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Treatment Planning Assignment

Martina Stewart
University of Wisconsin-La Crosse
Treatment Planning and Calculations
April 18, 2023
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Process:
When manifesting a plan, it is important to consider and evaluate the different tissue

densities the particles of the beam are going to be traveling through. Inhomogeneities such as

metal prostheses, bone, and lung or any other air cavities are important to consider. Due to the

difference in tissue densities throughout the body, there are tools that can be utilized to correct

this difference. A heterogeneity correction can be applied to a plan to account for the change in

inhomogeneities. In this treatment planning project, two plans were developed to evaluate the

differences with the heterogeneity correction on and without the correction. The two plans that

were created were focused on a tumor that is in the left posterior and superior aspect of the lung.

Both plans had an AP/PA beam arrangement, 6X beam energy, and a 1-centimeter multi-leaf

collimator margin around the planning target volume (PTV).

Research:

When inhomogeneities are present, many events can occur that will affect the dose

distribution of a plan. Different densities that the beam will travel through can cause an increase

in scatter, a range of absorptions of the primary beam, and photon interactions causing electrons

to be set into motion. As the beam travels through a lung for example, there could be a loss of

charged particle equilibrium. Then when the beam is about to exit the air cavity, it must build up

again before it enters the tissue. This effect that the photon beam experiences is known as

interface effects.1 Due to this effect, underdosing can occur at both the distal and proximal

interfaces. The range of underdosing that can occur is based on the energy, cavity size, and the

location. To counteract the dose that is lost from the interaction of the beam with different

densities, increasing the field size as well as introducing lateral interfaces are two possible

solutions that could be utilized.2

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When creating a breast plan, this interface effect can have a negative impact on the dose

distribution. When arranging tangent fields on a breast plan, there is lung tissue that is going to

be irradiated due to the nature of the body and field angles. Due to this, some parts of the breast

will end up receiving a higher dose because of the lower lung density.2 Another issue that could

arise is when treating either the bone or the soft tissue adjacent to the bone. When a beam is

entering into the soft tissue and then becomes in contact with the bone, the tissue receives an

increase of dose mostly from backscatter that is produced from the higher energy beams. The

bone also causes attenuation from the beam which then reduces the dose. The dose reduction

depends on the soft tissue thickness, bone thickness and density, and the beam energy. 3

High Z material that is used for hip prosthesis or dental fillings can alter the dose

distribution in a plan tremendously. Once the beam interacts with high Z material in any area of

the body, there is an abundance of scatter that is produced within the patient. Dental fillings for

example, can cause the mean dose of the plan to be higher. High doses can also appear around

the low dose streak coming from the high Z material. 4 Due to this scatter and unwanted high

dose, the patient could exhibit side effects to surrounding structures such as mucosal reactions in

the oral cavity. To help account for this scatter and dose inaccuracy caused from the dental

fillings, two to four millimeters of tissue equivalent material should be used to regain

homogenous dose distribution.2

There are two methods that are used to correct for inhomogeneities. The first method is a

one-dimensional method that is based on the path length that the beam travels from the source to

the point. During this path, the electron density information is gathered and applied to the ratio of

TAR and the power law method which are two examples of this type of correction. The second

method is a three-dimensional correction that gathers density data from a CT scan. This type of

method determines the change in the primary photon fluence and then calculates the scatter dose.
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The equivalent tissue-air ratio is a method that is an example of this type of correction that can

be applied. It does not matter which correction is used, the equation D’=D x CF can be applied to

find the corrected dose (D’) for either method. The uncorrected dose (D) is multiplied by the

correction factor (CF).1

Findings:

Plan 1 that was created is utilizing the heterogeneity correction, resulting in a mean dose

of 103.3% and a max dose of 108.9% to the PTV. The maximum hot spot for this plan came to

119.2 % and 100% of the dose only covering 93.3543% of the PTV, as displayed in Figure 4.

With the heterogeneity correction, 105 monitor units were delivered from the AP beam and 255

from the PA beam totaling 360 monitor units. The mean dose for the organs at risk for Plan 1 are

as follows: spinal cord- 0.8%, heart-0.4%, left lung-19.1%, and right lung-0.6%. In Plan 1, the

isodose lines are not smooth in shape.

Plan 2 does not use heterogeneity correction which resulted in a mean dose of 105.2%

and a max dose of 108.2% to the PTV. The maximum hot spot for this plan came to be 112%

with the 100% isodose line covering 100% of the PTV. Without the heterogeneity correction, the

AP beam required 136 monitor units and the PA beam needed 249, totaling 385 monitor units.

The mean dose for the organs at risk for Plan 2 are as follows: spinal cord- 1.3%, heart-0.7%, left

lung-19.1%, and right lung-0.7%. In Plan 2, the isodose lines are uniform in shape with the hot

spot being posterior.

Summary:

Both plans presented different dose distributions along the beam’s pathway. Plan 2

created a more uniform dose distribution throughout the patient because the planning system

assumed that all the tissue was of the same density. Another difference between the two plans
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was the number of monitor units that were needed. This difference of 25 monitor units is because

the planning system considers all the tissues to be of the same density and assumes that it is

penetrating through more tissue than it is. In Plan 1, the shape of the isodose lines fluctuate

greatly compared to Plan 2 because they are changing as they interact with different tissue

densities. Plan 2 displays better PTV coverage although this is not an accurate representation

because with the heterogeneity correction, only 93.3543% of the PTV is receiving 100% of the

dose. The comparison of these two plans confirms that we should be using heterogeneity

correction when planning tumors that are within the lung. The clinic that I am located at, utilizes

heterogeneity correction because it is a more accurate representation of the dose distribution

within the patient.

Plan 1 images with heterogeneity correction on:

Figure 1: Axial plane in Plan 1.
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Figure 2: Coronal plane in Plan 1.

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Figure 3: Sagittal plane in Plan 1.

Figure 4

Figure 5: DVH for Plan 1.

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Figure 6: MU Printout for Plan 1.

Plan 2 images with heterogeneity correction off:

Figure 7: Axial plane in Plan 2.
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Figure 8: Coronal plane in Plan 2.

Figure 9: Sagittal plane in Plan 2.

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Figure 10: MU printout for Plan 2.

Figure 11: DVH for Plan 2.

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References

1. McDermott P, Orton C. Dose distributions in two and three dimensions. The Physics &

Technology of Radiation Therapy. Madison, WI: Medical Physics Publishing;

2010:14.50-14.58

2. Papanikolaou N, Battista JJ, Boyer AL, Kappas C, et al. Tissue inhomogeneity

corrections for megavoltage photon beams. AAPM.

https://www.aapm.org/pubs/reports/RPT_85.pdf. Published August 2004. Accessed April

12, 2023.

3. Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th Philadelphia: Wolters Kluwer

Health; 2020.

4. Khaleghi G, Mahdavi H, Mahdavi SR, et al. Investigating dose homogeneity in

radiotherapy of oral cancers in the presence of a dental implant system: an in vitro

phantom study. Int J Implant Dent. 2021;7(1):90. Published 2021 Sep 6.

doi:10.1186/s40729-021-00372-5