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Shands James
March 13, 2016
Treatment Planning Project
Treatment Planning Project: Heterogeneity Corrections
Introduction:
In radiation oncology, tumors are treatment using ionizing radiation which causes DNA
damage and indirect cell damage from free radicals.1 The problem with using radiation to treat
cancer is that can do serious damage to normal tissue as well. Accuracy in treatment delivery is
essential in order to kill the tumor and spare as much normal tissue as possible. However,
radiation is effected by the density of the material that it comes into contact with and the human
body is not a homogeneous material. On a CT scan, object densities within the scan are measured
in Hounsfield units. Hounsfield units are a measure of the attenuation of the beam as it
transverses the body.2,3 The treatment planning system will see the Hounsfield units and
determine the density of the material. Then a calculation algorithm will attempt to correct for the
density changes within a patients body.4 When the heterogeneity correction is turned off, the
treatment planning system sees the whole patient as water density. The result of tissue
heterogeneities is that the dose distribution will change in the patient thus heterogeneities should
be accounted for during treatment planning. This gives a more accurate picture of what is
happening in the patient during treatment.
Purpose:
The purpose of this paper is to compare and contrast identical treatments plans with and
without the heterogeneity corrections turned on. This will enable to see the differences in dose
distributions, hot spots, monitor unit calculations, treatment volume coverage, and critical
structure sparing.

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Materials/Methods:
Two identical treatment plans were created using Varian Eclipse treatment planning
system on the same CT data set. The treatment volume was located in the middle of the right
lung which was labeled the gross tumor volume (GTV). Other structures that were contoured
included the right and left lungs, heart with pericardium, and the esophagus. Each plan was
prescribed to 300cGy x 10 fractions for a total of 3000cGy. The beam arrangement consisted of
two parallel-opposed fields at 0 degrees and 180 degrees positions (AP/PA). Multi-leaf
collimators were added to both fields and were auto-fit to the GTV with a 2 cm margin. The first
plan was calculated with the default calculation models and the heterogeneity correction turned
on (On plan). The second plan was calculated with the default models and the heterogeneity
correction turned off (Off plan). Neither plan was normalized so that the GTV coverage could
be assessed based solely on the heterogeneity correction being turned on or off. Screen shots
were taken at isocenter of the axial plane for each plan for comparison of the isodose lines.
Monitor unit printouts and dose volume histograms (DVH) were also printed out for each plan
for comparison of hotspots, monitor unit calculations, GTV coverage, and critical structure
sparing.

Results:
MU Calculations
The first thing that is compared is the differences in MU calculations by Eclipse with the
heterogeneity correction turned on and off. Each beam is weighted for 150 cGy which is 50% of
the prescribed dose per fraction. The On plan required less monitor units to deliver 150 cGy
per beam. Whereas the off plan required more monitor units. Tables 1 and 2 contain the
information for each calculation:

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Field

Machine

Energy

Field Size

Field

SSD

MU

88.9

185 MU

85.6

208 MU

Weighting
AP Lung

23 IX

6x

9.2 x 8.9 cm 50% (150

cGy per

PA Lung

23 IX

6x

beam)
9.2 x 8.8 cm 50% (150
cGy per
beam)

Table 1: MU calculation from Eclipse with the Heterogeneity Correction turned on.

Field

Machine

AP Lung

23 IX

Energy
6x

Field Size

Field

SSD

MU

9.2 x 8.9 cm

Weighting
50% (150

88.9

207 MU

85.6

238 MU

cGy per
PA Lung

23 IX

6x

9.2 x 8.8 cm

beam)
50% (150
cGy per
beam)

Table 2: MU calculation from Eclipse with the Heterogeneity Correction turned off.

Isodose Lines
When looking at the axial images of both plans that were taken at isocenter there are 2
noticeable differences. First is the pulling in of the isodose lines in the lung which is shown is
Figure 1 and 2. In the On plan the isodose lines seem to hug the GTV and the 95% line (green)
is covering the GTV. In contrast, the Off plan isodose lines do not hug the GTV as much and
the 98% lines (red) is covering the GTV. Secondly, the depths of the isodose lines are different.
For illustration, the 100% lines (thick yellow line) are used as an example. In figure 1 the 100%
stops shortly after entering the lung for both beams before showing up in the GTV. In figure 2,
the 100% line is present throughout the whole beam path and covering the GTV to a greater
extent. The isodose lines shift toward the skin surface when the heterogeneity correction is
turned on in lung cases.

