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In radiation oncology and in dosimetry specifically, the objective is to deliver the correct

dose to the appropriate treatment volume. Many factors go into making sure the correct dose is

calculated. There are multiple dose calculation algorithms available within treatment planning

systems that are based on radiation interactions within tissue.1 The most common are

convolution/superimposition algorithms. A principle-based algorithm called the Monte Carlo is

used in treatment planning systems today, as well as, model-based algorithms such as the

analytcial anistropic algorithm (AAA). For example, the Monte Carlo simulates all real physical

processes involving beam particles during transportation.2 The various types of tissue within the

body cause radiation particles to behave differently. This is due to the electron density of each,

including lung or air, soft tissue, water, compact bone and spongy bone. The use of heterogeneity

correction factors within the algorithms accounts for these tissue differences and assures the

correct dose is calculated and the distribution is shown correctly.

The first step in radiation treatment planning is a simulation computed tomography (CT)

scan. Within this CT scan are Hounsfield units (HU) that represent the many tissue densities and

linear attenuation coefficients.3 High Z materials such as prosthetic hip implants, dental fillings,

or tissue expanders cause image artifact due to beam hardening, scatter, and noise.4 The artifacts

are shown as bright and dark streaks. This results in incorrect HU information which leads to the

incorrect electron density.4 For example, a chest wall patient may have a tissue expander that

could cause image artifact on a CT simulation scan. To account for this incorrect density, the

artifact may be contoured and the density over-ridden to water. That is, just the artifact streaks

themselves should be overridden because this is where actual breast tissue is as opposed to air for

dose calculation purposes.

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There are two general categories for effects of tissue inhomogeneities. The first depends

on the primary beam absorption and the associated pattern of scatter. The second is the change in

secondary electron fluence.4 Compton effect is the predominant interaction with high energy

megavoltage (MV) beams.5 The attenuation of the beam is determined by electron density.4

Inhomogeneity corrections account for changes in electron density and atomic number of

tissues.6 Lung and air cavities lack electron equilibrium. This means for air cavities and lung,

there is a loss of electronic equillibrium due to the fact that less electrons are set in motion in air

compared to higher density materials. This leads to underdosing at distal and proximal air cavity

interfaces.6 As the air volume increases, the CAX dose at the distal interface decreases.6 If the

tissue preceding the air cavity is smaller than the secondary electron range, there will be

underdosage at the distal edge.6

There are two plans below for the treatment of a right lung tumor. Some studies suggest

that the beam energy should be 10MV or less for lung tumor treatment. The reason being, as

energy increases, dose equilibrium decreases.6

Both plans are AP/PA beams with 6MV energy and equal weighting. There is a 7mm

margin around the PTV. The critical structures shown on the DVH are the right lung, left lung,

esophagus, cord and heart. The GTV and PTV are also shown. The planning system used is

Eclipse from Varian. It uses a model-based algorithm AAA which uses the convolution method

for dose calculations. Essentially this algorithm provides an accurate dose calculation in

inhomogenous mediums and the accuracy is determined by how the algorithm simulates actual

scatter of the radiation beam.2

Plan 1 is with heterogeneity correcton turned on. The monitor units (MU) for the AP

beam are 177.5 and for the PA the MUs are 179. The PTV and GTV coverage are low. Dose
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build up regions are at the entrance of each beam where bone and soft tissue are, prior to entering

the lung tissue. This is caused by the fact that lungs have less electron density which leads to less

attenuation of the beam as mentioned previously.1 Electrons travel outside the limits of the beam

in low densities causing the dose profile to become less sharp.4

Plan 2 is without heterogenity correction turned on. This means the algorithm treats all

the tissue types as if they were the same. In this case, the algorithm sees the various tissues as

water which is used for the QA of the beam. The beam profile is more uniform and provides

more dose coverage to the PTV and GTV. The MUs for the AP beam are 190.4 and for the PA

beam 222.2. The MUs have increased to account for a higher density medium as opposed to a

low density one. With heterogenity correction turned off, the TPS does not calculate dose to the

lung any different than dose to the other tissues. Had the weighting and beam energies been

adjusted on Plan 2, a uniform dose distribution could be had with no dose lost in the lung tissue.
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Plan 1: With heterogenity correction on. DVH and sagittal view.

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Plan 1: With heterogeneity correction on. Axial and coronal views.

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Plan 2: With heterogeneity correction turned off. DVH and sagittal view.
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Plan 2: With heterogeneity correction off. Axial and coronal views.

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References

1. Khan, F., Gibbons, J., Sperduto, P. Chapter 34: Cancers of the thorax/lung. In:

Goolsby J, Moyer E, eds. Khan’s Treatment Planning in Radiation Oncology. 4th ed.

Wolters Kluwer; 2016: 604.

2. Kim DW, Park K, Kim H, Kim J. History of the photon beam dose calculation algorithm in

Radiation Treatment Planning System. Progress in Medical Physics. 2020;31(3):54-62.

doi:10.14316/pmp.2020.31.3.54

3. Washington CM, Leaver DT, Trad M. Principles and Practice of Radiation Therapy. St.

Louis, MO: Elsevier; 2021.

4. Metal artifacts in computed tomography for radiation therapy planning: dosimetric effects and

impact of metal artifact reduction. 2017; 62 (8)

https://iopscience.iop.org/article/10.1088/1361-6560/aa5293. Accessed April 24, 2023.

5. Gibbons, Khan. The Physics of Radiation Therapy. Philadelphia: Wolters Kluwer; 2020.

6. Papanikolaou, N., Battista, J., Boyer, A., Kappas, C., Klein, F., Mackie, TR, Sharpe, M.,

Van Dyk, J. Tissue inhomogeneity corrections for megavoltage photon beams. AAPM.

AAPM Report No. 85. August 2004. Accessed April 24, 2023.