1

Treatment Planning Project

Milica Ilic

University of Wisconsin- La Crosse

DOS 523 Treatment Planning and Calculations

04/17/23
 2

Process:

The human body is composed of various tissues and densities all throughout. These
different densities are what affect beam attenuation in photon beams. When there are multiple
different densities throughout the body, it is said to be inhomogeneous. It is important to
accurately represent tissue densities in computed tomography (CT) scans so that the dose
distribution presented when the beams are calculated is accurate. This treatment planning project
consisted of creating two different plans for a tumor located within the right lung. One plan
incorporated a homogeneity correction and one with a heterogeneity correction. The purpose is
to evaluate differences in the plan and observe key differences between both of the tissue
corrections. The contours included on both plans were the patient, left lung, right lung, tumor
volume, heart, and spinal cord. A standard AP/PA beam set up was created with a uniform 2 cm
margin around the PTV. The lowest beam energy of 6 MV was used for both plans. Plan 1 will
incorporate heterogenous calculations and Plan 2 will be homogenous based calculations.

Research:

Standard isodose charts and depth dose tables are recorded with a relatively homogenous
density throughout the medium.1 This is due to the fact that most linear accelerator machines are
calibrated with a water phantom. As mentioned previously, the human body is not a single
homogenous structure. The photon beams travel through various tissues which will all have their
own effect on how the beam is altered and attenuated. To create the best possible plan for
patients, tissue inhomogeneities must be accounted for and analyzed. These inhomogeneities are
what cause shifts in the dose distribution of a plan.1 These effects can be classified in two
categories. The first category being that the inhomogeneities can alter the absorption of the beam
and direction of scattered photons. The second category is that tissue inhomogeneities can also
affect the secondary electron fluence.1 Dose calculations are computed within the treatment
planning system (TPS) and a tissue correction factor is applied to the plan to account for the
different tissue densities that are present throughout all the CT slices.2 A TPS also will have the
capability of turning off inhomogeneous tissue corrections and calculate dose distribution as if
the beams were traversing through a homogeneous structure.

When it comes to treatment planning in the thoracic cavity, the density of the lung has a
great impact on the overall dose distribution. A lower tissue density, as seen in the lungs, will
 3

give rise to a higher dose within the lung and beyond it. When the beams travel through the thick
lung and finally reach the first few layers of soft tissue, there is a loss of secondary electrons
which leads to a decrease in dose.1 When creating a treatment plan for the lung, it is often desired
to use a lower beam energy because of the loss of lateral electronic equilibrium that occurs when
using higher energies. The use of higher energy beams can cause the possibility of underdosing
in the periphery of the tumor and causing the dose profile to not be as sharp.1 When it comes to
applying a tissue correction to the lungs for treatment planning, there has been a great deal of
literature that both support and reject doing so. The main argument against the use of a tissue
correction being that most clinical practice and prescriptions are based on tissue response to dose
in water.3 However, it was also found in studies that not using an inhomogeneity correction led to
a 5% underestimation of radiation damage to lung tissue. 3 There are other major body sites that
need to take into account different tissue densities. These include other air cavities in the body
that can alter dose distribution and how a plan is created. For example, the sinus cavities and
other air pockets that can be located throughout the bowel. There is increased range in laterally
scattered electrons in these air cavities because the electrons travel outside of the geometric limit
of the beam.1

When it comes to breast treatment planning, it may be difficult not to include some lung
tissue in beam blocks. This can be seen often on tangent breast plans. Because of this, certain
areas of the chest wall may receive higher dose due to the low density of the lung tissue. This is
because there is not much attenuation of the photon beam happening so when it reaches the soft
tissue, that is where most of the energy is deposited.3 This is also why it can be difficult at times
to cover the breast volume centrally. Located posteriorly to the breast tissue is the lung, which is
affected by how the beam traverses through the breast tissue and where dose buildup occurs.

Medically implanted devices of a high atomic number can play a role in treatment
planning and how dose distribution is impacted. This often includes different joint replacements
often seen in the hip or knee. Because of their high atomic number, they attenuate the photons
more than normal human tissues and cause perturbations known as interface effects. If beams are
set up to travel through such a device, the TPS will overcompensate in the amount of monitor
units needed to deliver the dose. This will also create a large amount of back scatter and
overdose surrounding tissue and organs at risk (OAR). 4 These implanted devices as well as
 4

dental fillings also cause streaking and artifacts in the CT simulation scan that is used for
treatment planning. Streaking artifacts will alter the CT density in the anatomic region where it is
located. These dark streaks often assign lower density values when in reality the density of the
affected region is higher. To correct for these artifacts, the areas where streaking occurs are
contoured and overridden to correct for the inaccurate density. If the artifact is not accounted for,
it can cause the TPS to not deliver enough radiation needed because it is not accounting for
tissue that is there. The same concept is used for when contrast is used. With contrast, it gives
structures a higher density than there will be on day of treatment. This is also accounted for by
overriding density values.

