1

Katelyn Fernando

DOS 523 Treatment Planning

March 24, 2022

Title Radiotherapy Treatment Planning Comparison with and without Heterogeneity

Corrections in Lung Tissue

Introduction

The human body is comprised of many different densities of tissue and may

contain high density materials such as medical hardware and dental fillings. Standard

isodose charts and depth dose tables used in radiotherapy treatment planning assume

homogeneous tissue which is not reflective of the heterogeneous composition of a

patient.1 Before computed tomography (CT) was available, patient composition was

assumed to be water equivalent.2 Now that we have three-dimensional patient

information that gives us tissue densities, we can consider the varying composition of

the human body.

Tissue inhomogeneities change the dose distribution of the beam by either

changing primary beam absorption or by changing the secondary electron fluence. 1

Points beyond the inhomogeneity are mostly affected by absorption of the primary

beam, while those within the inhomogeneity and at its boundaries are mostly affected by

the change in secondary electron fluence. High density tissue, such as bone, attenuate

more of the photon beam, causing a decrease in dose in the tissue beyond the bone.

Low density tissue, such as the lungs, cause an increase in dose in the tissue beyond

the lung.1
 2

Heterogeneity corrections in the treatment planning system can be used to

account for these density changes in patient composition. When the heterogeneity

corrections are turned off, the tissue in the body contour is assumed to be water

equivalent. This treatment planning project investigates the impact of heterogeneity

corrections in the inhomogeneous area of the lung.

Methods and Materials

An anonymized CT data set of a patient with a tumor located in the right upper

lobe and no mediastinal involvement was chosen for this comparison. The patient, right

lung, left lung, spinal cord, and heart were contoured. The GTV was also contoured,

and an expansion of 1 cm was used per physician preference for the PTV. Eclipse by

Varian was used with the AcurosXB version 16.1.0 algorithm to calculate dose to the

PTV. A standard lung dose of 60Gy in 30 fractions was used. Two plans were created

with parallel opposed AP and PA beams using 6MV photons. A margin of 0.5 cm was

used to shape the MLCs around the PTV. The plan normalization value was 100% and

the beam weighting was 50/50. Plan1 was calculated with heterogeneity corrections

turned on while Plan2 was calculated with heterogeneity corrections turned off.

Results

In Plan1: Heterogeneity On, the isodose lines break up in the lung, depositing

dose in the tissue surrounding the lung and the hot spot is 124.1% (Figure 1). The

monitor units from the AP field are 126 MU and from the PA field are 146 MU (Figure 2).

The mean dose to the right lung was 727 cGy, left lung 8.20 cGy, and heart 13.1 cGy

while the maximum dose to the cord was 76.9 cGy (Figure 3).
 3

In Plan 2: Heterogeneity Off, the isodose lines demonstrate an hourglass shape

and the hot spot is 174.0% (Figure 4). The monitor units from the AP field are 126 MU

and from the PA field are 212 MU (Figure 5). The mean dose to the right lung was 748

cGy, left lung 13.1 cGy, and heart 22.3 cGy while the maximum dose to the cord was

125.2 cGy (Figure 6).

Discussion

The isodose lines of Plan1 break up in the lung and deposit dose outside of the

lung while the isodose lines of Plan2 form an hourglass shape. This difference is due to

the increased dose to tissue beyond a low-density structure such as the lung. It is also

difficult to get dose to build up inside the lung so low energies are typically used. When

heterogeneity is turned off, the tissue inside the body contour is considered water

equivalent, causing the isodose lines to behave as if they were passing through a water

phantom. This causes more MUs to push from the PA beam because the beam now

has to travel through a denser treatment table and lung. This also causes the hotspot to

significantly increase in Plan2 as the system struggles to get dose to the PTV. The

contoured organs at risk also show an increase dose with Plan2 verses Plan1. This

shows that if heterogeneity corrections were turned off for a lung plan, the patient would

receive more dose than what was necessary. 3 According to Mah et al4 this may lead to

an underestimation of radiation side effects such as radiation pneumonitis by an

average of 7% and a maximum of 19%.

