Jamie Robinson

University of Wisconsin – La Crosse

Dos 523 – Treatment Planning and Calculations

April 23, 2023

Heterogeneity vs. Homogeneity Corrections in an AP/PA Lung Treatment Plan

Introduction

Radiation Therapy has been used for decades to treat lung cancer and has proven to be an
effective course of treatment. Thanks to clinical trials, dose regimens have been established to
enable this success. Despite success with these trials, RTOG has not used corrections for lung
density when determining treatment doses as treatment planning computers did not always have
this capability.1,2 As technology has evolved there has been debates over whether to use
heterogeneity corrections when completing treatment planning based off a computed tomography
(CT) scan.1 By using heterogeneity corrections, it would cause for multiple changes to be made
including prescribed doses.1 Some organizations have debated that tissue inhomogeneity
corrections should not be used at all.3

Although those organizations may or may not have a valid argument, the fact is when
radiation is delivered, the beam travels through many diverse types of matter including muscle,
air, fat, and bone.4 Each structure of matter in the body has a different electron density “which
affects the proportion of beam attenuation by Compton versus photoelectric interactions.”4 When
comparing the different types of tissues, the lung has a low density (0.25-0.33 g/cm3) compared
to soft tissue or bone and will therefore attenuate less of the radiation beam.5 Bone, on the other
hand, has a much higher density (1.8 g/cm3 for compact bone) and will absorb more of the
radiation.5

Materials and Methods

To aid in demonstration the differences within a treatment plan with heterogeneity

corrections off versus heterogeneity corrections on, a supine test patient was planned to treat a
left lung tumor with 6 MV energy using a Varian Eclipse planning system. An AP/PA field
arrangement was placed with equal weighting set. The tumor was contoured by the physician and
a 2 cm margin was created around the tumor volume. The test patient was prescribed 6000 cGy
in 30 fractions totaling 200 cGy per day to the 100% isodose line to cover 95% of the planned
tumor volume (PTV).

Contours were drawn around the body, spinal cord, heart, right and left lung (figure 1).
Due to the tumor's location, a calculation point was set off axis within it to achieve a better dose
distribution and a block was placed around the PTV. The field size was set asymmetric with the
x jaw set to 14.6 cm and the y jaw set to 15 cm to allow for adequate coverage of the tumor. The
Photon Optimizer (Version 15.6.06) was used for the optimization algorithm with a 0.25 dose
grid size to account for divergence, algorithm AAA_15606 and heterogeneity corrections off. A
second plan with heterogeneity correction on was completed with the same parameters for
comparison.

Results

The first treatment plan evaluated had heterogeneity correction off. In figure 2, the plan is
shown in a beam’s eye view (BEV) in an axial, coronal and sagittal view. Isodose curves were
generated, each represented by an assortment of colors to distinguish dose levels within the
anatomy. The100% Isodose line is bowing in and does not cover the planned tumor volume
(PTV). The axial slice shows the isodose curves traversing through the whole body regardless of
the tissue it is traveling through. Typically, in lung tissue, there is a loss of electronic equilibrium
that can occur which can result in a reduction of dose.4 These effects on dose distribution depend
on the density of the tissue (g/cm3), size of the volume, and the energy of the beam.4,5

The coronal view shows the dose distribution favoring the left side of the body. The
isodose curves are in a tangential formation and are angling away from the heart and toward the
chest wall. A majority of the dose is in the inferior portion of the field where the tumor is most
predominant and away from the central axis. The sagittal view shows the beam as an hourglass
shape. The PTV is fully covered with the 95% isodose line. In theory, this shows that if 100 cGy
is delivered at a depth of dmax, 95 cGy is delivered to the PTV with this field arrangement. The
margins are tight and do not allow for any error in setup or movement when considering the 95%
isodose line.
 The monitor units (MU) for both the AP and PA fields were calculated with
heterogeneity corrections off. Figure 3 shows the MU calculation form. The plan normalization
is 100% with the primary reference point at 100%. The AP MU calculated is 144 MU with a
reference dose of 186.3 cGy and a calc point reference dose of 103.1 cGy. The PA MU
calculated is 128 MU with a reference dose of 153.8 cGy and a calc point reference dose of 103
cGy.

