1

Joseph Spencer
DOS 523 Treatment Planning and Calculations
Heterogeneity Corrections for Lung Treatment Planning

Introduction
The treatment planning process is one of the most important steps in the preparation of
radiation therapy treatments. Radiation treatment planning has come a long way in recent years.
The advent of conformal planning using computed tomography (CT) data has improved accuracy
in dose calculations and given us a better understanding of tissue heterogeneities through the
beams path. Using CT data allows us to apply heterogeneity correction factors to a treatment
plan when the radiation beam passes through layers of fat, bone, muscle, lung, and air.1 This has
allowed improvements in computerized dose calculations which are crucial for better accuracy
during treatment planning and delivery. Accurate dose calculations maximize radiation dose to
target volumes, tighten target margins, and minimize normal tissue toxicities. Beam attenuation
is an important consideration when treating any area of the body with radiation. This is
especially true when treating an area in or near the lungs due to the drastic changes in tissue
densities. This case discussion will attempt to demonstrate the importance of using heterogeneity
correction factors in dose calculations by comparing two identically set up treatment plans of the
lung that were calculated with and without heterogeneity correction.
Methods
The CT data set of a previously treated lung cancer patient was selected and anonymized.
The criteria for selection were based on the location of the lung tumor as it had to be in the lung
without mediastinal involvement. In this case, the tumor was in the middle of the right lung
favoring the right lateral and posterior of the patient’s anatomical orientation. Two identical
treatment plans were created using the data set with an anterior to posterior and posterior to
anterior (AP/PA) field arrangement using the same beam angles and field sizes. An isocenter was
placed in the same location for both plans. A 0.8 cm margin was placed around the planning
treatment volume (PTV) as per clinical protocol to account for any possible movement of the
target during treatment. Both fields were weighted equally and assigned the lowest energy
possible which was 6MV. Both plans were assigned an arbitrary prescription of 50 Gy given in
20 fractions and both plans were normalized to get 100% of the dose to the isocenter. Once both
 2

plans were set up to identical specifications, one plan was calculated with the heterogeneity
correction on (Plan1_On) and the other with heterogeneity off (Plan2_Off). The heterogeneity
correction accounts for different tissue types, and when it is turned off, the treatment planning
software assumes all structures within the body contour have a water-equivalent density. To help
with plan evaluation, a lung structure set was used that includes the PTV, right lung, left lung,
spinal cord, heart, and external body structures as contoured to match patient anatomy. This
exercise was not meant to create a clinically acceptable plan but instead to compare both plans to
evaluate the dose distribution and effects of heterogeneity corrections on tissue densities and
plan outcomes.
Results
The plan with heterogeneity turned on delivered 174 monitor units in the AP field and
167.7 monitor units in the PA field (see Figure 1). Figure 2 shows that each beam exhibits a
buildup region superficially until maximum equilibrium is reached. After this buildup area, the
dose gradually decreases with depth and then builds up slightly again at the target. This is seen
best with the 100% isodose line in yellow returning to the target structure. The maximum hot
spot for the plan with heterogeneity turned on is 123.8% and is in the patient’s right breast, about
1.5cm from the skin’s anterior surface. As visualized from Figure 2, the isodose lines are slightly
angled due to tissue density variations and surface angles. This can be seen around boney
structures such as the scapula and ribs. The most drastic change to isodose lines is seen when the
dose reaches the lung tissue. There is a visible narrowing of the 95% (green) and 90% (orange)
isodose lines with an obvious breakup in the 100% isodose line (yellow). There is also a slight
dose buildup at the tumor target. Lower isodose lines (< 70%) maintain field borders of both
beams through the patient.
The plan with heterogeneity turned off delivered 205.6 monitor units in the AP field and
174.8 monitor units in the PA field (see Figure 4). The plan without heterogeneity correction was
hotter overall, with a maximum hot spot of 132.2% located in the same location as first plan.
Figure 5 also shows that each beam exhibits a buildup region superficially until maximum
equilibrium is reached and less dose falloff as the first plan. All isodose lines are symmetrical
with some slight angling due to the sloping chest surface seen in the sagittal view on Figure 5.
The 100% isodose line reaches the isocenter from both fields, but this time with no breakup. The
only obvious narrowing of isodose lines occurred in the 100% line, and it resembles the
 3

hourglass shape that is commonly observed by two opposing fields. Lower isodose lines (< 95%)
maintain field borders of both beams through the patient which is considerably different than the
plan with heterogeneity turned on.
Discussion
The results from this plan comparison show that the heterogeneity correction factor has a
significant effect on the dose distribution for a lung treatment plan. Heterogeneity factors
account for beam attenuation through various tissue structures and produce changes in dose
distribution. Attenuation of the beam in any medium is governed by electron density of the
medium.1 Tissue inhomogeneities will affect beam attenuation and electron fluence as we
observed in this case.1 For example, electronic equilibrium is lost at boundaries of low-density
such as the lungs or sinus cavities but increases at boundaries of high-density, such as bone.1
These build-up and build-down regions are why we note a change in the dose distribution
between both lung plans with and without heterogeneity corrections. Figure 7 reflects only the
AP field of the lung plan with heterogeneity correction to illustrate the changes in the isodose
lines. The dose travels further in the lung than chest wall as the beam is attenuated differently in
each tissue.
The heterogeneity correction factor is defined as the ratio of the dose in a heterogeneous
medium to the dose at the same point in a homogeneous water-like medium.2 Linear accelerators
and other radiation therapy treatment equipment are calibrated to coincide with standardized
isodose charts and depth dose tables that assume a homogenous unit density medium of water
which creates a need for a heterogeneity correction factor in dose calculations.1 Modern
treatment planning systems provide accurate dosimetry of heterogeneous tissues of patient
anatomy with the help of heterogeneity correction factors applied to CT data in the treatment
planning software. According to Das et al,3 CT numbers can vary depending on the type of
scanner, tube voltage, field of view (FOV), reconstruction algorithm and processing filters used
so it is important that the CT machine is carefully calibrated. CT data can also be misrepresented
due to CT related artifacts. Examples of CT artifacts include noise, helical, ring, streaking, metal,
and scatter. These CT artifacts can misrepresent CT data and must be accounted for when
applying heterogeneity corrections. Metal artifacts such as a hip prothesis or dental fillings
should be contoured and assigned Hounsfield Unit (HU) values that represent their true densities
to account for entrance dose buildup in surrounding soft tissues caused by electron
 4