The lung is a great example of the impact of heterogeneity corrections due to its

low density, but there are other areas of the body that will also be affected. Cavities

throughout the body, like in the sinuses, will behave similarly to lungs due to their low
 4

density. The interface of the breast and lung must be considered due to the dose

buildup outside of the lung causing increased breast dose. 2 High density material, such

as metal implants, will cause more dose attenuation and should be accounted for to

ensure an accurate dose distribution. Metallic hip prosthesis and dental fillings may also

cause artifacts in the treatment planning CT. These artifacts can cause streaking across

the scan which appear to be high density material that isn’t there. 2 Streaking can be

reduced by scanning the patient with Metal Artifact Reduction (MAR). If the streaking is

not corrected, the treatment planning system will push extra dose through the streaks to

compensate for what appears to be high density tissue. This will give an inaccurate

dose distribution. This may also occur if the patient was scanned with contrast. The

contrast will not be there for the patient’s treatment, so the HU for the contrast must be

corrected. If this is not corrected to soft tissue HU, the treatment planning system will

push extra dose to compensate for the apparent high-density material. Since the

presence of artifacts is rare in the lung, there shouldn’t usually be a reason to correct

the density of any area of the lung when planning. The density of the lung and other

areas of the body should reflect their true density for accurate dose calculations.

Conclusion

This project shows that heterogeneity corrections are important to ensure

accurate dose distribution in lung patients. Without the corrections, PTV coverage may

be inaccurate, and OAR may be overdosed. The American Association of Physicists in

Medicine Task Group 65 report 85 recommends that heterogeneity corrections are

applied to treatment plans to ensure accurate dose distributions, target coverage, and
 5

OAR sparing.2 As treatment techniques become more conformal, accurate

representation of the radiation beam in the inhomogeneous body will be essential.

 6

Figure 1. Isodose Lines of Plan1: Heterogeneity On

Isodose lines shown in the axial, sagittal, and coronal views. The 100% isodose line is
shown in yellow while the 95% is green. The hotspot is 124.1%
 7

Figure 2. Field Parameters and Monitor Unit Printout of Plan1: Heterogeneity On

The AP and PA fields are weighted 50/50 and use 6MV photons. The Monitor units for
the AP field are 126 MU while the PA field are 146 MU.

Figure 3. DVH of Plan1: Heterogeneity On

A cumulative Dose Volume Histogram showing the PTV, GTV, right lung, left lung,
heart, spinal cord, and external (patient) dose.
 8

Figure 4. Isodose Lines of Plan2: Heterogeneity Off

Isodose lines shown in the axial, sagittal, and coronal views. The 100% isodose line is
shown in yellow while the 95% is green. The hotspot is 174.0%
 9

Figure 5. Field Parameters and Monitor Unit Printout of Plan2: Heterogeneity Off

The AP and PA fields are weighted 50/50 and use 6MV photons. The Monitor units for
the AP field are 126 MU while the PA field are 212 MU.

Figure 6. DVH of Plan2: Heterogeneity Off

A cumulative Dose Volume Histogram showing the PTV, GTV, right lung, left lung,
heart, spinal cord, and external (patient) dose.
 10

References

1. Khan FM, Gibbons JP. Khan’s The Physics of Radiation Therapy.

6th Philadelphia,PA: Lippincott Williams & Wilkins; 2020.

2. Tissue inhomogeneity corrections for MV photon beams Report of Task Group No. 65

of the Radiation Therapy Committee of the American Association of Physicists in

Medicine. Madison: Medical Physics Publishing; 2004. American Association of

Physicists in Medicine Report 85. 

3. Chang DT, Olivier KR, Morris CG, et al. The impact of heterogeneity correction on

dosimetric parameters that predict for radiation pneumonitis. Int J Radiat Oncol Biol

Phys. 2006;65(1):125 131. doi:10.1016/j.ijrobp.2005.09.047

4. Mah K, Van Dyk J. On the impact of tissue inhomogeneity corrections in Clinical

Thoracic Radiation therapy. International Journal of Radiation Oncology

*Biology*Physics. 1991;21(5):1257-1267. doi:10.1016/0360-3016(91)90284-b