1

Kristen Dezell
DOS 523 - Treatment Planning
March 27, 2022

Introduction
The human body is composed of many types of tissues such as muscle, fat, bone, lung,
and air, each with varying densities and heterogeneities that change radiation dose distributions.1
Prior to the invention of computed tomography (CT) in the 1970s, radiation dose calculations
assumed the entire body was homogenous and equivalent to water, resulting in inaccurate
radiation dose calculations.2 While CT now allows us to determine the electron density
information of heterogeneous tissues in the body, standard depth dose tables and isodose charts
still assume calculations in homogeneous medium, so heterogeneity corrections need to be
incorporated into radiation dose calculations to improve clinical accuracy.3,4 Differences in
electron density from inhomogeneous tissue and the Compton effect can alter the attenuation of
primary photons, distribution of secondary photons, and secondary electron fluence. When
radiation traverses through an inhomogeneous region of tumor and lung, areas past the
inhomogeneity are affected by the primary beam, areas closer to the target are more affected by
photon scatter, and areas within the target and its boundaries are more impacted by the secondary
electron fluence.4
It is important to consider heterogeneity corrections in dose calculations, though it is also
important to realize the limitations of the CT scanner and resulting artifacts from metal
prosthetics, dental fillings, and contrast used in simulation. Photon interactions depend on the
tissue density through which it travels, and each of these materials can impact dose calculations.
Modern treatment planning systems (TPS) allow heterogeneity corrections to be turned on or off,
but the default is always on in order to achieve the most accurate dose calculations. Without a
heterogeneity correction, the chance of a geometric miss increases, especially with highly
conformal treatment plans.3 This project will compare the dosimetric effect of planning a lung
tumor case with and without a heterogeneity correction.
Heterogeneity Correction Project 2

Methods and Materials

The purpose of this project was to analyze the difference in dose distribution of a lung
tumor case by calculating dose with and without a heterogeneity correction. This particular case
included a 5.1 cm tumor within the upper lobe of the left lung. A 4DCT was acquired at
simulation to examine respiratory motion and the associated motion of the target. The physician
used the 4D average to contour the internal target volume (ITV) and planning target volume
(PTV), and the following organs at risk were also contoured for dose reporting and planning
purposes: body, proximal bronchial tree, esophagus, heart, left and right lungs, spinal cord, chest
wall, and skin.
The Eclipse TPS at my clinic uses a calculation model with an analytic anisotropic
algorithm (AAA). Though the AAA calculation is highly complex and more accurate than
historical algorithms, it is important to note that it can still overpredict dose beyond low density
heterogeneities in the lung due to its inability to account for altered attenuation along the primary
photon beam path.5 Nevertheless, both plans utilized an identical patient CT dataset prescribed
to 6000 cGy in 30 fractions using 6MV photons in an anterior and posterior equally weighted
beam arrangement and a plan normalization value of 100%. The multileaf collimators were
fitted with a 0.5 cm margin around the PTV as is the standard at my clinic. The only difference
between the plans was that Plan A was calculated with the default heterogeneity correction
turned on, and Plan B was calculated with the heterogeneity correction turned off.

Results
The first plan was titled Plan A and used the heterogeneity correction turned on. 10.3%
of the PTV was covered by the 100% isodose line (IDL), and this was located near the central
and inferior portion of the target (Figure 1). The 90-95% IDL resembled an expected hourglass
shape from the opposing beam arrangement, and the bowing in shape occurred near the PTV.
Furthermore, the 95% IDL broke up within the PTV, and lower doses of 0-85% appeared as more
of a box shape around the PTV (Figures 3-5). The periphery and superior portion of the target
were cool, and the hot areas were located in the posterior soft tissue with a global dose maximum
of 111.5% or 6691 cGy.
The second plan, titled Plan B, used a calculation with the heterogeneity correction
turned off. 41.8% of the PTV was covered by the 100% IDL (Figure 2), and the 100% IDL was
Heterogeneity Correction Project 3

located near the lateral and superior area of the target, leaving the medial and inferior portion of
the target cool. The 95-100% IDL appeared as an hourglass shape, and the 100% IDL broke up
within the PTV. The lower doses of 0-90% resembled a box shape around the PTV (Figures
6-8). The hot areas were located more in the anterior soft tissue with a global dose maximum of
114.2% or 6854.7 cGy.
Plan A showed less volume overall of 105-110% (Figures 3 and 5), while Plan B resulted
in a higher overall amount of 105-110% (Figures 6 and 8). The DVH comparison showed that
there is less mean and maximum dose to organs at risk like the heart, spinal cord, and healthy
lungs in Plan A (Figure 1) compared to Plan B (Figure 2). Additionally, Plan A required less
monitor units (MU) than Plan B. Plan A used 120 MU from the anterior beam and 125 MU from
the posterior beam, totalling 245 MU. Plan B used 139 MU from the anterior beam and 129 MU
from the posterior beam, with a total of 268 MU (Figures 9 and 10). There is an 8.6% increase
of MU from Plan A to Plan B.