A dose volume histogram (DVH) of the treatment plan with heterogeneity corrections off
was created to show “quantitative information with regard to how much dose is absorbed” within
each defined structure.6 In figure 4, the final DVH for no heterogeneity correction is shown with
each structure of interest, the coverage, specific volume of the structure, as well as the min, max,
and mean dose. The max dose for the PTV 6000 is 105.8% with 100% dose coverage. The heart
shows a mean dose of 37.6%. The Mean dose to the left lung was 74.5%, the right lung is 1.4%
and the spinal cord is 4.7%. With no heterogeneity correction on, the actual dose to the tissues
noted in the DVH may be lower compared to a plan with heterogeneity corrections on “due to
another build up region in tissue after the beam goes through the air.4

The second plan was recalculated with heterogeneity corrections on. In figure 5, the plan
can be viewed in the BEV in the axial, sagittal and coronal view. All parameters stayed the same
regarding the dose, fractionation, isocenter, field size, beam weighting, and calculation point.
This plan looks drastically different compared to the first. On the axial and sagittal view, the
100% isodose line is hugging the tumor and surrounding the soft tissue and ribs. The isodose line
does not show passing through the lung indicating the dose is only being deposited to what the
computer sees as actual tissues. The inhomogeneities that are found within the body are affecting
dose distribution, penetration of the beam and scatter charactoristics.5

The 6 MV energy is typically preferred when treating the lung as it gives appreciable
coverage to the PTV.2 However, in this case, the dose does not cross midline and appears to be
missing within the lung. Also, the dose shown around the tumor does not include the PTV
specified by the physician. It is not until the 70% isodose line, that there is full coverage over the
PTV. With these corrections applied, the tumor volume dose is increased due to secondary
electrons, but full coverage is compromised.2 If a higher energy were used to try to get better
coverage, it would cause a higher amount of secondary electrons traveling in the field and would
further compromise dose around the boundary of the tumor.2 Treatment plans with heterogeneity
corrections on do not always show accurately depict this.2

The monitor units (MU) for both the AP and PA fields are lower than the first treatment
plan with corrections off and can be seen in figure 6. The computer algorithm is perceiving there
is not as much matter to travel through, therefore it does not need as many monitor units. The
plan normalization changed from 100% to 99.6%, however, the calculation point remained
100%. The AP MU calculated is 113 MU with a reference dose of 147.1 cGy and a calc point
reference dose of 103.6 cGy. The PA MU calculated is 114 MU with a reference dose of 137
cGy and a calc point reference dose of 102.6 cGy.

The DVH for the plan with heterogeneity corrections on can be seen in figure 7. In this
DVH, the max dose to the PTV 6000 is 102.4%. The heart shows a mean dose of 31.5%. The
mean dose to the left lung was 68.6%, the right lung was 1% and the spinal cord was 3.4%. In
heterogeneous treatment plans, the organs at risk are lower compared to a treatment plan that is
homogeneous,7 although they are comparable in both DVH charts. All volumes are at
unacceptable limits.

Discussion

The dose uniformity was better with the heterogeneity corrections off; however, it was
not a true representation of the dose distributed throughout the treatment field. Within the air
cavity there is a small loss of electronic equilibrium at the cavity surface, just beyond the cavity
surface or in low-density tissues resulting in a change in the electron fluence and creating poor
uniformity index.4,5,7 Lower density tissues such as the lung, allow for more beam to pass
through as it is unable to attenuate as much dose as the higher density structures. This can lead to
underdosing especially when using higher energy radiation.4 This also applies for other air or
sinus cavities within the body.

