April Hardman

DOS 523: Treatment Planning

April 16, 2021

Treatment Planning with Heterogeneity Corrections

In the calibration or reference setting, the properties affecting a photon beam and its dose
distribution are proven within a controlled medium such as water or a water equivalent phantom.
The density of water is considered similar to the density of soft tissue, and thus the calculated
affects should correlate similarly within human tissue. These values create a foundation to build
upon for understanding and calculating the characteristics of therapeutic radiation. However, the
human body is heterogenous by nature. It has varying densities such as airspace, muscle tissue,
bone, fat, and often surgical clips or metallic implants. As a photon beam passes through these
tissue variants, the outcome may differ significantly than the results found within the theoretical
phantom setting. Heterogeneity corrections account for the various densities found within the
body. The treatment planning system is designed to replicate, with as much accuracy as possible,
the actual physical proprieties of the treatment beam under specific planned conditions. This
ensures that the intended calculated plan is congruent with the true delivered plan. In computed
tomography the density of a subject is identified with its Hounsfield number which very closely
correlates to the attenuation coefficient.1 These values are significant to dosimetry as the basis of
treatment planning is built upon the CT simulation scan. Dose distribution and validity is
dependent on the accuracy of these values. Otherwise, the treatment planning system will
consider the input values as if the scenario were at reference conditions.

The effect of heterogeneity corrections on a given treatment plan is easily recognizable

when applied to areas where the subject density is either extremely high or low in regard to the
Hounsfield unit. For this comparative planning study, a demonstration of the effects of
heterogeneity corrections will be compared to the calculations provided on the same plan without
these corrections. The parameters of the plan were created based off an isolated tumor found
within the lung field. Contoured structures included the patient, bilateral lung fields, spinal cord,
heart and PTV. A 2cm auto margin was placed around the periphery of the PTV. Simple beam
geometry with equally weighted parallel opposed AP/PA fields at 6MV beam energies were
used.
April Hardman
DOS 523: Treatment Planning
April 16, 2021

The first calculation by the treatment planning system is performed with heterogeneity
corrections on. Isocenter is placed in the center of the PTV volume, which resides slightly more
anterior than midline within this patient. The hot spot is 131.4% of the prescription dose and is in
the posterior soft tissues outside of the lung field. The distribution of the PA beam isodose is
uniform throughout the area of soft tissue but falls off quickly once the beam reaches lung tissue.
The PA isodose never reaches the target volume. The AP beam fully encompasses the PTV.
There are areas of increased dose in the anterior soft tissue and the isodose represents a cone like
shape. PTV coverage for this beam arrangement is demonstrated at 100% prescription dose of
6000cGy covering 23.7% of the target volume. The dose volume histogram (DVH) shows a
gradual fall off for the PTV volume.
April Hardman
DOS 523: Treatment Planning
April 16, 2021

The same patient was then calculated omitting the heterogeneity corrections with no other
changes to its plan parameters. When heterogeneity corrections are not in use, we see that the
shape of the isodose lines have formed an hourglass figure. There is pulling of the 100% isodose
line conforming to mid PTV. Overall, the isodose distribution is more homogeneous. This is
because with heterogeneity corrections turned off, the treatment planning system is calculating
everything as if it were of the same density. The PA beam shows areas of increased intensity
encroaching into the lung field, but the distribution is markedly more uniform than in the prior
calculation. The hot spot has decreased to 125.1% of the prescription dose. Coverage of the
target volume has more than doubled from the plan using heterogeneity corrections with 100% of
the prescription dose covering 52.8% of its volume. The DVH displays a rapid fall off from the
PTV, and overall, the dose to normal structures is lower, but the long range of low dose tail
across the DVH is equivocal.
April Hardman
DOS 523: Treatment Planning
April 16, 2021
April Hardman
DOS 523: Treatment Planning
April 16, 2021

