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Derek Smith Heterogeneity project (Lung) March 9 2014

When planning the Medical Dosimetry team works hard to give a plan that has an accurate and safe conformity to the planning target volume (PTV) to give the safest plan to a patient while giving the prescribed dose to the gross tumor volume (GTV). However, the human body has many variables that need to be accounted for when planning. Previous treatment planning software (TPS) didn’t utilize heterogeneity correction factors. Heterogeneity correction factors are algorithms that account for the variation in tissue throughout the human body. These variations are measured in Hounsfield Units (HU). Unfortunately some clinics don’t apply heterogeneity corrections because they instead just use a uniform HU of one. The largest concern that arises when dealing with deviations in human tissue is the overdose or lack of dose to tissue within a beam path. Lung cancer cases are of a higher concern regarding heterogeneity corrections. Lung cases are problematic in heterogeneity because of the high amount of air as well as the bone in the lung. However, some studies have shown doubts in reducing or increasing dose based on algorithms that may not entirely be accurate due to the large variation that occur in HU. A study published in the Journal of Radiation Oncology Biol. Phys. Described tested results from a volumetric study of measurements and calculations of lung density corrections for 6 and 18 MV Photons beams. The study concluded that one should take great caution in reducing dose base on simple algorithms.1 Treatment Planning Software (TPS) has taken a large stride in


applying algorithms that reflect a more accurate heterogeneity correction factor. For Example, Varian utilizes the analytic anisotropic algorithm (AAA). A study performed by the Journal of Applied Medical Physics found that the AAA fell within the tolerances recommended by TG-53.

Thus, this validates the use of some of these algorithms, but it was also concluded that there

may still be some enhancements to compensate for use of clinical tools such as the enhanced dynamic wedge (EDW). 2 These studies show that the use of heterogeneity factors are up for debate, but they have been proven to be an adequate and useful correction factor. These corrections are advantageous due to compensation for the overdose that can occur when a beam passes through air. Tissue behind bone receives a lower dose due to beam attenuation. The plan presented in this paper consists of a tumor in the superior portion of the right lung. The majority of the tumor was surrounded by air to the right and some tissue to the left. With a right sided lung the heart isn’t as much of a concern. The largest concern is largely based on the ipsilateral lung, esophagus, and spinal cord. The specific dosimetry goals are outlined in figure 1. The physician prescribed 15 Gy total with 3 Gy per fraction for 5 fractions. This plan was developed with the organs at risk (OR) in mind and a minimum of 95% coverage of the PTV. An anterior to posterior (AP) beam was placed with the gantry angle set at 180.0 ᵒ with a static 18MV photon beam energy. Another beam was placed posterior to anterior (PA) with a gantry angle at 160.0 ᵒ with a static 18MV photon beam energy. This plan can be seen in figure 2. To gain further PTV conformity a 15ᵒ wedge was utilized on the AP beam to pull the beam to the left in reference to the patient. The initial plan in figure 2 displays a uniform dose distribution with an amount pulling to the left of the patient due to the wedge. MLC were utilized and conformed to the PTV with a 1cm margin. Both plans with the heterogeneity corrections off and on fell within the Physician’s required OR constraints as seen in figure 3 and figure 5. The DVH


and the isodose lines displayed that the PTV had the required 95% coverage. The equivalent square of the PA and AP beams were ~ 17x17cm and 15x15cm at the isocenter due to the MLC margins. The collimator scatter (Sc) factor for both plans was 1.026, each had an inverse square factor (ISF) of 1, and the AP beam in both had a wedge factor (WF) of 0.776 due to the 15ᵒ wedge utilized. The variation in monitor units was clearly shown in the heterogeneity factors. MU calculations for each field without heterogeneity corrections were calculated as followed following table from figure 6 : MU= Radiotherapy Treatment planning dose (RTP) cGy (WF*dose rate cGy/MU*Sc*ISF) AP MU= 159.5cGy (0.773*.958*1.026*1.000)= 209 MU PA MU= 137cGy (NA*0.958*1.026*1.000)= 140 MU

