Treatment Planning Project 1

Treatment Planning Project

DOS 523
William Deere

Intro
The calculation algorithms in modern treatment planning system are capable of highly

accurate radiation dose calculations provided they have an accurate dataset to work with. We can

currently reliably achieve dose calculation accuracy that is within 1-2% if a model-based

algorithm is used. The addition of heterogeneity correction in the most popular treatment

planning systems used today help to achieve a more realistic dose calculation even in the

presence of tissue heterogeneities. The most relevant tissues and cavities from a radiation

dosimetry perspective are the ones that radiologically different from water, including lungs, oral

cavities, teeth, nasal passages, sinuses, and bones.1

Methods

For this assignment I set out to generate two treatment plans for a solitary lung tumor,

one with heterogeneity correction and one without. The plans are simple, utilizing the lowest

energy available in my clinic, 6MV, and a typical two beam arrangement with one anterior and

one posterior beam. Margin for both beams was set to what the physician would typically select

in my clinic, 5mm in all directions around the PTV. The plans were calculated to isocenter which

is in the PTV with a prescription of 250cGy per fraction for 24 fractions for a total dose of

6000cGy. The primary treatment planning system used in my clinic is RayStation by RaySearch

and not only does it have heterogeneity correction built-in, but it is always on. In a

comprehensive dosimetric performance evaluation of RayStation, its overall performance was

found to be satisfactory with central axis calculations agreeing with measurements within 2% for
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open fields and 3% for wedged fields.2 Since there is no option to turn off heterogeneity

corrections, it was recommended by the staff at my clinic to set the overall density of the external

contour of the patient dataset to the density of water. This will somewhat simulate but not

directly compare the difference between a treatment plan that uses heterogeneity correction to

one that does not. However, it demonstrates how lung tissue affects the dose calculation in a

modern treatment planning system which utilizes an accurate calculation algorithm with

heterogeneity correction.

Both plans are demonstrated in axial, sagittal, and coronal planes in cuts through the

tumor level at isocenter. A plan document was generated for both which demonstrates the beam

sets, a DVH including a pre-defined set of contours. The plan labeled Non-Hetero located in the

top left of each CT figure indicates the plan which has the density of the external contour set to

water. The figures will alternate between each plan for comparisons sake.

Hetero Correction Plan

Water Density Plan

As we can see from the beam sets, the monitor units for the plan with heterogeneity corrections

is lower than the plan with the density of the external contour set to water. This is due the

heterogeneity correction accounting for the lower density of the lung tissue. Lung tissue has a

average density of .31 g/cm3, compared to water which has an average density of 1 g/cm3. While

the 95% line of the water density plan at a glance looks like it provides more coverage, we can
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see the 100% isodose line curving inwards at the isocenter at midline. The DVH and region of

interest tables later provide more information regarding coverage. The patient’s external contour

has a thickness which is narrower laterally, and the resulting sloping of the contour promotes

dose build up laterally

Hetero Plan

Water Density Plan

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Hetero Correction Plan

Water Density Plan

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Hetero Correction Plan

Water Density Plan

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DVH for Hetero Correction Plan

Water Density Plan

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We can tell from the dose volume histograms here that the coverage for the water density plan is

superior. Average dose, D95, and D99 of the PTV are all higher in the in the water density plan.

This is not realistic since it is not taking into account the lower density of the lung tissue.

Because there is less build-up in the lung for the plan with hetero corrections, only some dose

builds up in the actual tumor when normalized to 100%. If this plan was prescribed as 100% of

the prescription dose to 95% of the PTV, the resulting monitor units would be significantly

higher than they are now. If the axial slice of each plan is compared, note the increased dose

medially and just beyond the lung tissue. This is because there is an increase in dose in soft

tissue beyond healthy lung, around 3% for a 4-MV beam.3

As mentioned previously, two other common sites of significant heterogeneity are air

cavities such as the sinuses and bone. The air-tissue interfaces between the cavities and soft

tissue are complex to measure or calculate due to lack of electron equilibrium. Underdosing

effects occur at both the distal and proximal air cavity interfaces.1 However, we know that using

lower energy photon energies will help to improve coverage over higher energies when air or

low-density tissue is present. As for bone, it both reduces the dose to tissue beyond it, but it also

has unique effects for the tissue immediately surrounding it. Beyond 1cm of hard bone we can

expect a reduction in dose of about 3% for 4MV and 2% for 10MV.3

Additionally, high Z materials such as implants in bone should be considered. This is

particularly applicable to dental implants or prostheses such as hip implants. For example, one

study examined the backscatter dose from dental implants and found it increases up to a

maximum of 53% and is primarily dependent on the physical density and electron density of the

metal crown allow.4 This has been a problem at my clinical site, as the team is still searching for

the most ideal way to deal with the backscatter of metal dental work. It can have detrimental
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reactions to the oral mucosa. The effect of high Z hip prostheses were studied in the AAPM Task

Group 63. The figure below indicates the dosimetric effect of various beams on a Co-Cr-Mo slab

at various depths. 1 Note the dose build up at the interface of the slab at beam entry and the

immediate reduction in dose just after the slab. One way to account for a hip prosthesis in the

treatment planning system utilizing heterogeneity corrections is to contour the implant and the

density can be set by the planner. The problem is that the CT number to electron density
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conversion factor may not account for the high-Z inhomogeneity and there are also image

artifacts.1
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References

1. Tissue Inhomogeneity Corrections for Megavoltage Photon Beams, Report of Task

Group No. 65 of the Radiation Therapy Committee of the American Association of

Physicists in Medicine. 2004.

2. Mzenda B, Mugabe KV, Sims R, et al. Modeling and dosimetric performance evaluation

of the RayStation treatment planning system. J Appl Clin Med Phys. 2014;15(5):4787.

https://10.1120/jacmp.v15i5.4787

3. Khan FM, Gibbons JP. Khan's The Physics of Radiation Therapy. Lippincott Williams &

Wilkins; 2014.

4. Chang KP, Lin WT, Shiau AC, et al. Dosimetric distribution of the surroundings of

different dental crowns and implants during LINAC photon irradiation. Rad Phys Chem.

2014;104. https://doi.org/10.1016/j.radphyschem.2013.11.026