Discussion
As mentioned previously, the many inhomogeneities of the human body affect the
primary photon beam, secondary photon scatter, and secondary electron fluence in radiation
therapy.1,4 The TPS was able to consider each of these inhomogeneities and electron densities of
tissue taken from the CT scan and apply them to the overall dose calculation using a
heterogeneity correction in Plan A. Reviewing the results of this project showed that Plan A
resulted in less PTV coverage and lower dose to healthy tissue, and less monitor units were
needed because heterogeneity was considered. The Compton effect is the primary interaction
with megavoltage photons, and this effect is dependent on the electron densities through which it
traverses.4 Bone has around a 1.5 relative electron density to water, while lung has only 0.2
relative electron density to water.6 This lower lung density therefore does not attenuate the
primary photon beam as much as higher density tissues, causing less secondary scatter of
photons and electrons within the field and less overall dose buildup.4 This loss of electronic
equilibrium near the interface between the target and lung explain why Plan A is cooler than Plan
B (shown in Figures 3 and 4 versus Figures 6 and 7).
The dose calculation in Plan B did not use a heterogeneity correction, resulting in the
TPS assuming the entire body had a density equivalent to water. More monitor units were
Heterogeneity Correction Project 4

required for this plan because more attenuation was assumed, as water is more dense than lung.
Therefore, there is more coverage of the PTV and higher dose to organs at risk nearby. However,
this is not reality because the lung actually attenuates less radiation due to the lower relative
electron density, and photons in fact would attenuate less than is shown in Plan B. With the
heterogeneity correction turned off, the true dose to the patient is unknown, and the increase in
monitor units results in unnecessary dose to the healthy tissues in the patient.
The breast and lung interface is another region where the dose distribution is impacted
from heterogeneities near the target boundary. In tangential breast photon plans, the low lung
density results in an increase in dose to the breast tissue beyond the lung as seen in warm areas at
the entrance and exit regions of each field.3 This loss of electronic equilibrium again occurs at
the lung and tissue interface.4 Similar to the lung, air cavities located in head sinuses can
dramatically impact dose distributions. In my clinical experience, I have evaluated many head
and neck proton verification plans that are scanned weekly during treatment. In patients where
the sinus is within or near the treatment field, sometimes the sinus is air-filled at the beginning of
treatment and later becomes infected and filled with fluid. This change in heterogeneity results
in an underdose to the patient because of the increase in density in the sinus, and these plans may
need to be replanned to account for the fluid.
Additionally, heterogeneity can affect dose accuracy in regions with high density
materials such as metal prosthetics and dental fillings. Some examples of metal used for
prosthetics include titanium and stainless steel, both much higher in density than body tissue.
Dental fillings are also often made of metallic material and affect the dose distribution by
increased attenuation of the primary beam and increased backscatter of electrons.7 These high
density materials can cause streaking artifacts visually seen on the CT scan and ultimately result
in photon starvation in radiation planning.8,9 In regards to dosimetry, the artifacts can impact
visualization for accurate contouring and require Hounsfield Unit (HU) overrides to contour
streaks with a density of normal tissue surrounding the metal. To help negate this, the CT
scanners at my clinic include an iterative metal artifact reduction (IMAR) on all scans with metal
or dental fillings. This allows for more accurate CT electron density numbers for dosimetry. 10
Another higher density material that can impact dose distributions includes contrast from
simulation. While metal prosthetics and dental fillings are permanent in the patient’s body,
contrast is typically only used for the initial planning CT scan for contouring and visualization
Heterogeneity Correction Project 5

purposes and will not be present for treatment. While all contrast agents at my clinic are
assigned an appropriate HU value, one study found that bladder contrast does not significantly
impact dose distributions and is not necessary to override in planning.11 On the other hand,
intravenous contrast used in the thorax has shown to increase dose in the lung.12 Overall, to
achieve the most accurate dose calculation, it is important to assign contrast agents an
appropriate HU value to tissue while planning as the contrast will not be in the patient’s body for
treatment.
Although heterogeneity information from a CT scan is crucial to achieving the most
accurate dose calculation, some rare instances require the heterogeneity correction factor to be
turned off. For dose calculations in the pelvis in a patient with hip prosthetics, lateral fields can
disturb the dose distribution and result in dose inhomogeneities to the target. In an emergent
situation when the metal material is unknown and cannot be determined or assigned an
appropriate HU value, the heterogeneity correction should be turned off and any streaking
artifacts should be contoured and overridden to an appropriate HU value.8,13

Conclusion
This project showed that heterogeneity corrections are beneficial in calculating accurate
dose distributions in treatment planning. When heterogeneity corrections are turned off, the
clinical dose to the patient is unknown and impossible to accurately determine. For radiation
safety and the avoidance of an underdose or overdose to the patient, the American Association of
Physicists in Medicine Task Group 63 recommends an inhomogeneity correction within 2%
accuracy.8 Though this could still under or overestimate the correction, it is better than no
correction at all.5,14 Target coverage and accurate dose calculations to organs at risk cannot be
guaranteed without a heterogeneity correction.
Heterogeneity Correction Project 6