Findings:

After all the desired plan comparison parameters were input, dose was computed for both
plans. Plan 1 incorporated heterogeneity corrections and Plan 2 did not. One of the first things to
compare between the two plans is the dose distribution. Figure 1 shows the dose distribution
throughout the isocenter of Plan 1. Even though the beams are equally weighted, the dose
distribution is not even. There is still the presence of the hourglass shape that is often seen when
using parallel opposed fields. However, it is clear to see that the patient’s posterior tissue is
receiving a much higher dose. This could be due to the fact that the patient seems to be thinner
anteriorly and thicker posteriorly. As the AP beam traverses through the patient, there is not
enough thickness in tissue to cause an immediate dose buildup. Thus, when the AP beam reaches
the posterior portions of the patient that is where the buildup happens, hot spots are created. It
can also be seen that the PA beam is traversing through bone, which is very dense and leads to
more radiation being applied to achieve the prescribed dose.

Figure 2 shows the dose distribution for Plan 2 with homogeneous dose calculations. The
dose distribution for Plan 2 appears to be much more homogenous than Plan 1. This is due to the
fact the TPS considering the different densities the beams are traveling through. The beams are
calculated as if they are traveling through a homogenous material, much like the water phantoms
that machines were calibrated to. There is a slight dipping of the 105% line on the lateral portion
of the patient because there is sloping of the patient tissue where the beam enters. The 95%
isodose also fully encompasses the tumor volume where in Plan 1 the 80% isodose line
encompasses the tumor volume. This could also be because there is not a lot of dense tissue the
 5

photons travel through, causing the exit dose to be higher anteriorly and posteriorly in Plan 1.
The lateral aspect of each beam enters the patient later than the medial aspect; thus, it is not
attenuated and reaches a greater depth in the patient in Plan 2.

Further evaluation will consider the different amount of monitor units (MU) for each
beam and plan required to deliver the prescribed dose. The MU for each beam of Plan 1 can be
seen in Figure 3 and Figure 4. The PA beam for the heterogeneous calculations in Plan 1
required 185.5 MU and the AP beam required 149.9 MU. This ties back to what was previously
mentioned that the PA beam needed to traverse through denser bone than the AP beam resulting
in more of a hotspot posteriorly. Figure 5 and Figure 6 show the MU calculation page for Plan 2
using homogenous tissue corrections. For Plan 2 the AP beam required 200 MU and the PA
beam required 205.8 MU to deliver the prescribed dose. The MU for these two beams is very
close because the TPS is viewing them as traveling through the same density tissue. This is also
because the tumor volume was relatively centrally located in the lung. The PA calculated MU is
slightly higher because it has a higher calculated depth. Therefore, the TPS is viewing the PA
beam as traveling through more tissue. The MU for Plan 1 is lower because of the tissue density
correction that is applied. It is accounting for less dense tissue due to the lung volume, resulting
in less MU needed. With Plan 2, the TPS is expecting for there to be more dense tissue to
traverse through, resulting in more MU needed to reach the point the plan is prescribed to.

Figure 7 and Figure 8 both reference the dose volume histogram (DVH) for Plan 1 and
Plan 2 respectively. In Plan 1 with a heterogeneous dose calculation correction 21.34% of the
PTV received the full prescribed dose. In Plan 2, 30.69% of the PTV received the full prescribed
dose which was 3,000 cGy. Upon further evaluation of each DVH, it is clear to see that Plan 2
with the homogenous dose correction the PTV received a more uniform dose. Overall, the mean
doses for critical each structure was lower for Plan 1 taking the different densities into account.

Summary:

There are many different aspects to consider in radiation therapy treatment planning. The
end goal of radiation therapy is to provide an effective dose for cancer cells while protecting
healthy tissue. It is clear that different tissue densities play a large role in decisions made during
this process. Whether tissue corrections are applied or not will vary from a case-to-case basis as
every patient and tumor are not the same. Without applying tissue correction, the TPS cannot
 6

accurately account for variances in tissue density and may overestimate or underestimate the
correct amount of absorbed dose by each structure.
 7

References:

1. Gibbons JP. Khan’s The Physics of Radiation Therapy.6th Philadelphia, PA: Wolters Kluwer
Health; 2020.
2. Tai DT, Dung TT, Binh DT, Anh MQ, Hai NV, Tuan HD. Evaluating the impact of tissue
heterogeneity corrections in a commercial treatment planning system (TPS), Prowess
Panther. International Journal of Radiology. 2017;4(1):124-127. Accessed April 19, 2023.
http://www.ghrnet.org/index.php/IJR/article/view/1862/2353
3. Papanikolaou N, Battista J, Boyer A, et al. Tissue inhomogeneity corrections for
megavoltage photon beams. Report of Task Group No. 65 of the Radiation Therapy
Committee of the American Association of Physicists in Medicine Members.; 2004.
https://www.aapm.org/pubs/reports/rpt_85.pdf
4. 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. Medical Physics. 2003;30(6):1162-1182. doi:https://doi.org/10.1118/1.1565113
 8

Figures:

Figure 1. Plan 1 Dose Distribution with Heterogeneity Tissue Correction.

 9

Figure 2. Plan 2 Dose Distribution with Homogeneity Tissue Correction.

 10

Figure 3. Plan 1 Heterogeneity Correction Monitor Unit Page for AP Beam.

 11

Figure 4. Plan 1 Heterogeneity Correction Monitor Unit Page for PA Beam.

 12

Figure 5. Plan 2 Homogeneity Correction Monitor Unit Page for AP Beam.

 13

Figure 6. Plan 2 Homogeneity Correction Monitor Unit Page for PA Beam.

 14

Figure 7. Plan 1 Dose Volume Histogram for Heterogeneity Correction.

 15

Figure 8. Plan 2 Dose Volume Histogram for Homogeneity Correction.