Paige Solie 1

DOS 523-501
Heterogeneity Corrections in Treatment Planning

Introduction

Medical dosimetry relies on both accuracy and precision to develop the most optimal
treatment plan for each individual patient. One prominent objective in treatment planning is to
ensure that the plan realistically models how the radiation will be delivered to and interact with
the patient’s body. A treatment planning system (TPS) can only create accurate and meaningful
plans if given sufficient information on plan parameters such as beam modification devices,
beam weighting, field size, dose fractionation, patient positioning, and tissue heterogeneity
corrections.1 If conditions are not being represented accurately then neither are the dosage to the
PTV or organs at risk (OAR).One example of a plan parameter that has significant effects on a
treatment plan is tissue heterogeneity and appropriately correcting for such. Not putting
heterogeneity corrections into a TPS would mean that the system assumes all material is the
same density as water. The human body, however, is not composed of only water. Soft tissue and
water have vastly different densities than bone, air cavities, lung tissue, or artifacts that may be
present in a patient such as dental fillings, IV contrast, or prosthetic joints that may be composed
of high-density materials such as metal.

Treatment planning systems convert density into a unit called Hounsfield Units (HU)
with information obtained from patient CT scans. Before CT scans were being used for patient
planning it was assumed that the density of the whole body was equal to that of water. The HU
value for air is -1,000 HU, water is 0 HU, and most tissues are close to 0 HU as well. Bone is
around 1,000 HU and metal artifacts can reach up to 3,000 HU.1 This scale of -1,000 to +3,000
HU shows how drastically materials in the human body can vary in density and explain why
there is a significant difference in how radiation interacts with different areas of the body based
on this inhomogeneity. Radiation interacts less with lower density materials such as air and will
travel further. More dense materials such as bone will absorb more radiation at the surface. Thus,
isodose lines shift toward the skin for bone and away from the skin for lung or air cavities.1 

A common clinical application of density having significant effects on dose distribution

is in cases where a patient has a prosthetic joint. Dose increases of up to 50% have been
measured in the backscatter direction within the range of electrons set in motion by 18 MV x-
rays in cases with metallic prosthetic implants encountered.2 Metal artifacts will also cause
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Heterogeneity Corrections in Treatment Planning

‘streaking’ on a CT scan due to beam hardening and scatter caused by the high atomic number
material.3 This streaking needs to be overridden to obtain the correct HU for tissue surrounding
the artifact in the TPS to create accurate treatment plan as the streak is not a real structure and is
an effect of the artifact being present. In the case of intravenous contrast agent being used in CT
scans, we know this would not be present during radiation treatment, so it needs to be overridden
and not accounted for in planning. A TPS allows the user to turn heterogeneity corrections on
and off to visualize the effect of density on dose distribution, which we will further explore with
this study by comparing a heterogeneity-corrected and a non-corrected plan.

Image 1: This image shows an example of artifact on a CT scan from a hip prosthesis before
(top) correcting for the heterogeneity difference and after (bottom) correcting for the artifact
streaking by overriding it.2

A TPS allows the user to turn heterogeneity corrections on and off to visualize the effect
of density on dose distribution, which we will further explore with this study by comparing a
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Heterogeneity Corrections in Treatment Planning

heterogeneity-corrected and a non-corrected plan on a lung tumor. Turning off heterogeneity

corrections will make the TPS assign 0 HU to everything in the plan as if it were all water.

Methods and Materials

I used an anonymized patient’s CT data set for this activity. This patient has a tumor
located medially in their left lung. The heart, spinal canal, body, planning target volume (PTV),
and left and right lungs were contoured for this plan. The TPS being used is Eclipse and the
calculation algorithm is Acuros XB. Two identical plans were created with the only difference
being the heterogeneity correction being turned off in the second plan. 6 MV AP and PA fields
weighted to equally distribute dose were used with a 2-cm auto-margin around the PTV.
6000cGy total was delivered over 30 fractions for a dosage of 200cGy per fraction. These plans
were compared based on their monitor units (MU), isodose distribution lines, and dose-volume
histograms (DVH). The isocenter is placed in the center of the PTV with 100% dose prescribed
to the isocenter. This led to similar coverage and max dose while allowing us to compare how
the isodose is distributed through the body according to the parameters we put into the TPS
rather than normalizing the plan to give equal PTV coverage in both. The goal of this study is to
explore how heterogeneity corrections affect treatment planning, not to create an optimal plan.

Results

Image 2: Axial plane view of plan without heterogeneity corrections.

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Heterogeneity Corrections in Treatment Planning

Image 3: Coronal plane view of plan without heterogeneity corrections.

Image 4: Sagittal plane view of plan without heterogeneity corrections on.

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Heterogeneity Corrections in Treatment Planning

Image 5: DVH of plan without heterogeneity corrections.

Image 6: Axial plane view of plan with heterogeneity corrections.

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Heterogeneity Corrections in Treatment Planning

Image 7: Coronal plane view of plan with heterogeneity corrections.

Image 8: Sagittal plane view of plan with heterogeneity corrections.

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Heterogeneity Corrections in Treatment Planning

Image 9: DVH of plan with heterogeneity corrections.

