PURPOSE/OBJECTIVES Three-dimensional (3D) printing is recognized as an effective clinical and educational tool in procedurally intensive specialties. However, it has a nascent role in radiation oncology. The goal of this investigation is to clarify the extent to which 3D printing applications are currently being used in radiation oncology through a systematic review of the literature. MATERIALS/METHODS A search protocol was defined according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Included articles were evaluated using parameters of interest including: year and country of publication, experimental design, sample size for clinical studies, radiation oncology topic, reported outcomes, and implementation barriers or safety concerns. RESULTS One hundred and three publications from 2012 to 2019 met inclusion criteria. The most commonly described 3D printing applications included quality assurance phantoms (26%), brachytherapy applicators (20%), bolus (17%), preclinical animal irradiation (10%), compensators (7%), and immobilization devices (5%). Most studies were preclinical feasibility studies (63%), with few clinical investigations such as case reports or series (13%) or cohort studies (11%). The most common applications evaluated within clinical settings included brachytherapy applicators (44%) and bolus (28%). Sample sizes for clinical investigations were small (median 10, range 1-42). A minority of articles described basic or translational research (11%) and workflow or cost evaluation studies (3%). The number of articles increased over time (P < 0.0001). While outcomes were heterogeneous, most studies reported successful implementation of accurate and cost-effective 3D printing methods. CONCLUSIONS Three-dimensional printing is rapidly growing in radiation oncology and has been implemented effectively in a diverse array of applications. Although the number of 3D printing publications has steadily risen, the majority of current reports are preclinical in nature and the few clinical studies that do exist report on small sample sizes. Further dissemination of ongoing investigations describing the clinical application of developed 3D printing technologies in larger cohorts is warranted.

https://aapm.onlinelibrary.wiley.com/doi/pdf/10.1002/acm2.12907

Three-dimensional printing in radiation oncology: A systematic review of the literature

Until recently, three-dimensional (3D) printing/additive manufacturing has not been used extensively to create medical devices intended for actual clinical use, primarily on patient safety and regu...

Three-Dimensional Printing of Medical Devices Used Directly to Treat Patients: A Systematic Review

A Delphi study and International Consensus Recommendations: The use of bolus in the setting of postmastectomy radiation therapy for early breast cancer.

PURPOSE This case series represents an initial experience with implementing 3-dimensional (3D) surface scanning, digital design, and 3D printing for bolus fabrication for patients with complex surface anatomy where traditional approaches are challenging. METHODS AND MATERIALS For 10 patients requiring bolus in regions with complex contours, bolus was designed digitally from 3D surface scanning data or computed tomography (CT) images using either a treatment planning system or mesh editing software. Boluses were printed using a fused deposition modeling printer with polylactic acid. Quality assurance tests were performed for each printed bolus to verify density and shape. RESULTS For 9 of 10 patients, digitally designed boluses were used for treatment with no issues. In 1 case, the bolus was not used because dosimetric requirements were met without the bolus. QA tests revealed that the bulk density was within 3% of the reference value for 9 of 12 prints, and with more judicious selection of print settings this could be increased. For these 9 prints, density uniformity was as good as or better than our traditional sheet bolus material. The average shape error of the pieces was less than 0.5 mm, and no issues with fit or comfort were encountered during use. CONCLUSIONS This study demonstrates that new technologies such as 3D surface scanning, digital design and 3D printing can be safely and effectively used to modernize bolus fabrication.

https://aapm.onlinelibrary.wiley.com/doi/pdf/10.1002/acm2.12703

A modern mold room: Meshing 3D surface scanning, digital design, and 3D printing with bolus fabrication.

We investigated two types of materials with very low Shore hardness, silicon rubber (Dragon Skin) and urethane liquid rubber (Clear Flex 30), for use in 3D printing patient-specific boluses. Boluses were manufactured with these materials using a mold casting method. NinjaFlex was also used to manufacture the bolus using a direct printing method. These patient-specific boluses were designed for 3D-printed elaborate human phantoms and their biological, physical, and dosimetric properties were comprehensively assessed. The results of cytotoxicity, skin irritation, and skin sensitization tests showed that Dragon Skin was the most biologically stable material. Furthermore, Dragon Skin exhibited excellent physical properties in terms of flexibility (Shore hardness 10A), durability (tensile strength of 475 psi and elongation at break of 1000 (%)), and preparation (5 h curing time). Accordingly, Dragon Skin was finally selected for the bio-compatible patient-specific elastic (BPE) bolus. The dosimetric characteristics were thoroughly investigated with depth dose curves and surface dose. Dragon Skin showed the lowest differences between the calculated dose under virtual bolus and the measured dose at the surface of the phantom head and the lowest amount of unwanted air gap between the bolus and phantom. Overall, Dragon Skin is a suitable material for patient-specific elastic bolus, and it could be implemented effectively in the clinic.

https://iopscience.iop.org/article/10.1088/1361-6560/ab1c93/pdf

Bio-compatible patient-specific elastic bolus for clinical implementation.

Purpose This patient study evaluated the use of 3-dimensional (3D) printed bolus for chest wall radiation therapy compared with standard sheet bolus with regard to accuracy of fit, surface dose measured in vivo, and efficiency of patient setup. By alternating bolus type over the course of therapy, each patient served as her own control. Methods and materials For 16 patients undergoing chest wall radiation therapy, a custom 5.0 mm thick bolus was designed based on the treatment planning computed tomography scan and 3D printed using polylactic acid. Cone beam computed tomography scanning was used to image and quantify the accuracy of fit of the 2 bolus types with regard to air gaps between the bolus and skin. As a quality assurance measure for the 3D printed bolus, optically stimulated luminescent dosimetry provided in vivo comparison of surface dose at 7 points on the chest wall. Durations of patient setup and image guidance were recorded and compared. Results In 13 of 16 patients, the bolus was printed without user intervention, and the median print time was 12.6 hours. The accuracy of fit of the bolus to the chest wall was improved significantly relative to standard sheet bolus, with the frequency of air gaps 5 mm or greater reduced from 30% to 13% (P Conclusions This study demonstrates 3D printed bolus in postmastectomy radiation therapy improves fit of the bolus and reduces patient setup time marginally compared with standard vinyl gel sheet bolus. The time savings on patient setup must be weighed against the considerable time needed for the 3D printing process.

Intrapatient study comparing 3D printed bolus versus standard vinyl gel sheet bolus for postmastectomy chest wall radiation therapy.

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Intrapatient study comparing 3D printed bolus versus standard vinyl gel sheet bolus for postmastectomy chest wall radiation therapy.

Good Luck With That … Making Your Own Opportunities.