Figure 1: Plan A - DVH with heterogeneity correction

Figure 2: Plan B - DVH without heterogeneity correction

Heterogeneity Correction Project 7

Figure 3: Plan A - axial dose distribution with heterogeneity correction

Figure 4: - Plan A - coronal dose distribution with heterogeneity correction

Heterogeneity Correction Project 8

Figure 5: Plan A - sagittal dose distribution with heterogeneity correction

Heterogeneity Correction Project 9

Figure 6: Plan B - axial dose distribution without heterogeneity correction

Figure 7: Plan B - coronal dose distribution without heterogeneity correction

Heterogeneity Correction Project 10

Figure 8: Plan B - sagittal dose distribution without heterogeneity correction

Figure 9: Plan A - Monitor units with heterogeneity correction

Figure 10: Plan B: Monitor units without heterogeneity correction

Heterogeneity Correction Project 11

References
1. McDermott PN, Orton CG. The Physics and Technology of Radiation Therapy. Madison,
WI: Medical Physics Publishing; 2010.
2. Price R, Xiong W, Li J, Ma C. SU-FF-T-356: From unit density to heterogeneity
corrected treatment planning for lung cancer: a Monte Carlo based dosimetric analysis of
the effects on prescription dose. Med Phys. 2005;32(6):2032-2032.
https://doi.org/10.1118/1.1998085
3. American Association of Physicists in Medicine. AAPM Report No 85. Tissue
inhomogeneity for megavoltage photon beams.
https://www.aapm.org/pubs/reports/RPT_85.pdf. Published August 2004. Accessed
March 10, 2022.
4. Khan FM, Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th Philadelphia, PA:
Lippincott Williams & Wilkins; 2020.
5. Robinson, D. Inhomogeneity correction and the analytic anisotropic algorithm. J Appl
Clin Med Phys. 2008;9(2):112-122. https://doi.org/10.1120/jacmp.v9i2.2786
6. Davis AT, Palmer AL, Nisbet A. Can CT scan protocols used for radiotherapy treatment
planning be adjusted to optimize image quality and patient dose? A systematic review. Br
J Radiol. 2017;90(1076):1-10. https://doi:10.1259/bjr.20160406
7. Chin DWH, Treister N, Friedland B, Friedland B, Cormack RA, Tishler RB,
Makrigiorgos GM, Court LE. Effect of dental restorations and prostheses on radiotherapy
dose distribution: a Monte Carlo study. J Appl Clin Med Phys. 2009;10(1):80-89.
https://doi:10.1120/jacmp.v10i1.2853
8. Alecu R, Reft C, Das IJ, Gerbi, BJ, Keall P, Lief, E Mijnheer, BJ, Papanikolaou N, Sibata
C, Van Dyk J. Dosimetric considerations for patients with hip prostheses undergoing
pelvic irradiation, Report of the AAPM Radiation Therapy Committee Task Group 63.
Med Phys. 2003;30(6):1162–1182. https://doi.org/10.1118/1.1565113
9. Giantsoudi D, De Man B, Verburg J, Trofimov A, Jin Y, Wang G, Gjesteby L, Paganetti
L. Metal artifacts in computed tomography for radiation therapy planning: dosimetric
effects and impact of metal artifact reduction. Phys Med Biol. 2017;62(8):49-80.
https://doi.org/10.1088/1361-6560/aa5293
Heterogeneity Correction Project 12

10. Axente M, Paidi A, Von Eyben R, Zeng C, Bani-Hashemi A, Krauss A, Hristov D.

Clinical evaluation of the iterative metal artifact reduction algorithm for CT simulation in
radiotherapy. Med Phys. 2015;42(3):1170-1183. https://doi:10.1118/1.4906245
11. Heydarheydari S, Farshchian N, Haghparast A. Influence of the contrast agents on
treatment planning dose calculations of prostate and rectal cancers. Rep Pract Oncol
Radiother. 2016;21(5):441-446. https://doi:10.1016/j.rpor.2016.04.004
12. Burridge N, Rowbottom CG, Burt PA. Effect of contrast-enhanced CT scans on
heterogeneity corrected dose computations in the lung. J Appl Clin Med Phys.
2006;7(4):1-11. https://doi.org/10.1120/jacmp.v7i4.2240
13. Ding GX, & Yu CW. A study on beams passing through hip prosthesis for pelvic
radiation treatment. Int J Radiat Oncol Biol Phys. 2001;51(4):1167–1175.
https://doi.org/10.1016/S0360-3016(01)02592-5
14. Ding GX, Duggan DM, Lu B, Hallahan DE, Cmelak A, Malcolm A, Newton J, Deeley
M, Coffey CW. Impact of inhomogeneity corrections on dose coverage in the treatment
of lung cancer using stereotactic body radiation therapy. Med Phys.
2007;34(7):2985-2994. https://doi.org/10.1118/1.2745923