Lung tumors are especially intricate when deciding on beam energy.

Patient
separation can be exceedingly large within the chest, but tissue density creates issues
beyond that. According to Khan, the effects of tissue inhomogeneities for points that are
within inhomogeneous tissue are mainly related to changes in electron fluence.1 This is
seen within the treatment planning systems when you load dose into a plan treating a
tumor of the chest. Thus, isodose distribution in the lungs is controlled by the density of
the lung tissue as well as depth for a specific energy.1 Lung tissue is considered
inhomogeneous as its electron density is so different than that of soft tissue or a water
equivalent phantom. This is very technical language, but it boils down to the fact that
change in density of the lung tissue alters the isodose lines with respect to the energies
selected.2 Interestingly enough, the alteration of dose from lower energy beams and
higher energies is unique.2

There was a study published in the International Journal of Radiation Research

in 2020, regarding the alterations of dose distribution from lung density. The main
takeaways from this article are the unique effects that field size, density, and energy
have on dose distribution in the lung. Within the lower density tissue of the lung, the
PDD increases for low energy beams.2 Immediately beyond the lung tissue there is a
loss of expected PDD in soft tissue. It works almost like a second build up region within
the patient. Khan mentions that areas beyond inhomogeneity are primarily affected by
attenuation of the primary beam.1

However, for very small fields or higher beam energies there is another issue for
treating through the lung. When the beam energy is higher or field size is smaller, there
is more scatter traveling outside of the field and the beam becomes less sharp.1 The
loss of lateral scatter contributing dose means a reduction in PDD within the lung. This
is contradictory to the phenomenon experienced from lower energies and larger fields in
the lung tissue. This would mean less dose to the outer portions of the tumor volumes
when using higher energies or smaller field sizes. At my clinical site our physicians who
frequently treat lung cancer prefer 6MV beams for all fields that traverse large areas of
lung tissue. If you were to use higher energy beams, you may need a bigger margin on
the volume to provide adequate coverage.

I have included a link to the research article representing the change in PDD with field
size and tissue density that helped me to better understand this subject. The figures are
on page 5.

http://ijrr.com/article-1-3093-en.pdf

1. Gibbons, Khan. The Physics of Radiation Therapy. 6th ed. Philadelphia:

Wolters Kluwer; 2020.
2. Zabihzadeh M, Ghahremani Z, Hoseini S, Shahbazian H, Hoseini
Ghahfarokhi M. Effect of lung inhomogeneity on dose distribution during
radiotherapy of patients with lung cancer. Int J Radiat Res 2020; 18 (3)
:579-586