Treatment Planning Project:

Effects of Heterogeneity Corrections on Lung Treatment Planning

Jina Lee

Dos 523
April 4, 2021
Objective

This project will explore the effects of heterogeneity corrections for a simple 2D lung plan.

Introduction and Purpose

Tissue inhomogeneity is a major factor in treatment planning that must be considered to

visualize accurate dose distributions within various anatomy. Depth dose tables such as TMR,

PDD, and standard isodose charts assume a homogeneous medium, and does not depict accurate

attenuation of a beam traversing through bone or any air cavities.1 Charge Particle Equilibrium

(CPE) occurs when a given type and energy leaving a volume is replaced by charged particles of

the same type and energy entering the same volume. The point where CPE occurs is also the

point of maximum dose (dmax). Within the lung, there is lateral electron equilibrium loss beyond

the geometric boundaries of the beam, resulting in increased low dose scatter and decreased

sharpness of the beam. Since there is no dense tissue to build up the secondary electrons or

contribute to dose as scatter, this causes a shift in the depth of CPE.1The general decrease in

beam sharpness and decreased centralized dose within the lung is known as the bowing effect,

and has been observed via Monte Carlo simulation to become more dramatic with smaller field

sizes (<6x6), increased discrepancy between lung and tissue densities, and larger energies.1,2 A

study of kerma and fluence distribution in lung found that there is negligible decrease in dose for

field sizes >5x5 for 6MV beams and for field sizes >16x16 for 15 MV beams.3 In this treatment

planning project, a treatment plan with no heterogeneity corrections will be compared to the

same plan with heterogeneity corrections on.

Methods

To evaluate lung tissue inhomogeneity in treatment planning, a patient with a relatively

free floating tumor not encompassed by the mediastinum was chosen. First, the treatment was

planned AP/PA with the heterogeneity correction settings off assuming solid homogeneous

tissue (Density = 1 g/cm3) throughout the path of the beam. The plan attempted to achieve 95%

coverage to 100% of the volume for a prescription of 300 cGy x 10 fractions. Each bock gave a 2

cm margin to the PTV. The same plan was then copied and heterogeneity correction settings

were turned on to evaluate effect on dose distribution without variations in treatment parameters.

Figure 1a: AP and PA beams with 2 cm margin to GTV in right lung

Figure 1b: Prescription and normalization

Results – Heterogeneity OFF plan

Figure 2a: Beam parameters and MU

Figure 2b: Dose distribution in axial, sagittal, and coronal views at isocenter

Figure 2c: Dose distribution throughout axial slices

Results – Heterogeneity ON plan

Figure 3a: Beam parameters and MU

Figure 3b: Dose distribution in axial, sagittal, and coronal views at isocenter
Figure 3c: Dose distribution throughout axial slices

With heterogeneity turned off, the resulting MU for the AP and PA beams were 194.5

and 213.3, respectively. The hotspot for this plan was 3287 cGy, or 109% of the prescribed dose.

The dose distribution was an expected symmetrical hour glass shape. With heterogeneity turned

on, the resulting MU for the AP and PA beams were 179.4 and 196.7, respectively. Both MU

values were about 8% less than the MU from the heterogeneity-off plan. The hotspot with

heterogeneity on was 3387 cGy, or 113% of the prescribed dose. The dose distribution was not

symmetrical, and broke off in sections of air adjacent to the tumor, especially on the posterior

side. The DVH for both plans were not significantly different- the most noticeable difference

was the increased low dose and decreased high dose in the ipsilateral lung for the “heterogeneity-

on” plan. The GTV coverage was also notable, with the heterogeneity-on plan covering 99% of
the GTV with 100% of the dose compared to 95% of the GTV receiving 100% of the dose with

the heterogeneity-off plan.

Figure 4: DVH of the two plans. Solid line – heterogeneity off; dashed line – heterogeneity on

Discussion:

Heterogeneity corrections played a critical role in the general dose distribution of the

lung and adjacent structures. Previously, it was discussed that there is a loss of CPE in air

cavities such as the lung due to lack of tissue that can absorb the beam to develop a build-up

region at the target nor contribute to the dose from lateral scatter; In general, the lack of lateral

scatter and shift of the d-max causes dose at the CAX to decrease.1 This is visible in the plan

with the heterogeneity corrections ON, where the high isodose lines (90-100%) bow inwards

where tissue is missing. In that same area where the high isodose lines concave towards the

CAX, the low isodose lines (<50%) bow slightly outwards, making the beam lose its sharpness
(Figure 5a). The dose along the CAX is further lost to electron travel beyond the geometric limits

of the beam within the lung, further confirmed by our DVH for the left lung, where there is a

higher amount of low dose due to scatter and consequentially a lower amount of high dose.