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Figure 1: Axial image of "On" plan at isocenter.

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Figure 2: Axial image of "Off" plan at isocenter

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DVH: Critical Structures, GTV, and Hotspots

DVHs are very useful tools that are used in treatment planning. Looking at a DVH can
help determine the sparing of critical structures, target volume coverage, and help compare two
different treatment plans to name a few things. To evaluate critical structure sparing the max dose
of each structure will be analyzed. However, in a clinical situation where the goal is cure a much
higher dose than 30 gray would be used and other dose constraints would be considered.
The dose statistics for the On plan are shown in Figure 3. The DVH shows only
approximately 10% of the GTV is getting the prescription dose. The hotspot for the whole plan is
3583.8 cGy and falls outside of the GTV. The max doses for the spinal canal, esophagus, heart,
right lung, and left lung are 1501.9 cGy, 2504.6 cGy, 2857.2 cGy, 3209.3 cGy (ipsilateral), and
95.7 cGy (contralateral) respectively.
The dose statistics for the Off plan are show in Figure 4. The DVH shows that
approximately 52% of the GTV is receiving the prescription dose. The hotspot of the whole plan
is 3873.2 cGy and falls outside of the GTV. The max doses for the spinal canal, esophagus, heart,
right lung, and left lung are 1685.3 cGy, 2856.4 cGy, 2960.7, 3304.5 cGy, and 95.7 cGy
respectively.
In the case of every single critical structure that was contoured, the max dose was higher
in the Off plan with the exception of the contralateral lung. The max doses for the spinal canal,
esophagus, heart, right lung, and left lung increased by 12.2%, 14%, 3.6%, 3.0 %, and 0%
respectively. The most significant of which was a 351.8 cGy increase of the hotspot for the
esophagus. It is also worth noting that the esophagus is receiving a higher dose than the GTV.
The hotspot also increased considerably for the Off plan as well- an increase of 289.4 cGy
(almost another 10% hot).

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Figure 3: DVH of "On" plan.

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Figure 4: DVH of "Off" plan.

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Conclusion:
The Eclipse treatment planning system determined that it needed more monitor units to
deliver 150 cGy to the isocenter per beam with the Off plan as opposed to the On plan.
When analyzing the CT images the most notable difference would be the way Eclipse would
have accounted for the lung tissue for each plan. Lung tissue has an approximate density of one
third of that of water. This means that Eclipse recognized that not as many monitor units would
be needed to deliver the prescribed dose because the beam would not be attenuated as much by
the lung tissue. In contrast, when the heterogeneity correction is turned off, Eclipse treated the
lung tissue as the same density as water. The result is that Eclipse thinks that it needs more
monitor units to deliver the prescribed dose.
There are consequences to turning the heterogeneity correction off. When turning the
heterogeneity correction off when treating a lung the hotspot increased approximately 10%.
Furthermore, the max doses for the critical structure increased significantly. If the prescription
had been a more therapeutic dose then there would be a danger of overdosing the critical
structures near the GTV. Since Eclipse assumes that the lung is denser than it actually is, a nonheterogeneity corrected plan could overdose the patients so caution should be exercised if the
correction factor is turned off.5 However, turning the correction off may have some advantages
when it comes target volumes in the abdomen and when a prosthesis or hardware is in the beam
path.

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Figure 5: Coronal and Sagittal plane of "On" plan.

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Figure 6: Coronal and Sagittal planes of "Off" plan.

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References
1. Baskar R, Dai J, Wenlong N, Yeo R, Yeoh K-W. Biological response of cancer cells to
radiation treatment. Front in Mol Biosci. 2014; 1(24). doi:10.3389/fmolb.2014.00024.
2. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott,
Williams, & Wilkins; 2014: 214-222.
3. McDermott PN, Orton CG. The Physics and Technology of Radiation Therapy. Madison, WI:
Medical Physics Publishing; 2010: 19-21-19-23.
4. Robinson, D. Inhomogeneity correction and the analytic anisotropic algorithm. J Appl Clin
Med Phys. 2008; 9(2).
5. Herman T, Gabrish H, Herman TS, Vlachaki M, Ahmad S. Impact of tissue heterogeneity
corrections in stereotactic body radiation therapy treatment plans for lung cancer. J Med Phys.
2010; 35(3): 170-173. doi: 10.4103/0971-6203.62133