backscattering.1 The streaking artifacts caused by metal can also cause higher or lower HU
values and should be contoured and assigned accurate HU values that represent tissue densities
in the area. An example of this can be found in Figure 8 showing CT artifact caused by a metal
port in a breast expander from a breast treatment simulation scan. Contrast is used during a
simulation scan to help delineate tissue structures but must also be contoured and assigned HU
values to exclude it from the planning calculation since it will not be present for daily patient
treatments. Figure 9 illustrates an example of this with contrast used during a retrograde
urethrogram for a prostate treatment simulation scan.
For this comparison, each lung treatment plan was calculated in the treatment planning
system, and the dose distribution was compared between both plans with and without
heterogeneity correction. The results showed significant differences in the dose distribution for
each plan regardless of having identical beam parameters. While studying various beam energies
effects on heterogeneity corrections, Akhtaruzzaman and Kukolowicz2 found that “the worst
results are obtained in heterogeneous anatomies, especially if the lungs are present” which makes
a lung plan a great example of the need for heterogeneity correction. This comparison
emphasized the importance of accounting for patient tissue inhomogeneities during treatment
planning because of the various tissues’ influence on the dose distribution. This assessment noted
differences in the amount of monitor units required to get 100% dose to the isocenter for each
plan. The plan without the heterogeneity correction required an increase of monitor units to
deliver prescription dose to the target volume because it treated all structures with the same
single density. The plan with heterogeneity didn’t require as many monitor units to get
prescription to the target but didn’t provide as much coverage to the PTV, as seen on the DVH in
Figure 10. The DVH also shows that OAR doses were comparable with an increase in dose to the
right lung for the plan without heterogeneity correction.
Summary
From a radiation dosimetry perspective, tissues of the lungs, sinuses, and bone are
significantly different radiographically from water. Therefore, heterogeneity correction factors
are vital in achieving accurate dose distribution in radiation treatment planning. Modern
advancements in treatment planning software and algorithms have made it possible to achieve
clinical goals to deliver accurate treatments. This assignment used a real CT data set from a
previously treated lung patient to emphasize the concept of heterogeneity corrections factors on
 5

dose calculations. The results from this plan comparison showed significant differences between
treatment plans with and without heterogeneity corrections. Using a lung case was beneficial in
showing the effects of tissue inhomogeneities on dose distributions where adjacent regions of
high-density and low-density tissues can have significant impact on dose attenuation. Applying
heterogeneity correction factors are very important when accounting for a variety of tissue types
and artifacts in the beams path. If the goal of radiation therapy is to maximize dose to the target
while sparing adjacent structures, then heterogeneity correction factors must be applied as shown
through this lung plan comparison.
References:
1. Gibbons JP. Ch.12. In: Khan’s the Physics of Radiation Therapy. 6th ed. Philadelphia, PA:
Wolters Kluwer; 2020:222-231.
2. Akhtaruzzaman M, Kukolowicz P. Dependence of tissue inhomogeneity correction factors on
photon-beam energy. Nukleonika. 2018;63(1):3-7. doi:10.1515/nuka-2018-0001
3. Das IJ, Cheng C-W, Cao M, Johnstone PAS. Computed tomography imaging parameters for
inhomogeneity correction in Radiation Treatment Planning. J of Med Phys. 2016;41(1):3.
doi:10.4103/0971-6203.177277
 6

Figure 1. Treatment beam parameters and monitor units with heterogeneity corrections turned
ON. The AP and PA beams delivered 174 and 167.7 monitor units, respectively.

Figure 2. Axial, coronal, and sagittal views of Plan1_On at isocenter with heterogeneity
corrections turned ON.
 7

Figure 3. DVH and dose statistics for Plan1_On with heterogeneity corrections turned on.
 8

Figure 4. Treatment beam parameters and monitor units with heterogeneity corrections turned
OFF. The AP and PA beams delivered 205.6 and 174.8 monitor units, respectively.

Figure 5. Axial, coronal, and sagittal views of Plan2_Off at isocenter with heterogeneity
corrections turned OFF.
 9

Figure 6. DVH and dose statistics for Plan2_Off with heterogeneity corrections turned off.

Figure 7. Axial view of the AP field of the lung plan with heterogeneity to show changes in
isodose lines caused by beam attenuation in chest wall versus lung tissue.
 10

Figure 8. CT streaking artifact from metal expander port on the left. Contoured and overwritten
streaking artifact on the right.

Figure 9. Contrast used during a retrograde urethrogram being contoured and assigned a lower
HU value.
 11

Figure 10. Plan comparison of DVH and dose statistics for plans with heterogeneity corrections
turned on (triangle) and off (square).

Figure 11. Side by side axial view of plans with heterogeneity corrections turned on (left) and
off (right).