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Brittany Bird
Treatment Planning Project
April 23, 2017
Heterogeneity versus Homogeneity Correction Factors
Introduction: The human body consists of several different tissue densities including fat, bone,
muscle, tissue, and air that need to be taken into consideration during treatment planning.
Varying tissue densities will interact with radiation in a different manner. Lung tissue has a
lower density and attenuates less of the primary beam, whereas, bone has a higher density and
attenuates more of the primary beam. Dose calculations performed without the proper tissue
density correction can cause an increase in planning deviations. The effect of inhomogeneity on
dose largely depends on the size of the volume, density of the inhomogeneity, and the energy of
the beam.1 These inhomogeneities can ultimately alter the penetration of the primary beam and
enhance certain scatter characteristics.
Before IMRT, cancer treatment facilities used a homogeneity correction, which assumed
the patients body as a homogenous water medium. With the heterogeneity feature instilled and
turned on in the treatment planning system, electron densities can be corrected for using the
appropriate algorithm. A 3D rendering of the CT scan allows us to delineate the boundaries of
the inhomogeneities and determine the correct relative electron density.
Methods and Materials: A CT data set of a patients lung volume was imported into Velocity,
where specific critical structures were contoured. The data set consisted of an average, 0%, and
50% respiratory phase. The organs at risk (OR) as seen in Figures 1 and 2, included the aorta,
esophagus, external patient body, heart, left lung, right lung, spinal cord, total lung, and trachea.
These structures were contoured on the average phase in the Velocity software. The Radiation
Oncologist contoured the GTV on both the 0% and 50% respiratory phase. The CT data set was
then exported to the Eclipse Version 11.0 TPS. In Eclipse contouring, the user origin was set to
where the BBs intersected and an exact IGRT couch medium structure was inserted. An ITV
structure was created by using the Boolean tool to merge the GTV_0% and GTV_50% together.
Then a PTV was created by adding a 0.5 cm margin from the ITV. In external beam planning in
the Eclipse Version 11.0 TPS, a 6 MV photon energy was selected. An anterior-posterior (AP)
and a posterior-anterior (PA) beam was inserted and orientated to align with the isocenter
placement in the ITV. Multi-leaf collimators were added to each beam and given a 1 cm margin
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to fit around the PTV for any additional set-up uncertainties or patient movement. Field
weighting was kept the same for both fields at a 50% distribution. The prescription was listed
for the patient to receive 7000 cGy at 200 cGy per fraction for a total of 35 fractions. Plan
normalization was set for 100% of the prescription dose to cover 95% of the target volume. The
treatment plan was calculated using the Anisotropic Analytical Algorithm (AAA) and evaluated
for when heterogeneity correction factors are turned on and off.
Results: The differences between the heterogeneity and homogeneity lung volume treatment
plans are eye opening and demonstrate the significance of utilizing a heterogeneity correction
factor. The isodose distribution with no heterogeneity correction as seen in Figure 3 in the axial,
coronal, and sagittal view, illustrates the coverage to appear uniform and the isodose lines
shifting inward on the anterior aspect of the patient. The treatment plan with the heterogeneity
correction turned on in Figure 5, demonstrates the isodose lines becoming less uniform and less
conformal. This is in part due to the correction factor implemented in the algorithm taking into
consideration the presence of the air cavity. There is also a variance in the monitor units as seen
in Figures 7 and 8 on the treatment planning report under the field data section. In the plan with
the heterogeneity correction turned off, the AP beam is receiving 146 monitor units, whereas in
the heterogeneity plan, the AP beam is receiving 122 monitor units. The same can be displayed
with the PA beam with 116 and 124 monitor units respectively.
A dose volume histogram (DVH) is an essential tool used by the planning team and
Radiation Oncologists during optimization and when evaluating treatment plans. A DVH
demonstrates a two-dimensional analysis that can easily be interpreted and displays quantitative
measurements for critical structures and tumor volumes. It is important to verify that constraints
are being met, especially for structures that have a low threshold radiation tolerance. Data sets
created using CT or other modalities, consist of a set of voxels. The dose values obtained from
each voxel is represented on the DVH. The DVH in Figure 4, shows that the ITV is receiving a
maximum dose of 7971 cGy with the homogeneity plan and 8171 cGy with the heterogeneity
treatment plan as seen in Figure 6. An issue that presents with using a DVH, is the users ability
to contour precisely over the anatomical region. Everyone contours differently, and a DVH is
what represents the structures that were contoured that received dose values in each voxel. If a
dosimetrist inadequately contours a known critical structure, although the heterogeneity
