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Stacey Song

DOS521: Treatment Planning and Calculations

April 30, 2023

Objective

The objective of this assignment is the planning of a lung tumor case with heterogeneity
correction and without heterogeneity correction to observe the differences between the two
results.

Purpose

Our bodies consist of different organs which consist of different types of cells and cavities.
Because of these differences, the human body as a medium usually has inhomogeneity (different
tissues) which affect the treatment photons in different ways as they are sent through the body to
the target site. The Treatment Planning System (TPS) is very sophisticated, but it should always
factor in this aspect of the human body or the planning should not be considered realistic. The
following examples outline this fact and underscores the need to always consider homogeneity
when planning treatments.

Methods
A patient with right lung cancer was selected for this assignment. The tumor was not located in
the mediastinum. The total dose was prescribed at 36Gy total at 1.8Gy daily dose. The plan was
normalized at Cal point. 6MV energy was used with beam weighing. MLC for both AP and PA
beams were arranged with a 2cm margin for the GTV. Plan 1 was calculated with heterogeneity
correction, and Plan 2 was calculated without heterogeneity correction. All the conditions were
the same except for this heterogeneity distinction. For the calculations, Varian’s Anisotropic
Analytical Algorithum(AAA) was used.
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Results

Figure 1.1: The Isodose distribution views and MU for AP/PA with heterogeneity correction.

Figure 1.2: Global dose maximum with heterogeneity correction.

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Figure 1.3: DVH with heterogeneity.

Plan 1: Figure 1.1 displays the shape of the isodose distribution for the target volume with
heterogeneity correction. The MU for AP field is 131, the PA field is 132, the maximum global
dose is 130.1%.

Figure 2.1: The Isodose distribution views and MU for AP/PA fields without heterogeneity
correction.
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Figure 2.2: Global dose maximum without heterogeneity correction.

Figure 2.3: The DVH without heterogeneity correction.

Plan 2: Figure 2.1. displayed the shape of the isodose distribution for the target volume without
heterogeneity correction. The MU for AP field is 135, the PA field is 132; the maximum global
dose is 119.5%.
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Discussion:

Figure 3: The combination of Plan 2(left) and Plan 1(right).

When comparing Plan1 and Plan2, there are a several notable differences worth
mentioning. The isodose lines of both Plan 1 and Plan 2 for 90%, 85% and 80% share similar
shapes. However, starting at 95% and above there are noticeable differences that show up. In
the axial view of Plan 1, 95% of isodose line is slightly concave toward the target volume. And
100% and above isodose lines are distributed close to the target volume. Meanwhile, in the
sagittal view of Plan 2, 95% of isodose line is more concave superiorly toward the target volume.
However, at 100% and above for Plan 2, the isodose lines are distributed toward both sides of the
skin tissue and not close to the target volume.

When comparing the two plans, the DVHs display more differences between the two.
The target volume coverage is evenly distributed for Plan 2 unlike the gradient coverage in Plan
1. Also, the maximum global dose is much higher for Plan1 (130.1%) than for Plan 2 (119.5%).

Even though Plan 2 shows more conformal isodose distribution, better target volume
coverage alone with less maximum global dose, the question is whether we can choose Plan 2
over Plan 1 when we treat a patient. The purpose of radiation treatment is delivering adequate
dose to kill the cancerous cells within the target area, at the same time we need to consider
sparing surrounding organs. The information we gain from the plans should be realistic.
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According to Khan, the electron density of the medium through which the beam travels
plays a large part in determining the appropriate dosage.1 When the beam travels through thick
density mediums like bone and its immediate vicinity the absorbed dose “may be several times
higher than the dose in the soft tissue in the absence of bone.” 1 This is due to the “electron
fluence arising from the photoelectric absorption in the material contents of the bone.” 1 In
keeping with this, if there is less tissue within the area, there is less interaction between the tissue
and the radiation, thus the treatment requires less dosage. Consequently, the dosage in each plan
must take into account inhomogeneity within the PTV as examined from different views. In this
respect the results for Plan 1 and Plan 2 comply with Khan’s theory because one takes into
account the inhomogeneity while the other does not.

Also having less scatter dose toward the edges of the target area due to the less tissue to
interact within the area complies with Sinousy et al. study regarding heterogeneity correction for
breast treatment. Also Sinousy et al. found this phenomenon became more serious as when
higher than 6MV energies are used.

Another case highlighting the importance of heterogeneity correction is when a patient

has a hip prosthetic. Since the material used for hip prosthetic is of high density, if heterogeneity
correction is not applied, the end result is a loss of accuracy in dose calculation. 3

Conclusion

The human body consists of differing tissues of differing densities, and thus
heterogeneity correction should be considered an important parameter in dose calculation for
cancer patients. Because different densities play such a crucial role in affecting the actual dosage
delivered to the target site, this parameter should not be underestimated. From the examples
provided one can see that even if one view provides similar results (see Plans 1 and 2), additional
views can still reveal a difference in actual dosage coverage when heterogeneity is not taken into
account.

Consequently, when developing treatment plans density should always be considered. All
mediums in the path of the treatment beam can affect the actual dosage and thus the effectiveness
of the treatment. Those developing the plans should consider the mediums including any foreign
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additions like prosthetic hips that might have high (or lower) absorption and may/may not
provide scattering of the beam.
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References

1. Khan FM, Gibbon JP. The physics of Radiation Therapy. 5 th ed, Philadephia,
PA:Lippinocott Williams and Wilkins; 2014.
2. Sinousy DM, Attalla EM, Hanafy MS, el al. Dosimetric Study of Tissue Heterogeneity
Correction for Breast Conformal Radiotherapy. Iranian Journal of Medical Physics.
September, 13, 2018.
3. Hazuka MB, Ibbott GS and Kinzie JJ. Hip Prosthese During Pelvic Irradiation:Effects
and Corrections. National Library of Medicine.
https://pubmed.ncbi.nlm.nih.gov/3133330/ Accessed April 28, 2023.