Nicole Peckham 1

DOS 523 Treatment Planning and Calculations

Treatment Planning Paper

Introduction
In radiation treatment our success in treating a patient and delivering a proper dose
distribution depends on being able to create an accurate treatment plan that is representative of
the live patient tissue and how that radiation will interact with that tissue. There are several
important factors that must be considered and implemented to achieve this. First, the use of CT
simulation is the most accurate way to obtain patient images for treatment planning. Not only do
you have a 3D representation of the patient and their anatomy, but a CT comes with CT numbers
or Hounsfield numbers which are essentially a representation of tissue densities. Second, the
treatment planning system (TPS) uses this information from the CT to calculate the treatment
plan using dose calculation algorithms. Within the TPS a density table from the CT scanner used
to obtain the images is assigned to the data set when it is imported, this tells the TPS how to
calculate dose for that specific scan. This is important for large institutions that have may have
multiple CT simulators. Modern TPS’s can calculate treatment plans using heterogeneity
correction, which enables the TPS to know that is it calculating dose through different densities,
which can have a major impact on the outcome of the plan. In some TPS’s you can apply this
feature manually while in others it is automatically used.
Density of tissue has a major effect on the absorption of radiation and thus must be
considered when treatment planning. For MV photon beams, the Compton effect is the dominant
mode of interaction with tissue, and the attenuation is controlled by electron density.1 This is
why beam energy is important in lung tissue, which mostly comprises air. With 6 MV, the Dmax
is shallower, and the build-up region is smaller making it more appropriate for lung tumors,
because the density of lung tissue is low. Because of the lower density in lung tissue, there is
more loss of lateral scatter in electrons, which reduces the dose along the central axis, and
ultimately can cause underdosing in the peripheral tissue of the tumor.1
Beam energy is not the only factor that is affected by tissue densities. For points that lie
beyond a region of inhomogeneity (multiple densities within an area), the main effect is the
attenuation of the primary beam.1 Because of the low density of the lungs, the dose within and
beyond the lung increases, then as it exits into soft tissue there is a loss of secondary electrons
which results in a decrease in dose.1 This concept is important to keep in mind when planning
treatment lung. Also, of importance would be to consider lung and breast interface when treating
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the breast. When treating the breast some amount of lung must be included to properly treat the
entire breast volume. The amount of lung within the tangential breast fields causes a reduction in
the dose received by the target volume.2
Loss of electronic equilibrium is also what affects the dose at air cavity interfaces. This
results in the dose to tissue in front of and beyond the air cavity to be lower than expected.1 An
example of when this would be important is when treating primary sinus tumors or treating a soft
tissue volume that includes a sinus cavity.
Extreme examples of difference in tissue density would be patients with metal dental
fillings or prosthetic joint replacements. The presence of a high density inhomogeneity, such as a
hip prosthesis, in a patient results in attenuation of the radiation through the inhomogeneity as
well as local perturbations known as interface effects.3 The magnitude and the extent of these
effects depend on the energy of the radiation as well as the density, atomic number, and size of
the inhomogeneity.3 This not only impacts the treatment of patient’s with hip prothesis but also
acquiring an accurate treatment planning CT. The current standard for image reconstruction is
filtered back projection, which causes streak artifacts when attempting to create images from
patients with high density materials implanted.3 To overcome this, the artifact can be contoured,
and the density can be assigned within the TPS.
Taken from my own TPS, the density of the soft tissue in the pelvis is very near 1.0
g/cm3, as would be expected. This patient happens to have gold fiducials implanted in the
prostate for alignment as well as a hip prosthesis. The density within the artifact streaking caused
from the seeds and the prothesis drops to 0.7 g/cm3 to 0.86 g/cm3. This is a direct display of how
these metal objects attenuate more of the radiation, so the normal tissue beyond receives less
dose. This brings about two important points. First, because these streaks in the treatment
planning CT will not actually be present in the live patient during treatment, they should be
overridden to soft tissue to reflect the actual absorbed dose to the target volume more accurately.
Secondly, to not cause unacceptable dose inhomogeneities within the target volume beam
arrangements that avoid the prosthesis are preferred.3
There are some other situations where you might want to override a density in planning.
One example would be if you acquire a treatment planning CT, and the patient has fluid in their
lungs. Oftentimes the fluid will be drained prior to initiating treatment, the density of the fluid
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can be overridden to match that of normal lung tissue to use the original planning CT, but
account for the fluid drainage.4 While it would be more accurate to perform a second treatment
planning CT this technique would prevent additional exposure for the patient and save time and
resources. While not applicable to lung planning, another example of overriding air density when
treatment planning would be to override bowel that is filled with gas. The TPS tends to try and
force dose to air when attempting to avoid critical structures; to avoid the dose going into air
filled bowel the density can be changed while planning and once you have an acceptable dose
distribution you can revert the density back for the final dose calculation. 5
The flowing outlines a lab completed to discover differences in dose distribution and
absorbed radiation dose in a patient with and without heterogeneity correction.

