1

Keith Larsen

Treatment Planning Project

4/22/21

Objective: Compare an AP/PA lung plan with heterogeneity correction turned on and off.

Purpose: Tissue density is one of the more impactful factors in determining how radiation
interacts in depositing its dose. A fundamental advantage of CT based radiation planning is the
CT’s ability to provide density-based information in Hounsfield units.1 Hounsfield units are
numbers associated with tissue density. Using algorithms, the treatment planning system (TPS)
can incorporate the HU’s and differentiate the various densities in the beam path and correctly
represent the beam’s interactions with the tissues it encounters.

Air, with an HU of -1000, has a very low amount of beam attenuation when compared to
water equivalent tissue with an HU of approximately zero.2 This is due to the fact that Compton
scatter in tissue is a major factor in dose contribution from photon beams that is diminished in air
cavities.1 This applies to all beam energies, but the percent increase in dose beyond the lung
tissue is most significant with lower energy beams and smaller field sizes. Along with the lower
beam attenuation over equivalent distances, air cavities also create the need for radiation beams
to re-establish electronic equilibrium once contacting tissue on the opposite side of the cavity.1,3
This can lead to lower peripheral dose than would be seen in tissue only. Furthermore, due to the
lack of tissue in the lung, the penumbra of the beam effectively widens and dose at the central
axis can be decreased. This is caused because the low-density areas of lung allowing the
electrons to scatter outside the parameters of the treatment field size rather than staying within
their expected boundaries that are seen when traveling through water equivalent tissue. This
leads to the possibility of receiving less dose than expected around the field edges and is most
prominent at the surface beyond the cavity.

These factors are important to understand in lung planning as the tumor can often be
centered in the middle of the air cavity. Without heterogeneity corrections, the TPS treats the
entirety of the volume as if it were water equivalent which can have a dramatic effect on
planning outcomes. This project will examine the difference of a plan with the heterogeneity
corrections turned on compared to the same plan with the corrections turned off.
 2

Materials and Methods: A patient was selected with a left sided lung tumor. The body, lungs
spinal cord, tumor and heart were all contoured. A 6MV photon plan with parallel opposed
AP/PA beams was created with a 2cm blocked margin around the PTV with equal weighting.
The prescription was for 6000cGy in 30 fractions. Calculations were performed using the AAA
13714 planning algorithm with the heterogeneity correction on. A second plan was then run with
all parameters the same except with the heterogeneity correction turned off. Both plans were
normalized so that 95% of the PTV received 100% prescription dose. For the Heterogeneity
factor turned on plan (H-On), this was the 94% isodose line. For the heterogeneity factor turned
off plan (H-Off), this was the 97% isodose line.

Results: With H-On, the calculated monitor units resulted in 125 for the PA beam and 122 for
the AP beam. After normalization, the dose maximum measured at 122%.

Figure 1: H-On, Axial

 3

Figure 2: H-On, Coronal and Sagittal

Figure 3: H-On Parameters

Figures 1 and 2 display the dose distributions of H-On. The axial image displays the typical
hourglass isodose shape of a photon beam extending through low density cavities. The bending
in of the curves is due to loss of Compton scatter from the lack of tissue to interact with. Looking
at the axial view, the 90% isodose line is needed to cover the entirety of the PTV on that slice.

With H-Off, the monitor units resulted in 144 for the PA beam and 134 for the AP beam.
The dose maximum measured at 120.7%.
 4

Figure 4: H-Off Axial

Figure 5: H-Off Coronal and Sagittal

 5

Figure 6: H-Off Parameters

Figures 4 and 5 display the dose distributions for H-Off. The isodose curves now display as if
treating entirely through tissue with the 98% isodose line covering the entirety of the PTV in the
axial slice.

Figure 7:Comparision DVH: Square=H-On, Triangle=H-Off

Discussion: Figure 7 displays the discrepancy between the two plans with the only difference
being that the heterogeneity correction factor is turned off. Less monitor units are needed for H-
On due to the low attenuation of the lung tissue. With H-Off treating the entirety of the beam
 6

path as going through water equivalent tissue, more monitor units are needed to push dose
through what the computer views as a higher density pathway than what is in fact present.

