLUS
�Conformity
� The treatment more closely matches the plan
�Reduces air gaps
�Speeds up the placement during setup
�We send a message to patients that we customize our treatments to them
Ear
Wrist
MERT
Face
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PROCESS TO PRINT A 3D BOLUS
Decide to use 3D
bolus during txplanning
Use TPS
contouring tools to make a bolus and calculate
dose
Export plan and
structure dicomfiles to convert to
.STL file
Load into Cura,
and print!
Cura
Printed bolus
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� 1000 3D printers on the market!
� Taz 6 – fused filament fabrication (FFF)
� Print volume: 11x11x10”
� Fast print speed (up to 200 mm/sec)
� Wide array of filament choices including flexible
� Cost of printer+ optional tool-head: $3000.00
EQUIPMENT CHOICES - PRINTER
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TAZ 6 PRINTER ANATOMY
Filament
Print bed
nozzleX-rails
Y-rails
Z-rails
Close up
Toolhead
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�Hard filament: easiest to print with:
�PLA, ABS, co-polyester
�Flexible filament – most difficult to work with: Ninjaflex, Filaflex
�Semi Flexible – easier to work with: Cheetah, Polyflex
�1 kg spool of filament = $70.00
EQUIPMENT CHOICES - FILAMENT
Pick ONE, master it!
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�Basic:
� Cura – slicer software, which converts an STL file to GCODE.
� STL: contains the coordinates of the vertices of triangles that make up part.
� GCODE: contains instruction for the printer to print each layer
�Advanced:
� 3DCAD: Tinkercad, Fusion 360, Onshape
� 3D manipulation: Blender, Meshmixer
EQUIPMENT CHOICES - SOFTWARE
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�CASES
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Case 1:Squamous cell of Right Neck
� VMAT used to cover deeper extension
� 3D bolus used to fully cover shallow areas
Rx line
CTV
Bolus
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Case 1:Squamous cell of Right Neck
� CBCT confirmation
� US gel used for better contact
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Case 2: Squamous cell right ear
� 12 MeV Electrons
� Manual thickness modulation
� Result:
� Evenly distributed dose through ear
� Pay attention to increase in lateral scatter
Axial
Coronal
Actual printed bolus
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� Bolus printed in 2pieces to ensure proper fit
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OTHER USES OF 3D PRINTING IN RAD ONC
BRACHYTHERAPY
Custom applicators
HDR surface molds
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Case 3: Breast Cancer
� 5 field breast boost
� 200cGy x 5
� 6 MV photons 3DCRT
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Case 4: Breast cancer
� VMAT chest wall
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Hanging filament strands due to lack of structural support
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TEST PLANS
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ELECTRON COMPENSATED BOLUS – 16 MEV ELECTRONS
ECT bolus created in p.d software
Covers CTV in pink color
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PLAN WITH PRINTED BOLUS
inside
outside
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PLANAR ISODOSE COMPARISON
� Curves agree well, which means bolus was printed correctly
Magenta is virtual bolus
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OTHER USES OF 3D PRINTING IN RAD ONC
PHYSICS
Chamber inter-comparison jigA10 chamber holder
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Test Plan:
�Treating entire nose with opposed beams
Hand made wax bolus
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Open fields with bolus block
CTV coverage
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BOLUS BOX CAN BE PRINTED AS A SHELL AND FILLED WITH WATER AND CAPPED SHUT
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PLANNING TIPS
�Make the bolus “printable”
�Avoid entering deep into ear canal
�Complicated bolus prints better if it is thicker
�Avoid overhangs and small footprints
�Vary the thickness in areas where more scatter would be beneficial – you can do that now!
�Add thickness to enhance scatter
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� Piece quality depends on:
� Nozzle temperature
� Printing speed
� Extrusion rate
� Possibly filament vendor, color
�Ensuring the print starts correctly – base layer adhesion
ACHIEVING GREAT RESULTS DURING PRINTING
Poor results due to low extrusion rate
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OTHER USES OF 3D PRINTING IN RAD ONC
PATIENT EDUCATION
Tandem and ovoid demonstrationProstate implant
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COMMISSIONING:
�Literature review
�Patient safety aspects
�Material properties
�Effort
�Billing
�QA tests, documentation
�Dosimetry – PDDs, OSLs, etc
�Staff training
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�Flexible Filament Properties
Property Ninjaflex Cheetah
Material Thermoplastic
poly urethane
Thermoplastic
poly urethane
Manuf spec
density (g/cc)
1.19 1.22
Measured
density
1.12 1.20
CT scan HU 100 120
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PATIENT SAFETY – NINJAFLEX/CHEETAH
MSDS SHEET:
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STERILIZING
�Softening temperature of NinjaFlex is 120C, which is also typical autoclave
temp, so testing needs to be done
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DOSIMETRY – PHOTON PDDS
� 3D Printed 6 x 6 cm slabs of material in varying thickness
� 6 x 6 fields, 100 SSD
� Sunnuclear edge detector
Detector holder
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6X PHOTON PDD – NINJAFLEX VS WATER
30
40
50
60
70
80
90
100
110
0 10 20 30 40 50 60 70 80
PER
CEN
TAG
E D
EP
TH D
OSE
DEPTH (MM)
6 MV PHOTON PDD OF NINJAFLEX VS. WATER
Ninjaflex diode
chamber in Water
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PDD – ELECTRONS MEASUREMENT SETUP
IBA EFD electron diode
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9 MEV ELECTRON PDD – NINJAFLEX VS. WATER
0
20
40
60
80
100
0 20 40 60 80 100
Pe
rce
nt
De
pth
Do
se
Depth (mm)
9 MeV electron PDD of Ninjaflex vs. Water
Water - Chamber
NinjaFlex - Diode
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ABSOLUTE DOSIMETRY - OSLDS
3D printed mini OSLD watertank
Ninjaflex vs water
9 MeV Electron (dmax)
-2.2%
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QA OF 3D PRINTED BOLUS
We complete a checklist with the following:
�Visual inspection to detect improperly printed part
�Dimensions are measured
�CT scan of bolus to ensure uniformity within part. Average HU must be >100
�CBCT scan on 1st day, if possible to verify fit
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BILLING
�Special Physics consult ordered which covers physics time to work with dosimetrist in designing part in TPS, and for the QA that is performed
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QUESTIONS