Adjacent to the lung tissue where the two beam exits the thickness of the lung, there lower

isodose lines come slightly inward as depicted by the arrows in Figure 5a. This is also due to the

fact that there is a loss of CPE in areas of lower density- once the beam comes out of the volume

of lung and hits tissue, it can start depositing dose that will be absorbed by the tissue. The

buildup of dose occurs to re-solidify CPE and the maximum dose in normal density tissue, and

the isodose lines come back out straight after some depth. Dose beyond the thickness of the lung

also increased significantly- the hotspots increased to greater than the acceptable 110%. Since air

cannot absorb the primary beam and can only attenuate the beam slightly via scatter, the

resulting beam received soft tissue beyond the lung is much more potent compared to a beam the

dose received by soft tissue beyond bone or homogeneous soft tissue. Figure 5a also shows that

the further away from the inhomogeneity, the more even the dose distribution becomes and

seems to be affected less by the inhomogeneity. Although there is less high dose around the

CAX of the heterogeneity-on plan, scatter of the low density of lung causes low dose to spread

out, causing increased integral dose in the lung.

Compared to the symmetrical dose distribution of the heterogeneity-off plan, the dose

distribution of the heterogeneity-on plan also conforms its higher dose around the volume of the

tumor where density is greater than the surrounding lung. This can be one advantage of using

heterogeneity corrections- dose to the tumor is conformal because the tumor density allows the

dose to be placed there instead of the normal lung or additional air filled spaces such as the

trachea. However, depending on the intent of treatment, the physician may include some of the
lung as the PTV to cover microscopic disease. In this case, it may be more difficult to get

coverage out to the air filled space especially when the peak dose is shifted due to the lack of

CPE buildup within the lung.

Figure 5a: heterogeneity-on plan. Bracket: constricted high dose and increased lateral scatter; Top and
bottom arrows: areas of slight constriction to adjacent tissue due to loss of CPE in low density area

The treatment planning software generated MU in the plan with heterogeneity corrections

is 8% lower than the homogeneous plan for both beams. This difference is attributed by the

application of an inhomogeneity correction factor. There are three ways to adjust the TAR value

to account for the density differences: The isodose shift method, the tissue-air ratio method, and

the Batho-Young (power law) method.4 The Batho-Young method takes into account the

reference point location and its distance to the inhomogeneity. This method, Monte-Carlo

simulation, and the equivalent TPR/TMR method is more commonly used to account for

inhomogeneities.4 A secondary software is also utilized to check MUs. For this case, RadCalc

software may be used to obtain the heterogeneity factor, which takes into account the different

scatter and absorption of multi-density phantoms or patients. During the actual MU hand
calculation, this factor is used in the bottom denominator to account for the output actually being

absorbed in the tissue. Another method is to obtain TPR/TMR using effective depth. Effective

depth takes into consideration the electron density and thickness of the tissue that the beam must

pass to reach the reference point.5 In summary, there are many ways to account for

heterogeneous tissue such as the lung. Heterogeneity must be accounted for in order to

accurately predict and plan the placement of dose.

Conclusion

Heterogeneity corrections have a significant impact on dose distribution, and thus must be

accounted for during treatment planning. The lung replaces the homogeneous tissue and presents

a thickness of lowered attenuation of the primary beam. Because of the general lack of tissue, the

beam must traverse through air, where lateral scatter usually occurring at surrounding tissue and

CPE buildup of the primary beam is lost. These effects lower the overall dose contribution from

scatter and secondary electron buildup, resulting in a decreased dose at the CAX. When the beam

is inside the lung, electrons can travel further laterally beyond the geometric definitions of the

beam, causing covexed low isodose lines. Beyond the lung, the soft tissue receives the dose that

the lung could not absorb. When planning a lung treatment with heterogeneity corrections on,

additional beam segments and control points may be necessary to reduce hotspots to an

acceptable amount (110%) in comparison to a plan with no heterogeneity involved.

Sources:

1. Gibbons JP, Khan FM. Electron Beam Therapy: 12.5. In: Khan's the Physics of Radiation
Therapy. Philadelphia, PA: Wolters Kluwer; 2020:222-231.

2. Zabihzadeh M, Ghahremani Z, Hoseini S, Shahbazian H, Hoseini Ghahfarokhi M. Effect of

lung inhomogeneity on dose distribution during radiotherapy of patient with lung cancer.
Int J Radiat Res. 2020;18(3):579-586. doi:10.18869/acadpub.ijrr.18.3.579

3. Kumar S, Nahum AE, Chetty IJ. Monte-Carlo-computed dose, kerma and fluence distributions
in heterogeneous slab geometries irradiated by small megavoltage photon fields. Physics in
Medicine & Biology. 2020;65(17):175012. doi:10.1088/1361-6560/ab98d1

4. F. LML. Inhomogeneity Corrections. In: Principles and Practice of Clinical Physics and
Dosimetry. Madison, WI: Advanced Medical Pub.; 2006:69-76.

5. Eiler D. Lecture presented: Tissue inhomogeneities, beam spoilers and tissue compensators,
Oh My! At The Ohio State University, School of Health and Rehabilitaiton Sciences;
September 2019; Columbus, OH