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Tenzin Yiga
DOS 523: Treatment Planning
May 6, 2020

Heterogeneity corrections for lung treatment planning

Introduction
Radiation therapy has long been used as an effective treatment modality against many
forms of cancer. Although standard isodose charts and depth dose tables assume that the body is
a homogeneous medium such as water, it is in fact composed of different tissues and cavities
with varying densities such as fat, bone, muscle, and air.1 These heterogeneities in density effect
how the beam is attenuated and scattered differently than when compared to a medium such as
water.2 Through the advancements in technology such as the advent of computed tomography
(CT), it is now possible to derive electron density information of patients which can be
incorporated into the dose calculation process.3 To increase the therapeutic benefit of radiation
therapy, the presence of these heterogeneities within the body should be taken into account to
ensure the dose delivered is accurately predicted. The purpose of this project is to compare the
affects of treatment planning with and without heterogeneity correction in the case of non
mediastinal lung tumors.

Materials and Methods

For this project, I chose a patient that had a left upper lobe (LUL) lung tumor. The
required contours were the body, right lung, left lung, spinal cord, tumor, and heart. The plans
each contained an anterior (AP) and posterior (PA) opposed beam. Both beams were set at 6MV
energy with equal weighting and the field parameters were set at a 2 cm margin around the
planning target volume (PTV) with isocenter in the center of the PTV. Utilizing the Eclipse
treatment planning system and Anisotropic Analytical Algorithm (AAA), two separate plans
using the same dataset were generated. Plan 1 represents the plan with heterogeneity correction
kept on and Plan 2 represents the plan with heterogeneity correction turned off. For the purpose
of this project both plans were kept at no plan normalization and have a prescription dose of
5000cGy total.
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Results
Figure 1 shows Plan 1 had a 3D dose maximum of about 116% with a 3D minimum PTV
coverage of 90.6%. As displayed in Figure 2, the monitor units (MU) for the AP and PA beams
were 610 and 616 respectively. Figure 3 shows Plan 2 had a 3D dose maximum of about 111%,
with a 3D minimum PTV coverage of 95%. As displayed in Figure 4, the MUs for the AP and
PA beams were 632 and 654 respectively. Lastly, Figure 5 shows the side by side comparison of
the dose volume histogram (DVH) for both Plan 1 and Plan 2.

Figure 1: Isodose distribution shown for Plan 1 using heterogeneity correction in the transverse view (A), frontal view (C), and
sagittal view (D). The multiplanar view (B) shows the location of the PTV in dark blue. The green 100% isodose line represents
5,000cGy prescription dose.
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Figure 2: MU printout for Plan 1 with heterogeneity correction on displayed for both AP and PA beams.

Figure 3: Isodose distribution shown for Plan 2 with no heterogeneity correction in the transverse view (A), frontal view (C), and
sagittal view (D). The multiplanar view (B) shows the location of the PTV in dark blue. The green 100% isodose line represents
5,000cGy prescription dose.
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Figure 4: MU printout for Plan 2 with heterogeneity correction turned off displayed for both AP and PA beams.

Figure 5: Side by side comparison of the DVH for Plan 1 (triangle) and Plan 2 (square) labeled according to color.

