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Peter Hirschi
Dos 523 Treatment Planning
March 3, 2015
Heterogeneity Correction Factor on Treatment Planning System.

Abstract: When treating patients that are made up of inhomogeneities tissue i.e. muscle, bone,
and lung, all of which have different electron densities, it is difficult to accurately calculate the
many complex interactions occurring within the patient. Todays computer based treatment
planning systems (TPS), although not perfect, can account for many of the different factors
effecting dose delivery with good accuracy. This paper will give an example of a treatment plan
using a heterogeneity correction factor and compare it to the exact same plan that does not utilize
a heterogeneity correction factor. Three factors will be discussed. 1. Differences in density and
its correlating attenuation factors. 2. Build up region of tissue after the beam passes through the
lower density area of the lungs. 3. Lateral scatter of secondary electrons in low density tissue.
Process: Two 6mv parallel opposed AP/PA lung treatments were created on a Varian Eclipse
TPS that utilizes the AAA planning algorithm. The patient was simulated on a 16 slice CT
scanner. The patient data was imported to Eclipse. The body, right lung, left lung, spinal cord,
and heart were contoured. A 10 degree wedge was used for the AP field. A 1.5 cm margin was
added to the GTV of the lung tumor. The plan was normalized to a 100% at isocenter. A
prescription of 33 fractions delivering 200 cGy daily was applied. A plan (phlab1wedge) was
created using all the factors just listed with the AAA algorithms heterogeneity correction factors.
Then, a second plan was created (phlabheteroff) identical to the first plan with the exception that
the heterogeneity correction factors were not used. Both plans data was then exported to IMsure
so a comparison between the calculation factors could be observed. Dose-volume histograms
were created for both plans for comparison as well.
Research Results: Figure 1 shows the plan with heterogeneity correction factors (HCF) turned on
while figure two shows the plan with (HCF) turned off on the TPS.

Figure 1 with HCF

Figure 2 without HCF

The most profound difference between the two figures is the coverage of the 100% isodose line.
With the HCR turned off (figure 2), the treatment field edge near the left side of the patient is a
nice straight line, showing even coverage of the 100% isodose line. While in figure 1, the same
100% isodose line recedes nearly to middle of the field. The 100% line shown in figure 1 is not
even close to being a nice conformal line like the one in figure 2. One of the factors causing the

100% line to recede in figure 1 is the lateral scatter of secondary electrons. Photons from the xray beam interact with the electrons in the tissue causing them to travel in all directions. Most
travel in a forward direction, but some electrons can travel in any direction including laterally. In
less dense material like the lungs, these lateral moving electrons travel farther because there is
less electron dense material to react with them. Also because of the less dense lungs tissue, fewer
electrons are being produced by photons to replace the electrons traveling out of the field. Figure
2 is assuming all tissue has the same density so neither concept is accounted for. Therefore, the
plan without HCF shows an inaccurate uniform dose on the field edge even through the lungs.
Figures 3 and 4 show a great example of lateral electrons effects on treatment planning.

Figure 3

Figure 4

A study done by Cephas Mubata, compared a pencil beam algorithm (figure 3) to a Monte Carlo
calculation (figure 4) of the same lateral beam. The pencil beam algorithm did not account for
the lateral scatter of electrons in less dense material just like the lung treatment plan shown
earlier that did not use a HCF. Notice the nice straight isodose lines similar to figure 2. The
Monte Carlo calculation (Figure 4) is a much more accurate calculation that accounts for lateral
movement of electrons. The blue in figure 4 shows the dose spreading in the lungs.1
Standard isodose charts that were used before tissue inhomogeneities were corrected for,
assumed that all of the medium was a humogeneous unit of density.2 Since the advent of CT
machines accurate tissue densities ranging from very dense bone to low dense tissue of the lungs
can be used for more accurate dose calculations. A common way to account for density
differences within the body is the isodose shift method that adjust the depth of the calculation by
giving different values to different densities of tissue. For example, 1 cm of lung is given a depth

of 0.4 cm to account for less density, while bone is given a depth of greater than one to account
for greater density causing more attenuation of the beam.3
Figure 5 shows the printouts of both lung treatment plans details.