From the above images it can be observed that the isodose lines in the plan without
heterogeneity corrections are much smoother and take on an hourglass shape encompassing a
large area of the field. The isodose distribution with corrections is much different, with the 100%
isodose line encompassing a smaller portion near both the anterior and posterior surfaces and a
small area of the PTV it is prescribed to in the isocenter. The plans have a similar maximum dose
of 114% and 115% respectively.

Images 10-11: Monitor Unit (MU) comparison without heterogeneity correction (left) and with
correction (right)
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MU comparisons show that homogenous plans require more monitor units than
heterogenous plans to deliver the same radiation prescription. The plan without heterogeneity
corrections has 141.8 MU for the AP field and 129.2 for the PA field while these numbers
decrease to 123.9 MU and 109.2 MU for the plan with heterogeneity corrections. We know that
lungs are composed of mainly air so there is very little attenuation of radiation in the lungs. This
means that less MU would be required to get the prescribed coverage of the target than if it were
surrounded by more dense materials such as bone, fat, or muscle. Conceptually, it makes sense
that the plan with heterogeneity corrections turned off would require more MU because the TPS
is creating a plan based on the assumption that the radiation is traveling through water. With
water being 0 HU versus air –1,000 HU, the TPS would require more radiation to get to the same
reference point.

Image 12: DVH Plan Comparison, square=without heterogeneity correction, triangle= with

The Eclipse TPS features the ability to put multiple DVHs into one comparative DVH to
easily compare two plans at once. The heart, body, and right lung receive similar dose in both
plans. The spinal canal, right lung, and PTV all receive less dose in the plan with heterogeneity
correction calculated. This shows that this plan is colder overall, which exemplifies how not
taking heterogeneity into account can lead to unnecessary over dosage of radiation.
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Heterogeneity Corrections in Treatment Planning

Discussion

This study provided an example of how heterogeneity corrections alter clinical treatment
plans being designed using the Eclipse TPS. The first major difference between plans is the
isodose line distribution difference. When we manipulate the system to think that the body is
homogenous, the radiation travels through the body more uniformly delivering 100% dose to
most of the field in an hourglass shape isodose distribution. The plan with correction had higher
dose build ups near the anterior and posterior surfaces of the patient and less dose going to the
center of the body near the PTV.

The plans also differed in the amount of monitor units required, with the homogenous
plan requiring higher MU. We know that lungs are primarily composed of air so there is very
little attenuation of radiation in the lungs. This means that less MU would be required to get the
prescribed coverage of the target than if it were surrounded by more dense materials such as
bone, fat, or muscle. Conceptually, it makes sense that the plan with heterogeneity corrections
turned off would require more MU because the TPS is creating a plan based on the assumption
that the radiation is traveling through water. With water being 0 HU versus air –1,000 HU, the
TPS would require more radiation to get to the same reference point.

Another step in comparing plans is evaluating the DVH. The homogenous plan had
higher coverage than the heterogenous plan, deceptively making it look like a better plan on the
surface. When looking at the PTV coverage, the heterogenous plan only had around 18% of the
PTV receiving 100% dose whereas the homogenous plan had around 59% of the PTV receiving
100% dose which is a significant difference. We can also observe steeper dose fall-off in the
heterogeneous plan as radiation has little to no attenuation in the air filling the lungs. One thing
of note when considering homogeneous plans is that there have been reports that prescribing
doses without heterogeneity corrections in the lung may lead to an underestimation of pulmonary
toxicity risk of as high as 19%.4 Implementing heterogeneity calculations can help to take away
ambiguity in outcome interpretation and risk assessment and reduce dose uncertainty. As these
plans did not have any normalization set for coverage, we could manipulate the plan with
corrections to have 100% dose cover 95% of the PTV to further optimize this plan.
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Conclusion

Research has shown that homogenic calculations do not accurately represent how
radiation interacts with areas of differing density throughout the body and as such have been
widely replaced with heterogenic calculations. This study demonstrates the importance of
heterogeneity corrections and how they drastically change the outcome of treatment planning. A
homogenic plan may look better at first glance but it is not as accurate of a plan and may result in
over-exposure and/or under-treatment. There are many clinical situations in which heterogeneity
needs to be accounted for such as dental fillings, prosthetic joints, and usage of IV contrast.
Medical dosimetrists need to account for these parameters in treatment planning to create a plan
that will most benefit the patient and deliver as much radiation as possible to their tumor while
sparing their normal tissues. Inferior quality plans have drastic effects on patients such as
diminished quality of life and medical side effects if critical structures such as the spinal cord or
heart are over irradiated as well as an increased risk of recurrent disease if tumors are
underdosed. One must always prioritize patient goals in treatment planning and strive to create as
accurate and precise plans as possible. Treatment planning systems can only create accurate
plans if given sufficient information to do so, including using heterogeneous corrections to
account for tissue inhomogeneities within the body.
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References:

1. Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Wolters
Kluwer Health; 2020.
2. Reft C, Alecu R, Das IJ, et al. 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. doi:10.1118/1.1565113
3. Barrett JF, Ricci ZJ, Triche BL, et al. Artifacts in CT: Recognition and Avoidance.
RadioGraphics. https://pubs.rsna.org/doi/10.1148/rg.246045065. Published November
1,2004. Accessed March 23, 2022.
4. 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):125–31. http://dx.doi.org/10.1016/j.ijrobp.2005.09.047