Plan PA AP Prescription Isodose

MU MU Line
H-On 125 122 94%
H-Off 144 134 97%
Figure 8: Plan Comparisons

The H-off plan is able to be prescribed to the 97% isodose line as opposed to the 94%
isodose line for H-on due to what it sees as additional scatter contributions in the fields. Figure 4
compared to Figure 1 displays how much more dramatically the lateral coverage of the beam is
when the TPS attributes tissue density to the air cavity. In some situations with a thin tumor
volume, it is possible that there may not be enough dose build up region for electronic
equilibrium to reestablish in the tumor volume which could lead to extremely high entrance
doses in order to reach prescription coverage at the mid tumor calculation point. With this tumor
mass measuring nearly 4cm thick and using 6MV beams, electronic equilibrium is able to
reestablish, though the H-on plan displays poor peripheral dose coverage. H-off on the other
hand displays better peripheral coverage as the TPS does not correctly display the need to
reestablish dmax depth as it believes it is treating entirely through water equivalent tissue as
opposed to an air cavity.

The monitor units displayed would suggest that if this plan were treated with the H-Off
parameters, the actual dose delivered to the patient would be higher than prescribed due to the
higher MU’s from H-off. To further evaluate this, a plan was run using all of the exact H-off
parameters including MU’s and prescribed dose line, but this time with the heterogeneity factor
turned on.
 7

Figure 9: Heterogeneity factor On, using Off MU's

Figure 9 displays a dramatically higher dose delivered in this scenario. In reality, when
correcting for attenuation, the H-off plan is delivering 110% of prescription dose to 95% of the
PTV and the global hot spot is now 139%. This example displaying a 10% variance agrees with a
study by Ding et al,4 that also found a general variance of approximately 10% comparing plans
with a correction factor turned off versus on. The hotspot is located approximately at dmax depth
 8

on the PA beam entrance due to the higher MU count on that field. The higher tissue doses on
opposite sides of the lung would be expected as it is characteristic of dose through lung tissue to
deliver a higher dose percent at the tissue beyond the air cavity, especially at lower energies.1 As
discussed previously, not accounting for the correct density of lung tissue led to a dramatic
overuse of MU’s which is resulting in a much higher dose than what was prescribed.

Further heterogeneity correction concern would be if there were any areas of artifact in
the image planes. Hip replacements, dental work, ports and any other number of objects
containing metal may be near the treatment area. These objects will cause streaking that will
artifact into normal tissue and provide incorrect tissue densities that would be accounted for in
treatment planning. These values can be corrected for by a number of methods including
contouring the area of artifact and assigning correct HU’s. When possible, avoiding treating
through these areas of metal is preferable. Other objects of note that may need contouring and
HU corrections assigned are any wires or BB’s placed on the patient at the time of scan as these
could provide artifact and would not be present for treatment. Any contrast agent taken for
simulation purpose such as small bowel contrast must be accounted for in treatment planning as
they will appear as a much higher density and will be accounted for as such even though they
will not be present for treatment. These also can be contoured and assigned tissue equivalent
HU’s when necessary.

Conclusion: As displayed by the examples discussed, tissue density can have a profound impact
on treatment planning and the dose delivered to a patient. Lung tissue in particular can exhibit
unique dose distribution characteristics that are necessary to understand in the field of dosimetry.
Correctly calculating what dose is being delivered to OAR and PTV is essential for successful
treatment, and heterogeneity corrections being used are necessary for the most accurate
calculations. It is important in the field of dosimetry to understand the impact of heterogeneity
corrections and when they should be employed. Further consideration should be given to objects
in the scan that will provide artifacts or that will not be present for treatment.
 9

References

1. Gibbons JP. Khan’s The Physics of Radiation Therapy 6th. Treatment Planning II: Patient
Data Acquisition. Philadelphia. Lippincott Williams and Wilkins. 2020. 230.
2. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. St. Louis,
MO: Elsevier;2016.
3. DesRosiers PM, Moskvin VP, DesRosiers CM, Timmerman RD, Randall ME, Papiez LS.
Lung Cancer Radiation Therapy: Monte Carlo Investigation of “Under Dose” by High
Energy Photons. Technology in Cancer Research & Treatment. June 2004:289-294.
doi:10.1177/153303460400300306
4. Ding, G.X., Duggan, D.M., Lu, B., Hallahan, D.E., Cmelak, A., Malcolm, A., Newton, J.,
Deeley, M. and Coffey, C.W. Impact of inhomogeneity corrections on dose coverage in the
treatment of lung cancer using stereotactic body radiation therapy. Med. Phys., July 2007:34,
2985-2994. https://doi.org/10.1118/1.2745923