There is less attenuation of the photon beam when traversing through low density lung
tissue as opposed to water equivalent tissue or greater. This results in an extended lateral spread
of the electrons due to the loss of electronic equilibrium, increasing the width of the penumbra,
and leading to a loss of dose within a beam near its edge.2 Changes in the associated photon
scatter distribution alter the dose distribution more strongly near the inhomogeneity rather than
farther beyond it.1 Beams traversing through lung must also undergo a secondary build up phase
when they approach the tumor volume. Therefore, there is a loss of dose at the periphery of the
tumor that correlates with the area of the secondary build up region. If the tumor volume is small
and isolated by lung tissue, which is the case in this example, the lack of density surrounding the
entire volume will also reduce the backscatter that contributes to the dose and result in
underdosed treatment volumes. The same principle applies when an air or sinus cavity is
traversed by the beam. The most significant decrease in dose occurs at the surface beyond the
cavity, for large cavities (4 cm deep) and the smallest field (4 × 4 cm2). 1 When evaluating the
monitor units listed for each beam, we can see that the machine assigns higher monitor unit
values to the plan without heterogeneity corrections. This is because the treatment planning
system is planning to deliver a beam that is being attenuated in soft tissue density, which requires
more monitor units from the machine than it would if the beam were only traversing through air.
April Hardman
DOS 523: Treatment Planning
April 16, 2021

A side-by-side comparison view of the two plans with combined DVH charts emphasizes the
differences between the two plans. The combined DVH graph above depicts the isodose lines of
structures with the heterogeneity corrections “on” as square symbols and triangle symbols for
structures in the plan with corrections “off”. We can see that the dose to normal structures is
higher for the beams with heterogeneity on, but the PTV coverage is significantly lower with a
longer fall off region as opposed to the plan with the corrections turned off.
April Hardman
DOS 523: Treatment Planning
April 16, 2021
April Hardman
DOS 523: Treatment Planning
April 16, 2021

The beam profiles give a graphical representation of the pronounced secondary build up for the
plan with heterogeneity corrections on and offer a comparative view of the dose gradient for
each plan.
April Hardman
DOS 523: Treatment Planning
April 16, 2021

The importance of heterogeneity correction applies significantly in other treatment

scenarios as well. For patients with metal implants or prosthesis, metal artifact known as
“streaking artifact” can occur on the CT image. They occur because the density of the metal is
beyond the normal range that can be handled by the computer, resulting in incomplete
attenuation profiles.3 Streaking erroneously places opaque Hounsfield units in voxels of areas
where high density may not be found, such as the soft tissues surrounding the metal implants.
When the treatment planning system is given these density values, it assumes that the beam will
be fully attenuated in these areas and it does not account for true distribution of dose in the
structures surrounding the artifact. Heterogeneity corrections can be altered to allow the planner
to override false Hounsfield assignments with proper values to depict the truer properties of
matter. Materials having high atomic numbers have greater radiation attenuation properties.
When treatment planning systems encounter these areas, such as one would find with a hip
prothesis or breast tissue expander, the metal implant can function as a shield, absorbing the
photon beam, leaving any areas beyond the expander or prosthesis to be underdosed.

Dosimetrists need to a have a full understanding of photon interactions to decide when to

apply or remove heterogeneity corrections to improve the validity of calculations or to apply
beam manipulation techniques, as necessary. Typically, a deep-seated volume in the body would
warrant the use of higher beam energies, but in areas like the lung the effects of electronic
disequilibrium are exaggerated at higher energies and the use of heterogeneity corrections in this
circumstance can depict the true nature of the beam in this setting. Heterogeneity corrections are
typically always kept on, ensuring the best possible accuracy. Dosimetrists can override and
assign different density values to selected structures when Hounsfield units are erroneously
assigned but understanding the mechanisms at play can dictate the proper rationale during
treatment planning and help to ensure dose accuracy at the time of treatment.
April Hardman
DOS 523: Treatment Planning
April 16, 2021

References:

1.Gibbons, JP. Kahn’s the physics of radiation therapy. 6thEd. Philadelphia, PA. Wolters Kluwer
Health. 2020.

2. Wang L, Yorke E, Desobry G, Chui CS. Dosimetric advantage of using 6 MV over 15 MV

photons in conformal therapy of lung cancer: Monte Carlo studies in patient geometries. J Appl
Clin Med Phys. 2002;3(1):51-59. doi:10.1120/jacmp.v3i1.2592. Published January 1, 2002.
Accessed April 16, 2021.

3. Barrett J, Keat N. Artifacts in CT: recognition and avoidance. RSNA RadioGraphics 2004;
24(6):1679–1691. 10.1148/rg.246045065. Published November 1, 2004. Accessed April 16,
2021.