The effects of inhomogeneities continue to be described by how a particular structure

absorbs the radiation beam and the amount of scatter being created.4,5 When taking soft tissue
into account, for example with a breast/lung interface, CT scans show that there is increased dose
enhancement in soft tissues, especially in those that lie close to bone.4 This is impart to an
increase in electron scattering particularly at the entrance of the photon beam.4 The transmission
side of a soft tissue shows a “rise in dose perturbation effect due to forward scatter of electrons
from bone and buildup of electrons in soft tissue.”4

The boundaries around a structure, or what may be considered the “transitional zone,”
also present problems especially near air cavities, bone, and metal prostheses.8 When bone is in
the path of the beam, the dose going through the bone is decreased by approximately 2% due to
its high density.4 It is an even higher decrease in dose when high density metal is within the field.
High density metal and contrast will present with “streaking” on a CT scan. Although there are
modifications and filters that can be applied on the CT scan, the metal and contrast streaking
tricks the computer planning system into thinking there is a tissue or an accountable density. It is
not a true representation of the planning field of interest.

There are several methods that can be used to correct for inhomogeneities in dose
calculations.4,8 These methods include, but are not limited to, the Tissue Air Ratio (TAR)
Method, Power Law Method, and the Equivalent TAR Method.4,8 The TAR Method does not
consider the location of inhomogeneities.4,8 It utilizes the principle of TAR and does not depend
on SSD.4 In the Power Law Method, is a method that assumes only Compton interactions and
uses a ratio of TAR raised to a power.4 It assesses the relative location of inhomogeneities when
completing calculations, however, it does not consider the dose build up region.4,8 The
Equivalent TAR Method, is different from the others as it considers the impact that scatter has on
heterogeneity.8 It considers the set field size and depth.8 With these methods taken into
consideration, multiple algorithms have been developed to aid in treatment planning.

Conclusion

In conclusion, “lung inhomogeneities can lead to significant variations in delivered

dose.”1 In the two treatment plans that were created for this report, more radiation was absorbed
in tissues with higher electron density and a decrease in dose occurred at surfaces beyond air
cavities.4 Research has been proven that the “existing density-correction algorithms are accurate
enough to significantly reduce variations”1 and the current dose prescription are sufficient for
optimal results.4

Sources:
1. Ortin C, Chungbin S, Klein E, et al. Study of lung density corrections in a clinical trial
(RTOG 88-08). Elsevier. PubMed. Int. J. Radiation Oncology, Biology, Physics.
1998;41(4):787-94. http://dx.doi.org/10.1016/S0360-3016(98)00117-5
2. Khan F, Gibbons J, Sperduto P. Khan’s Treatment Planning in Radiation Oncology,
fourth edition. Philadelphia, PA: Wolters Kluwer; 2016.
3. Papanikolaou N, Klein E, Hendee W. Heterogeneity corrections should be used in
treatment planning of lung cancer. Med. Phys. Am. Assoc. Phys. Med. 2000;27(8):1702-
1704.
4. Gibbons JP. Khan's The Physics of Radiation Therapy, 6th Edition. Philadelphia, PA:
Lippincott, Williams, and Wilkins; 2020.
5. Bentel G. Radiation Therapy Planning, 2nd Edition. New York: McGraw-Hill Companies,
Inc; 1996.
6. Lenard N, Vann A, Tobler M, Apinorasethkul O. Tools in Conformal Planning.
[SoftChalk]. La Crosse, WI: University of Wisconsin-La Crosse. Planning Tools
(softchalkcloud.com) Last updated November 7, 2022. Accessed April 21, 2023
7. Zhigong W, Xingchen P, Yan W, et al. Influence of target dose heterogeneity on dose
sparing of normal tissue in peripheral lung tumor stereotactic body radiation therapy.
Radiation Oncology. 2021;16:167. https://doi.org/10.1186/s13014-021-01891-6
8. Washington C, Leaver D, Trad M. The Principles and Practice of Radiation Therapy. St.
Louis, Missouri: Elsevier; 2021.

Figures
Figure 1. Contours
Figure 2. Heterogeneity Corrections Off
Figure 3. MU Printout for AP/PA Lung with No Heterogeneity Correction

Figure 4. DVH with Heterogeneity Corrections Off

Figure 5. Heterogeneity Corrections On
Figure 6. MU Printout for AP/PA Lung with Heterogeneity Corrections On
Figure 7. DVH with Heterogeneity Corrections On