Figure 5

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Figure 6 is another print out of both plans details.

Figure 6

Notice the Depth and Eq. Path Length numbers encased in the black border. Depth represents the
measured depth to isocenter while the EQ. Path Length accounts for density differences of the
patient. Notice the PA field changes from a depth of 13.8 to a EQ. Path Length of 6.9 because
most of the beam is traveling through lung before getting to isocenter. Both plans were exported
to a secondary MU check software called IMsure. Figure 7 shows the factors used in calculating
the MUs needed.

Figure 7

Notice the PA field requires a substantial amount of fewer MUs when the HCF is used. This is
because without the HCF turned on the TPS assumes the lung tissue is attenuating the beam as
much as normal tissue. So the TPS increases the MU to push dose through 13.8 cm of tissue
when in fact a majority of the tissue is less dense lung that the HCF accounts for. When
importing information to IMsure, the two factors that have to be input are the projected depth
and the effective depth, shown in Figure 8.

Figure 8

Notice with the HCF on the Eff. Depth is different then the Proj. Depth while the plan with the
HCF off has the Proj. Depth values identical to the Eff. Depth. This demonstrates one of the the
ways the AAA algorythim accounts for inhomogeneities. To expand on this concept, the values
for Proj. Depth and Eff. Depth were made identical on the plan utilizing the HCF (far right) in
order to show the difference in MU when inhomogeneities are not accounted for.

The IMsure software should have calculated MUs closer to the 121.3 MU the TPS had
calculated, but because Eff. Depth was not accounted for IMsure calculated 154.6 MU, a 27.4%
increase in MUs, a substantial overdose. (Figure 9)
To correct accurately for inomogeneities, another concept that must be accounted for is the dose
buildup in the distal interfaces between muscle equivalent tissue and lung tissue.3 In this case,
after the PA beam travels through a great distance of lung and then hits the tumor, a dose build up
region occurs on the surface of the tissue much like the skin-sparing effect seen on the surface of
the patient. Figure 10 shows the beam profile of the PA field for both plans.

Figure 10

On the left is the PA beam profile with the HCF turned off. Notice how it is a nice steady
decrease in dose. The PA beam profile on the right has the HCR turned on. Notice the drop in
dose as the beam enters the lung then the buildup in dose as it enters the tumor. This buildup
region causes less uniform coverage of the tumor volume because the surface tissue adjacent to
the lung is receiving considerably less dose. The color wash in the images is also reflective of the
beam profile. The image on the left shows the color wash disappearing in the lung volume before
reappearing on the tumor, while the image on the left shows a solid color wash all the way to the
tumor area.
Figures 11 and 12 show the DVH for both plans.

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Figure 11

Figure 12

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In conclusion, this brief example shows the importance of correcting for inhomogeneities within
a patient. Differences in beam attenuation, build up region on muscle tissue adjacent to air
cavities, and lateral scatter of electrons are just a few factors that affect dose delivery when
inhomogeneities are present. In fact, a study was done at MD Anderson in 2001 in which 30
patients with non-small lung cancer had treatment plans created utilizing the traditional
homogeneous point calculations. If the plans would have been used for treatment, 14 of the 30
patients prescribed dose would have been delivered to less than 90% of the PTV.4 While current
TPS are pretty accurate, they will continue to be improved until they accurately reflect every
effect of inhomogeneitic mediums on the treatment beam.

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References
1. Mubata, Cephas. Applications of Monte Carlo Methods in Radiotherapy.
Presentation given at The Royal Marsden NHS Trust. London, UK.
2. Kahn, F. The Physics of Radiation Therapy. 4 th ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2010:13.
3. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996
4. Frank SJ, Forster KM, Stevens CW, et al. Treatment planning for lung cancer:
traditional homogenous point-dose prescription compared with heterogeneitycorrected dose-volume prescription. Int J Radiat Oncol Biol Phy 2003; 56(5):13081318. doi: http://dx.doi.org/10.1016/S0360-3016(03)00337-7