Treatment Planning Project: Heterogeneity

Ashley Coffey
Patients come in all shapes and sizes and when it comes to the advancement of 3D
treatment planning, the computer can now take in account these differences in tissue like it
couldnt be done before. Planning programs, like Eclipse and Pinnacle, can assign numbers to
different tissues based off of the density recognized in the scan. With lung, the primary densities
are lung/air and soft tissue. These both carry different densities (lung = 0.25 g/cm3 and soft tissue
= 1.00 to 1.50 g/cm3) which affects the path of the beam.1 There is an advanced setting in these
programs that will turn these different densities on or off, known as the heterogeneity
correction setting. With the setting on, the program will differentiate the densities and
incorporate them into the plan. In the off setting, the densities are overridden to create a
uniform structure with a density of 1.00 g/cm3.
In Pinnacle, a mock lung patient was used to evaluate the differences in plans using
heterogeneity corrections while on and off. The patient had a lung tumor in the upper posterior
aspect of the left lung. As specified, an AP and PA beam with 6MV energy were added with a
50/50 weighting. The prescription was set to deliver 200cGy per fraction for 30 fractions,
totaling a standard lung dose of 60Gy. A margin of 1.5cm was added to the CTV to create the
PTV; from that point, another half-centimeter margin was added around the PTV on the block
created. Contours for both the right and left lung, the heart, spinal cord, external/patient, CTV,
and PTV were included. The plan was kept simple under these guidelines in order to evaluate the
differences in the beam for the heterogeneity setting not for receiving any particular coverage of
the tumor. From this point, two copies were created of this plan. One plan was calculated with
heterogeneity on while the second was calculated with heterogeneity off.

Contours used for both plans

Lung and tissue densities vary in such a way that radiation beams will also behave
different when traveling through them. Since the density of lung is smaller and the cavity is filled
with air, there will be more scatter and travel with low energy. There is little absorption factor in
air than there is in soft tissue. We can see the behavior of the isodose lines in air bowing in from
the soft tissue and traveling farther in air. With heterogeneity off, the treatment planning system
views the entire density of the patient as a uniform density (as if it is soft tissue). The beams will
not travel as far (due to the assumed attenuation) and the shape of the isodose lines will be more
conformal. Because turning the correction off assumes all densities are the same, the MUs will
increase as the planning program believes it needs to push the beams further. The issue with this
is that it is not applicable to a clinical setting when treating lung since that is not how the
radiation will actually behave.

Heterogeneity On

Heterogeneity Off

With the heterogeneity on, there are fewer MUs that come through due to the nature of
lung and air and full dose can be accurately delivered. With heterogeneity off, there are more
MUs because the treatment planning system doesnt recognize that beams are traveling through
air and still assume it is soft tissue. Therefore, to get coverage, the beams are pushed harder to
penetrate deeper. If treating a patient with a plan with heterogeneity off, the true dose will be
inaccurate; the plan will be over dosed due to the increase in MUs. It does not paint an accurate

representation of what is actually happening to the isodose lines and coverage with heterogeneity
off.2

Difference in MU
On- 210 MU per treatment

Off- 216 MU per treatment

The amount of damage done to the normal tissue and lungs would be higher than
anticipated with the corrections turned off. The larger the field size is, the more MUs are
delivered and the more you can overdose the tumor. You also are increasing the dose to a larger
volume of lung that in turn can result in worse side effects and late effects to the patient. If a
constraint was not met on normal lung tissue with the corrections on, it would be noticeable on
DVH where in the case with it off, it would meet constraints. In a field where patient safety and
effective treatments are important, the use of heterogeneity corrections absolutely should be used
for plans involving any sort of lung. The TG-65 guidelines suggest that facilities should try
various plans with and without heterogeneity dose corrections and to compare the plans to find
an average difference in volume doses.3 While the move to heterogeneity corrections isnt a
necessity, it is a strong recommendation in order to keep toxicity low and to keep treatment plans
accurate.

DVH for both Heterogeneity On (Solid line) and Off (Dashed line)

As a result of this project, the use of heterogeneity corrections seems to be useful in

radiation planning. Even though the beams and dose will be more conformal and appealing in the
off setting, it is not an accurate representation of what is happening every day at the treatment
machine. The patient could be severely overdosed and harmed if the corrections are turned off.
However, the only time where the heterogeneity correction could be turned off and used for
planning is when treating a heterotrophic bone or any type of metal replacement, such as with
hip or extremity. This is typically acceptable due to the scatter of the metal component in the
patient. It is difficult to develop a plan and determine any pattern of dose when the CT scan
produces so much artifact from bone. It will not be completely accurate, as we discussed above

but in these anatomical landmarks, there is not much concern for organs at risk to evaluate.
When treating any other area where organs are at risk for overdose and side effects,
heterogeneity should be utilized. The move towards using these corrections has been prominent
lately due to the accuracy discovered through heterogeneity studies. It is better in practice to use
these corrections for patient safety and further advancements in radiation oncology.
Comparison of both On and Off

References
1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott, Williams, & Wilkins; 2014:201-240.
2. Chaikh A, Giraud J, Balosso J. A method to quantify and assess the dosimetric and clinical
impact resulting from the heterogeneity correction in radiotherapy for lung cancer. Int J
Cancer Ther Oncol 2014; 2(1):020110. http://dx.doi.org/10.14319/ijcto.0201.10.

3. Klein, E. Hetergeneity Corrections in Clinical Trials. [PowerPoint]. St. Louis, MO.

http://www.aapm.org/meetings/amos2/pdf/29-7954-83775-558.pdf. Accessed March 8,

2016.