Discussion
The most substantial difference between Plan 1 and Plan 2 is the isodose distribution as
displayed in Figure 1 and 3 respectively. Plan 1 (plan with heterogeneity correction) displays the
dose buildup on the anterior and posterior end of the patient due to the higher density of the soft
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tissue in the area compared to the lower density of the lung. The 3D dose maximum for Plan 1
was higher at 116% while Plan 2 had 111% which can also be expected because of the fact that
the body is not a homogeneous medium and dose will build up in the areas of higher density.
Plan 2 (plan without heterogeneity correction) shows a more uniform dose distribution and
generates better PTV coverage with a 3D minimum of 95% compared to Plan 1 at 91%. This is
due to the more even attenuation of the beam through the body than what we would expect to see
from Plan 1, based on the assumption that the body in Plan 2 is overall homogenous.
From the DVH displayed on Figure 5, we can compare both Plan 1 and Plan 2 side by
side. There is not a great difference in the curves representing the organs at risk (OAR) between
the two plans. The left lung of Plan 2, referenced as the orange line with squares, has slightly
more dose than in Plan 1. This is due to larger volume of lung treated with the more uniform
dose distribution of the plan without heterogeneity correction. The MU values displayed in
Figure 2 and 4, show Plan 1 had 610 and 616 MU for the AP and PA beams respectively while
Plan 2 had 632 and 654 MU. The reasoning behind the lower MU for Plan 1 is because when
heterogeneity correction is being used, the varying densities (such as the low attenuating lung
tissue) are taken into account and results in less MU needed to push the same dose.
When working on treatment plans such as lungs, the dose distribution within lung tissue
is primarily governed by its density. Lung tissue in general is less dense mainly due to the
functionality of the lung as a respiratory organ that contains both tissue and air. Low density
results in an increase of electrons traveling outside of the geometric limits of the beam therefore
causing a decrease in the sharpness of the dose profile. We can also see a greater loss of laterally
scattered electrons due to the same reason, causing the dose to be reduced along the axis.1 When
planning without heterogeneity correction we are essentially assuming more attenuation in the
lung than what is actually occurring. As treatments in radiation therapy become increasingly
more conformal with the advancements in technology, incorrect isodose coverage depiction can
lead to an increase in the opportunity for geographic misses.3
Another issue dealing with inhomogenities within a treatment area can occur when
patients have metal in the body causing artifacts on the CT dataset. This can commonly be seen
in cases such as a patient with a hip prosthesis, dental fillings, and etc. These artifacts can lead to
incorrectly reconstructed Hounsfield units (HU) and should be corrected for to avoid a loss of
accuracy in dose calculation.4 Simple corrections can be adjusted for manually by contouring the
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correction region and assigning the average HU of the nearby areas with no artifact disturbance.
The research conducted by Ziemann et al4, shows that when simulating a pelvic patient with a
double-sided total endoprosthesis by using a phantom equipped with two steel bars, the plan
calculated without heterogeneity correction lead to a dose error in the isocenter of up to 8.4%. In
the same conducted research, the manually corrected plan reduced dose error to 4.1%.4 As a
result, we can see that heterogeneity corrections are an important aspect of treatment planning in
terms of dose calculation accuracy.

Conclusion
Heterogeneity correction should be used in treatment planning to ensure accurate dose
calculations and delivery. Varying densities in the human body greatly effect the attenuation and
scatter of the beam, especially in cases such as lung cancer because the density of lung tissue is
lower compared to the other tissues of the body. As observed from this project, the isodose
curves were significantly different between Plan 1 and Plan 2, showing the difference in
attenuation caused by the assignment of different densities. With the potential risk of either an
over or under dose to treatment area, we must take into account the inaccuracies that can be
introduced regarding dose distribution when heterogeneity correction is turned off. This will help
obtain a more optimal plan in clinical practice and should be applied when possible.
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References

1. Khan FM, Gibbons JP. The Physics of Radiation Therapy, 5th ed. Philidelphia, PA:
Lippincott Williams and Wilkins; 2014.
2. Washington CM, Leaver D. Principles and Practice of Radiation Therapy, 4th ed. St.
Louis, Missouri: Mosby; 2016.
3. Papanikolau N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections for
megavoltage photon beams. AAPM Report of Task Group No. 65; 2004.
https://www.aapm.org/pubs/reports/rpt_85.pdf. Accessed May 6, 2020.
4. Ziemann C, Stille M, Cremers F, Buzug TM, Rades D. Improvement of dose calculation
in radiation therapy due to metal artifact correction using the augmented likelihood image
reconstruction. J Appl Clin Med Phys. 2018;19(3):227‐233. doi:10.1002/acm2.12325