Stephanie Sanford

Treatment Planning Paper

April 23rd, 2017
Heterogeneity Corrections
Introduction
Isodose charts and depth dose tables are created with an assumption of consistency of
density within the material being measured. The consideration for varying densities of fat, bone,
muscle, lung and air which the human body is also composed of are negated though they can
cause changes in the dose distribution of that patients plan. [1] Consideration for this
inhomogeneity has historically been very difficult to correct for in dosimetric calculations but
with advancements in technology current treatment planning systems are able to take these
differing densities into consideration. Through the use of CT Simulation data sets which collect
information about the electron density (electrons/cm3) of the inhomogeneity as well as their size
and location within the patient, dosimetrists can now utilize this important information when
creating an accurate treatment plan and dose calculation. [2]
Method and Materials
Identical opposed field plans were generated with one being calculated utilizing
heterogeneity corrections and the other calculated with assumed homogeneous tissues
throughout. These plans were created on a Pinnacle3 Treatment Planning System (Philips Inc,
Madison, WI) and independent second check calculations were performed on dosimetric
calculation software RadCalc (LifeLine Software, Tyler, TX). A parallel opposed beam
configuration was implemented with anterior (AP) and posterior (PA) angles of beam entry.
Both beams were equally weighted and a 6MV photon beam energy was utilized. A clinical
treatment volume (CTV) {shown in orange outline} was outlined by the physician as well as the
Internal Gross Tumor Volume (IGTV) {shown in aqua outline} from the 4DCT obtained at the
time of simulation. This IGTV encompasses a volume of the motion of the lesion during normal
respiration. A planning treatment volume (PTV) {shown in aqua colorwash} was then created
with an expansion of the CTV. A block was created to conform to the contoured PTV with a 2-
cm margin utilizing multi-leaf collimators. The following organs at risk were also contoured for
dose tracking, left lung {shown in green outline}, right lung minus the IGTV {shown in aqua
outline}, spinal cord {shown in red outline}, and heart {shown in pink outline}. 60Gy was
 Sanford 2

prescribed to the target in 30 fractions of 2Gy. Two trials of this plan were created one
calculated by the Collapsed Cone Convolution (CCC) Algorithm without heterogeneity
corrections implemented and is labeled as Homogeneous (Figures 1,2) and the second trial was
calculated by the CCC Algorithm but with heterogeneity corrections utilized. This second trial is
labeled as Heterogeneous (Figures 3,4). Monitor unit calculations were then verified
independently for verification of the results of the treatment planning system (Figures 8,9).
Results
The dose distribution between the two plans shows significantly different results. In the
Homogeneous plan the anterior hotspot is significantly larger than in the Heterogeneous
plan. (Figure 5) In fact, the max point dose for the former plan is nearly 92Gy (Figure 1) where
the later max point dose is 76Gy (Figure 3) and both are located in the anterior chest wall. In the
monitor unit calculation for this plan the treatment planning system (TPS) calculated 172
monitor units would need to be delivered to the AP field for the calculation point to reach 150
cGy. This was confirmed by the second check calculation to within 0.7%. (Figure8) Whereas the
Heterogeneous plan AP calculation only required 129 monitor units and was verified within
4.7 % agreement by the second check calculation. (Figure 9)
Isodose lines on the Homogeneous plan are shown to be smooth and even throughout
while the Heterogeneous plan, in comparison, shows lines that are somewhat jagged and
broken up in areas. While neither PTV is not adequately covered by the 100% isodose line in
either of these plans the Heterogeneous plan does show slightly superior coverage. Utilizing
the cumulative Dose Volume Histogram (DVH) to evaluate each plan, coverage can be
quantified by the volume of the target being covered by the prescribe dose and/or dose volume
constraints may also be evaluated to limit dose to surrounding critical structures. [3] In this case,
the plan with heterogeneity correction included is covering the PTV at 42.44% vs 35.61% for the
plan without. (Figure 6)
Discussion
When considering the isodose shift method for correcting isodose charts for the presence
of inhomogeneities, curves can be shifted toward the skin when inhomogeneities are more
electron dense than water such as bone but will move deeper or farther from the skin surface
when the inhomogeneities are less electron dense than water such as air. [1] While the beam may
 Sanford 3

