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Treatment Planning Project

LUNG PLAN

This plan was done with a 1cm margin around the PTV according to doctor preference. The AP
MU is 119 and the PA MU is 123.
DVH
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Heterogeneity can have a significant impact on radiation treatment planning. It can affect

the dose distribution within the patient's body and may cause under- or over-dosing of certain

areas. For example, if there is a large air cavity within the treatment field, the radiation dose may

be reduced in that area, which could lead to under-dosing of the tumor. Similarly, if there is a

region of high tissue density, such as bone or metal implants, the radiation dose may be increased

in that area, which could lead to overdosing of the surrounding healthy tissue.

Per Khan, Compton effect in photon beams is the main type of interaction, and so the

attenuation of a beam is affected by electron density.1 When the beam interacts with low density

materials or air cavities (such as the lung), loss of electronic equilibrium can occur.

Because of this, beam energy is an important consideration to make when treating the lung due

to the lower density of the organ volume (it is lower density because it is filled with air). The

introduction of the lung cavity presents an inhomogeneity within the body, meaning not all the

tissues are the same. This causes the dose distribution to change. When a high energy beam

interacts with the lung, electrons begin to move out of the path of the beam, which causes the

beam hardness to soften, or to become less penetrating.1 This is because electrons travel farther

in lung tissue than in water‐density tissue, resulting in a wider penumbra, and thus a greater loss

of dose near the beam edge.2 A wider penumbra causes the dose of the beam to be lower, which

can cause an under-dose of the tumor. Because of this wider penumbra, a greater margin around

the tumor volume is required to provide adequate dose, but this results in more normal tissue

being irradiated, which is not optimal.3. This lack of dose to the tumor volume can also happen

with small field sizes of treatment under 4x4 cm2 as electronic disequilibrium can occur. Lateral

electron disequilibrium can occur when the field size is too small or the density of the volume (in
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this case lung tissue) is too low to allow electrons to enter into the tumor volume. 4 In our clinic

we only use 6MV photons for lung treatments to avoid the loss of dose.

When you turn the heterogeneity correction off, the treatment planning system essentially

treats the patient as a water phantom where it does not see a difference between tissue, bone, and

air. By ignoring the density difference of different anatomical areas, the area being treated can

result in a large overdose or underdose. In bone-tissue interfaces, the dose behind the beam is

decreased. When the lung is in the path of the beam, the dose behind the lung is increased. In air

cavities, the dose beyond the cavity is lower. All of these different interfaces require

heterogeneity corrections to account for these density and dose changes.

NO Heterogeneity Correction
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Heterogeneity Correction

Plan Eval
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When I turned the heterogeneity correction off, my hotspot increased from 115.6% to

119.8%. This aligns with the previous statement of the dose increasing when the lung is present.

There is no heterogeneity correction available to account for the lung volume density. The

coverage of the tumor volume is much higher on the non-corrected plan versus the correct plan

resulting in a hotter plan and overall higher total dose to the left lung.

When calculating dose in a treatment planning system, Hounsfield Unit values play a big

role in electron density and stopping power estimates.5 As technology has progressed, there have

been more and more hip replacements with high atomic number objects such as titanium, (which

has an atomic number of 22). Heterogeneities affect dose accuracy when metal artifacts such as a

hip prosthesis or dental fillings are present near the treatment field. There are three main reasons

why image artifact can pop up when simulating a patient with hip prosthetics. The first is beam

hardening, which occurs when the CT beam interacts with the high atomic number (titanium).

When a beam interacts like this, the low energy photon beams of the CT are absorbed by

the titanium and the average beam energy increases, or “hardens”.5 The second reason for artifact

is called scatter, which occurs when Compton scatter goes through the patient, the x-ray path is

then altered, and the beam hits the detector in a different direction other than centerline.5 This

along with the beam hardening causes dark streaks we commonly see in our CT images, and the

metal shows up as white. Noise also occurs, which makes the artifact streaks in the image worse.