Plan Set-up
I recently completed an SBRT lung practice plan and when reading the instructions for
this lab, I thought of this patient given the size and location of the tumor. The patient’s tumor is
only 1.8 cm and symmetrical, knowing that the intent of this lab was to discover the differences
that heterogeneity correction has on dose distribution, I thought that having a symmetrical tumor,
would make the differences easy to visualize. Figure 1.0 displays the size and location of the
tumor as well as the required structures, which include a body contour, right lung, left lung,
spinal canal, and targets. Please note that the heart was also contoured, just not visible at the
level of the target volumes.

Figure 1.0. Axial slice displaying size and location of tumor.

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The plan was set-up with an AP and PA beam directly opposed to each other, using a 2
cm uniform margin around the PTV, 6 MV beam energy, and equal field weighting. Since the
prescription did not matter, I set this plan to deliver 300 cGy over 10 fractions for a total dose of
3000 cGy, scaling so that 100% of the dose would be delivered to 95% of the volume of the
PTV. In setting up this plan there was no intention of creating an acceptable plan for treatment;
the point was just to have a dose distribution display with heterogeneity correction turned on and
one where no correction was applied. Figure 2.0 shows a beams eye view (BEV) of the treatment
field as well as beam orientation.

Figure 2.0. Beam orientation and BEV of the PA beam.

The TPS used for this lab was RayStation. RayStation is unique in that heterogeneity
correction is essentially always turned on, this is easily visualized within the TPS by moving the
mouse around any point within the CT image and the density of that point is displayed in the
upper left hand corner.4 In order to perform this lab and visualize what the plan looks like
without heterogeneity correction, I had to change the density of the entire body to water which
has a density of 1.0 g/cm3. Thus, resembling a heterogenous tissue. When in reality the beam is
passing through multiple tissues with different densities. The anterior chestwall had a density of
1.02 g/cm3 similar to that of water. The posterior chestwall had a similar density of 1.08 g/cm 3.
The ribs had a density of 1.2 g/cm3. The tumor itself had a density of 0.63 g/cm3, while the lung
tissue had a density of 0.12 g/cm3. Different densities mean differences in attenuation compared
to a single density.
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Plan Outcomes

Heterogeneity Corrected

Figure 3.0 is a display of the isodose distribution in axial, coronal and sagittal planes for
the heterogeneity corrected plan. As seen in Figure 4.0, each beam has 180 MU. The max point
for this plan was 3469 cGy which is 116%. The volume above 110% is 49.7 cc. For a DVH from
the heterogeneity corrected plan refer to Appendix A at the end of this report.

Figure 3.0. Isodose distribution in axial, coronal, and sagittal planes.

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Figure 4.0. Beam report including MU and dose for each field.