After a plan without heterogeneity correction factors was made, it was copied and pasted with the exact same parameters and recalculated to account for the presence of irradiated media other than water.3 The plan with heterogeneity corrections on showed immediate dose distribution differences. Comparing the 100% isodose line from each plan, it is apparent from the sagittal view that the plan with heterogeneity corrections has far greater overall coverage as well as coverage inferior to the patient. This change in dose distribution is due to the air the beams is travelling through to treat the tumor within the lung. Tissues outside low density heterogeneities,


such as the air in the ipsilateral lung, receive a higher dose because of the reduced absorption of lung tissue.4 Thus, with the heterogeneity corrections on it reflects a dose distribution with a higher dose to the tissue beyond the air in the lung. This is also seen when comparing hotspots in both treatment plans. As expected due to the heterogeneity correction through air, the hotspot was higher in the plan with the heterogeneity correction factors on. There was a difference of about 4.6% in which the “heterogeneity on” plan had a hot spot of 113.8% and the “heterogeneity off” plan had only 109.2% hotspot. The hotspot was also more posterior to the patient in the “heterogeneity on” plan compared to the “heterogeneity off” plan that had a hotspot anterior of the patient. There are a few factors that go into the reasoning behind this such as the AP beam having slightly more beam weight, but the major factor is due to accounting for a higher dose past air in the lung. There was also a difference in dose distribution through bone in the ribs and the sternum. Comparing the transversal view of each plan it is apparent that past the bone in the “heterogeneity on” plan there is lower dose. This is due to increased scatter, or shielding effect, before the beam hits bone and tissues behind bone receiving less dose which causes dose to be moved toward the surface which is evident from the 90% isodose lines in the “heterogeneity on” plan. PTV coverage was close to the same when comparing the 95% isodose line, but the difference was more apparent in the 100% isodose line. The “heterogeneity on” plan showed that nearly all of the PTV was covered by the 100% isosdose line in each patient orientation. The “heterogeneity off” plan shows that the 100% isodose line covers about 25% less of the PTV from the frontal patient view. Overall the change in dose distribution is affected by the shape and size of the effective heterogeneity as well as the beam energy. Lower energy beams would show more differences in dose distribution due to the increased probability of receiving a higher or lower dose with heterogeneity corrections on.


The plan with heterogeneity correction factors naturally showed higher MU results because the heterogeneity correction factors are taken into consideration in each beam’s MU calculation as shown below: MU= Radiotherapy Treatment planning dose (RTP) cGy (WF*dose rate cGy/MU*Sc*ISF*heterogeneity correction factor) AP MU= 164cGy (0.773*.958*1.026*1.000*0.992)= 218 MU PA MU= 141.5cGy (NA*0.958*1.026*1.000*1.001)= 144 MU The block equivalent square at the isocenter was a prevelant difference between the two plans. The block equivalent square at the isocenter was smaller by about 2cm because the heterogeneity correction was accounting for the air within the PTV. These heterogeneity factors were calculated using Varian’s anisotropic algorithm (AAA). This AAA algorithm is a convolutionsuperposition photon-based computation algorithm introduced commercially in 2005 that is utilized within the treatment planning software (TPS) to account for tissue heterogeneity.2 This calculation helps give a more accurate dose distribution that either moves the dose farther or closer to the PTV based on the various heterogeneities and their HU’s. The plan with the heterogeneity correction factor would need some possible field weight adjustments or field-infield technique in which a separate field-in-field would block out the hot spot with an MLC to reduce the hotspot. However, the second plan fell within the acceptable physican OR and coverage constraints stated in figure 1 and the “heterogeneity on” plan DVH in figure 5.


There is still a lot of debate as to whether or not heterogeneity corrections should be used, and some clinics still use homogenous treatment plans. Heterogeneity correction factors have been proven to be a sufficient correction based on TG-53 criteria.2 It is crucial to give a patient the best treatment plan with the most accurate dose distribution. In most cases dose accuracy is a vital role in ensuring OR constraints are met. Without meeting these constraints a patient’s wellbeing can be affected by radiation therapy. The goal in all radiation oncology departments is to treat affected tumor sites while maintaining patient well-being. Heterogeneity corrections are a helpful and precise tool that will grow in accuracy in the future as well as benefit these goals.


References 1. E.E. Klein, A. Morrison, J.A. Purdy, M.V. Graham, J. Matthews. A volumetric study of measurements and calculations of lung density corrections for 6 and 18 MV photons. Int J Radiat Oncol Biol Phys, 37 (1997), pp. 1163–1170. 2. Breitman K, Rathee S, Newcomb C, et al. Experimental validation of the eclipse AAA algorithm. J Appli Clini Med Phys, 8(2) (2007), pp. 76-92. 3. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:945. 4. Washington CM, Leaver D. Physics, Simulation, and Treatment Planning. St. Louis, MO: Mosby Elsevier; 1996:275.


Figure 1: Physician OR constraints for treatment in the lung


Figure 2: Treatment plan with heterogeneity factors off in frontal, sagittal, and transversal view.


Figure 3: Heterogeneity off DV


Figure 4: heterogeneity correction on plan in frontal, sagittal, and transversal view


Figure 5: Heterogeneity correction factors on DVH


Figure 6: heterogeneity off photon calculation sheet


Figure 7: heterogeneity correction factor on photon calculation sheet