This streaking can result in dose inaccuracies within the treatment planning system, and so it is

important to take this streaking into consideration when planning. To help reduce the possible

dose inaccuracy of metal streaking or other contrast artifacts, new algorithms and metal artifact

reduction (MAR) methods have been introduced to account for the change in density, and

specifically in our clinic we use OMAR reconstruction, or Orthopedic Metal Artifact Reduction.
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The OMAR algorithm was developed by Philips, and is an “iterative projection modification

method optimized for imaging orthopedic implants.”6 OMAR uses “segmentation and replaces

data points identified as metal with interpolated values”6, and works very well for large metallic

implants such as the hip or dental work.

When planning a pelvis with hip prosthetics, the beam can be attenuated greatly by the

high atomic number of the metal, as discussed earlier. Because of this, different beam angles and

planning techniques, such as avoidance zones, can be used to avoid inaccurate dose calculations

for the patient’s treatment. When treating a patient with these avoidance zones, traditional IMRT

fields can achieve better dose but can increase bladder and rectum doses. VMAT planning

achieves better plans while better sparing organs at risk.7 When talking to the dosimetrists in my

clinic, they said they would never treat a prostate/pelvis patient through the prosthetic, because

the dose distribution can go down (attenuate) by almost 10-20%. They always create avoidance

sectors around the patient’s hips. They did talk about integral dose for VMAT plans however.

Integral dose, or low dose essentially, is higher in a pelvis than static IMRT plans because of the

constant entry point of a VMAT plan. There are more entry points, so there are lower dose points

everywhere, rather than IMRT where you only have that low dose entry where the static IMRT

fields are entering.

Treatment planning for radiation therapy is a complex process, and the incorporation of

heterogeneity data is essential to achieve optimal results. By accounting for heterogeneity,

medical dosimetrists can ensure that the radiation dose is delivered precisely and effectively,

resulting in the best possible treatment outcome for the patient.

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References
1. Gibbons JP. Treatment Planning II: Patient Data Acquisition. In: Khan's the Physics of
Radiation Therapy. 6th ed. Philadelphia, PA: Wolters Kluwer; 2020:222, 230-231.
2. Wang L, Yorke E, Desobry G, Chui C-S. Dosimetric advantage of using 6 MV over 15 MV
photons in conformal therapy of lung cancer: Monte Carlo Studies in patient geometries. Journal
of applied clinical medical physics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724543/.
Published January 1, 2002. Accessed April 18, 2023.
3.Ekstrand KE, Barnes WH. Pitfalls in the use of high energy x rays to treat tumors in the lung.
International Journal of Radiation Oncology*Biology*Physics.
https://www.sciencedirect.com/science/article/pii/036030169090290Z?via%3Dihub. Published
December 22, 2009. Accessed April 18, 2023.
4. Chan KW(K. Lateral electron disequilibrium in radiation therapy. Western Sydney University
ResearchDirect.
https://researchdirect.westernsydney.edu.au/islandora/object/uws:538#:~:text=Electron%20diseq
uilibrium%20will%20happen%20when,going%20into%20the%20dose%20volume. Published
January 1, 1970. Accessed April 18, 2023.

5. Giantsoudi D, De Man B, Verburg J, et al. Metal artifacts in computed tomography for

radiation therapy planning ... IOP Science. https://iopscience.iop.org/article/10.1088/1361-
6560/aa5293. Published March 21, 2017. Accessed April 19, 2023.

6.Ali AM. Evaluation of Orthopedic Metal Artifact Reduction application in three-dimensional

computed tomography reconstruction of Spinal Instrumentation: A single saudi center
experience. Journal of clinical imaging science.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5868229/. Published March 12, 2018. Accessed
April 19, 2023.

7.Parenica H, Mavroidis P, Jones W, Swanson G, Papanikolaou N, Stathakis S. VMAT

Optimization and Dose Calculation in the Presence of Metallic Hip Prostheses. SAGE journals.
https://journals.sagepub.com/doi/10.1177/1533033819892255. Published December 1, 2019.
Accessed April 19, 2023.