interact with the ribs modestly in this plan there will be significantly more interaction with the air
contained within the lungs.
The difference of isodose distribution showing an increase hotspot anteriorly happens
because the treatment planning software is considering all tissues to be water equivalent in
density in the Homogeneous plan. The calculation point is placed posteriorly to be centered
within this posteriorly located lesion and the system therefore requires more dose to be delivered
to reach the prescribed AP dose of 100cGy in this equally weighted plan. In the
Heterogeneous plan the system identifies the voxels, represented by lungs filled with air, to
have a lower, near zero density material for the beam to traverse. Because the density is lower in
the material preceding the lesion, as compared to the Homogeneous plan, the isodose lines will
shift deeper so less dose needs to be delivered to penetrate to the deeper-seated lesion. Because
less dose needs to be given from the anterior field the hotspot is therefore reduced anteriorly. The
monitor unit calculations further support this conclusion by the significant reduction in MU
required for the AP field of the Heterogeneous plan as compared to the Homogeneous plan
calculation for the same field.
In a study, conducted at Princess Margret Hospital in Toronto, a retrospective review of
12 Non-Small Cell Lung Cancer patients receiving SBRT treatments for their disease,
researchers found that target coverage could be improved by utilizing Heterogeneity Corrections
(HC). [4] Similarly in this case target coverage was improved with use of HC while surrounding
healthily lung tissues received less dose. Dose constraints to the healthy tissues can often be a
limiting factor when creating a treatment plan and including HC can improved both coverage
without over dosing surrounding critical structures.
Conclusion
Comparison of these two plans demonstrates the effect the inclusion of a heterogeneity
correction can have on a thoracic plan where densities the beam can traverse may vary greatly.
Each patient and treatment plan is unique so consideration of these factors is important to create
a plan that accurately depicts the dose distribution to the targeted tissues and surrounding critical
structures. To properly consider the advantages of utilizing heterogeneity corrections further
study of a larger group of cases should be evaluated however this specific case does identify that
it should be of consideration when creating treatment plans within areas of significant
inhomogeneity. Without proper consideration for inhomogeneity of densities within the patient a
 Sanford 4

target could potentially be under dosed or an organ at risk may be overdosed leading to adverse
side effects or compromised outcomes. To provide excellent patient care it is important that the
dosimetrist be cognoscente of these critical considerations when creating an optimal radiotherapy
plan.

Figure 1 - AP/PA Plan with No Heterogeneity Correction Utilized, Axial, Sagittal and Coronal
Views
 Sanford 5

Figure 2 - AP/PA Plan with No Heterogeneity Correction Utilized, Dose Volume Histogram
 Sanford 6

Figure 3 - AP/PA Plan with Heterogeneity Correction Utilized, Axial, Sagittal and Coronal Views
 Sanford 7

Figure 4 - AP/PA Plan with Heterogeneity Correction Utilized, Dose Volume Histogram
 Sanford 8

Figure 5 - Trial Comparison showing Axial View with Calculation Point (Green)
 Sanford 9

Figure 6 - Dose Volume Histogram Comparison of Two Plans

 Sanford 10

Figure 7 - Dose Volume Histogram Comparison of Two Plans

 Sanford 11

Figure 8 - MU Calculation without Heterogeneity Correction

 Sanford 12

Figure 9 - MU Calculation without Heterogeneity Correction

 Sanford 13

References
1. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2014.
2. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
3. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2012.
4. Franks KN, Purdie TG, Dawson LA, Bezjak A, Jaffray DA, Bissonnette JP. Incorporating
Heterogeneity Correction and 4DCT in Lung Stereotactic Body Radiation Therapy
(SBRT): The Effect on Target Coverage, Organ-At-Risk Doses, and Dose Conformality.
Med Dosim.2010;35(2):101-107. http://doi:10.1016/j.meddos.2009.03.007. Accessed
April 23, 2017.