Non-heterogeneity Corrected
Figure 5.0 is a display of the isodose distribution in axial, coronal and sagittal planes for
the non-heterogeneity corrected plan. As seen in Figure 6.0, the PA beam has 192 MU and the
AP beam has 193 MU. The max point for this plan was 3301 cGy which is 110%. Given that the
max point for this plan is 3301, the volume above 110% is zero. For a DVH from the non-
heterogeneity corrected plan refer to Appendix B at the end of this report.
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Figure 5.0. Isodose distribution in axial, coronal, and sagittal planes.

Figure 6.0. Beam report including MU and dose for each field.

Plan Comparison/Summary

The most obvious differences between these two plans is seem when looking at
the isodose distributions. Figures 7.0, 8.0, and 9.0 show side-by-side comparisons in coronal,
axial, and sagittal planes. In the coronal view, the diameter of the isodose lines is measured,
showing an overall smaller diameter on the non-heterogeneity corrected plan, however, it can be
seen that the red 100% isodose line is larger therefore covering more lung volume. As shown on
the DVH for this plan in Appendix B this leads to better PTV coverage. However, these two
factors also lead to an increased dose to the OAR. For example, the V20 Gy for lung on the
heterogeneity corrected plan was 20.65%, while the V20 Gy for the lung on the plan without
heterogeneity correction was 21.62%. The axial and sagittal comparison show that for the non-
heterogeneity corrected plan the isodose distribution is much straighter and again the red 100%
covers more volume. This is due to the density being uniform, or homogenous, the dose falls off
faster in water because it has a greater density.
Another difference between these plans in seen on the MU printouts in Figure 4.0 and
6.0. The plan using heterogeneity correction calculated less MU when compared to the non-
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corrected plan, 180 MU versus 192 MU respectively. This makes sense because once again the
dose travels farther in the lung because of the density, reaching the target quicker, ultimately
require less MU. We need more MU in the plan without heterogeneity correction because the
TPS thinks the radiation is traveling solely through water, which attenuates the radiation faster.
Lastly, the plan with heterogeneity correction was 16% hotter than the second plan with
heterogeneity correction turned off. This is seen again because dose falls off faster in water than
in air so the radiation travels farther giving a higher dose to the plan with heterogeneity
correction.

Figure 7.0. Coronal comparison displaying circumference of irradiated tissue.

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Figure 8.0. Axial comparison.

Figure 9.0. Sagittal comparison.

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While one would think that an overall cooler plan with better PTV coverage would be a
better plan, this is not an accurate depiction because the entire volume has a density of 1.0 g/cm3
which does not reflect what is actually going on in the patient. The beams in both plans pass
through soft tissue and muscle, lung, bone, and more soft tissue and muscle when exiting the
lung. When trying to get the most accurate dose distribution and best representation of what is
happening when the treatment plan is delivered heterogeneity correction gives a more accurate
picture. Even if that means slightly lower PTV coverage and an overall higher max dose. These
facts do not mean the plan is inadequate, so long as the tumor is still receiving the prescribed
dose and the dose to OAR is within acceptable limits. As demonstrated above the effects of
tissue density and heterogeneity correction are paramount in performing a proper dose
calculation and creating the best possible plan for the patient. With continued research and
constantly advancing technology, this will only become more accurate.
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Appendix A. DVH for heterogeneity corrected plan.

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Appendix B. DVH for non-heterogeneity corrected plan.

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References

1. Gibbons JP. Khan’s the Physics of Radiation Therapy. Sixth. Wolters Kluwer; 2020. 222; 230.
2. Sinousy D, Attalla EM, Hanagy MS, Abou-Elenein HS, Mohamed Ahmed Abdelmajeed, Osama
M. Dosimetric Study of Tissue Heterogeneity Correction for Breast Conformal Radiotherapy.
DOAJ (DOAJ: Directory of Open Access Journals). Published online March 1, 2019.
doi:https://doi.org/10.22038/ijmp.2018.31579.1374
3. 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/10.1118/1.565113
4. Brandon Mader, Chief Medical Physicist, St Charles Cancer Center. April 20 th, 2023.
5. Amber Tesch, Medical Dosimetrist, St Charles Cancer Center. April 25th, 2023.