correction factor is applied, the DVH can be irrelevant. The DVH also fails to display any hot or
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cold spots, but can be beneficial when comparing another treatment plan to see if its more
superior.2
Discussion: Inhomogeneity corrections can be accounted for by applying the isodose shift
method, power law tissue-air ratio method, and by taking the tissue-air ratio into consideration to
correct for surface contour irregulartories.3 The TAR method essentially converts the
inhomogeneity to a material equivalent to water, making the point beyond the inhomogeneity
closer or further away from the surface. Locations in the body farther than the inhomogeneity
are affected by the attenuation of the primary radiation beam, while photon scatter alters the dose
distribution near the inhomogeneity. For megavoltage energies, Compton interactions take
precedent and is dependent on electron density. Areas of reduced density as in lung tissue or air
cavities present with difficulties as there is a loss in electronic equilibrium. For higher energies
in the kilovoltage range, the photoelectric effect is more predominant as the primary radiation
beam comes into contact with high atomic structures. As a result, increased absorption within
the structure and increase electron fluence occurs.
A study by Ding et al,4 evaluated the impact of heterogeneity corrections on tumor and
normal lung dose when performing SBRT on lung cancer patients. The same treatment plan
variables and prescription was used for both the heterogeneity and homogeneity treatment plans.
Their study reported that without utilizing heterogeneity corrections, the tumor received a
significant lower dose as well as the normal lung tissue. Another study conducted by Herman et
al, concluded that the dose to the PTV reduced by 6% for the maximum dose and 13% for the
minimum dose.
It is important to account for inhomogeneities, because they alter the dose distribution
and can ultimately cause the patient to be overdosed. Artifacts such as dental fillings, radiopaque
BB markers, pacemakers, prosthetics, and solder wire should also be corrected for by assigning
the affected area with the appropriate Hounsfield unit. The artifacts distort the CT data set with
streaking and can cause computational errors if the high and low density areas are not taken into
account.
Conclusion: The implementation of heterogeneity correction factors utilized in various
treatment planning algorithms increases the accuracy of the dose distribution. The composition
of the human body is non-uniform and the attenuation of the primary radiation beam is affected
differently as it traverses tissue densities. Evaluation of a finalized treatment plan is falsely
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represented on the DVH of a homogenous plan. Cross-sectional imaging can now be assigned
Hounsfield units and the linear relationship with attenuation coefficients and electron densities
can be determined.3 Dose distribution to the target volume and surrounding critical structures
can meticulously be depicted if the heterogeneity correction is utilized in the calculation
algorithm. As further research is implemented, the incorporation of heterogeneity factors into
algorithms will become more precise. Heterogeneity corrections in treatment planning, is an
important concept that should be applied when formulating the best optimal plan beneficial for
the outcome of the patient.
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References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996:41-
42.
2. Sambasivam S. Dose-volume histogram. [SlideShare].
http://www.slideshare.net/sasikumars/dose-volume-histogram. Published on April 19,
2014. Accessed April 19, 2017.
3. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014: 201-238.
4. Herman TDLF, Gabrish H, Herman TS, et al. Impact of tissue heterogeneity corrections
in stereotactic body radiation therapy treatment plans for lung cancer. Med Phys.
2010;35(3):170-173. http://dx.doi.org/10.4103/0971-6203.62133
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Figures

Figure 1. CT axial view showing various critical structure contours.

Figure 2. A second CT axial view showing additional various critical structure contours.
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Figure 3. A lung treatment plan demonstrating the isodose distribution with the heterogeneity
correction turned off.
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Figure 4. A cumulative DVH evaluating the PTV and ITV coverage with the heterogeneity
correction turned off, along with the minimum, maximum, and mean dose to critical structures.
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Figure 5. A lung treatment plan demonstrating the isodose distribution with the heterogeneity
correction turned on.
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Figure 6. A cumulative DVH evaluating the PTV and ITV coverage with the heterogeneity
correction turned on, along with the minimum, maximum, and mean dose to critical structures.

Figure 7. Portion of the treatment planning report showing the MU for fields with the
heterogeneity correction turned off.

Figure 8. Portion of the treatment planning report showing the MU for fields with the
heterogeneity correction turned on.