Lauren Brandl

DOS 523: Treatment Planning in Medical Dosimetry

04/25/2019
The Effect of Heterogeneity Corrections in Treatment Planning
The human body is a complex arrangement of tissues, cavities, and organs all consisting
of varying composition and properties. Oftentimes, structures of entirely distinct characteristics
are seated next to or overlapping one another, such as a lung residing alongside the heart. The
significant changes in density between the two proximal organs may present a profound problem
when planning a radiation treatment, given the nature of photon and electron interactions in
different media. To greater understand these characteristics, treatment planning systems are now
all equipped with advanced calculation algorithms, which take into account the change in density
throughout the body when creating a treatment plan. These corrections for tissue heterogeneity
are oftentimes essential in predicting accurate dose to the target and surrounding structures.
In order to evaluate firsthand the variation in dose distribution with and without the
correction for tissue heterogeneity, a plan with a tumor inside of the left lung near an interface
with soft-tissue was selected. The computed tomography (CT) dataset of this patient was
provided to students in the Medical Dosimetry Clinical Practicum I course to be used in a
treatment planning lab. This patient was an ideal model, given the data had been anonymized and
the ideal location of the tumor for the purpose of analyzing the effect of heterogeneity correction.
Two plans were created with the Eclipse treatment planning system, one using heterogeneity
corrections taking into account the large portion of air in the lung field, and the other without,
assuming the same tissue density throughout the field. Both plans used an anterior to posterior
(AP) beam and a posterior to anterior (PA) beam to cover the planning target volume (PTV),
which had already been contoured. In order to calculate the dose to the surrounding normal
structures, the patient’s external body surface, bilateral lungs, spinal canal, and heart were also
contoured. No artifact was present in the patient’s scan; therefore no density overrides were
performed for any volumes.
When treating the lung it is important to take note of the energy used, as the lower
density of air (in comparison to soft tissue) causes electrons to scatter outside of the normal
trajectory of the beam and into the lung.1 This effect is more common in higher energies above
6MV. However, at lower energies and greater depths, high doses are often recorded within and
just beyond the boundaries of the lung as a result of significantly less attenuation of the beam in
air.1 For these reasons, a lower beam energy of 6 megavolts (MV) was used to create both plans,
due to of the large amount of lung and air the beam would be traveling through before reaching
the PTV. The the possibility of underdosing the periphery of the PTV was a concern if a higher
energy was used, because it would have penetrated deeper, and there would be a greater chance
of losing lateral electrons to scatter. In addition, following a low-density region such as air could
result in a second build-up region of dose in the tissue of the tumor and further loss of PTV
coverage in this area.1 The tumor was nearly in the transverse center of the patient in terms of
anterior to posterior directions, positioned slightly closer to the anterior patient surface.
Therefore, in both plans a beam weighting of 53% of the dose coming from the AP beam and
47% of the dose from the PA was used for equal distribution and decrease in point dose max
(Dmax). No normalization was used and a placeholder total dose of 60 Gy was prescribed.
Furthermore, a 1-centimeter blocking margin was placed around the periphery of the tumor. A
beams eye view with relation to the body may be seen below for the AP beam, and the block is
outlined. The left lung is contoured in blue, the PTV in red, and the heart in maroon.

Finally, both plans were calculated and a view of the isodose distributions, field monitor units
(MU), and cumulative dose volume histogram (DVH) may be seen below first for the
Heterogeneity-Corrected (HC) plan.
 At the interface of soft tissue and air, lateral electronic equilibrium is lost resulting in
significantly different isodose distribution than what is observed in a homogenous medium.1 In
viewing the isodose lines of the above HC plan, we can see the bowing in and hourglass shape of
the 90% line traveling through the lung as a result of some lateral electron scatter lost. The 100%
isodose line covers the PTV centrally inside the soft tissue with a small build-up margin
surrounding. According to the DVH, 100% of the dose covers only 11.1% of the PTV volume.
As seen in the sagittal and coronal views, the superior/inferior coverage is poor, with the 90%
isodose line covering less than the entire target superiorly and towards the left where the PTV
extends into the air of the lung. Upon referencing the DVH, it is found that 100% of the volume
is receiving approximately 84.7% of the prescribed dose, and the Dmax of the PTV is 101.8%.
The soft tissue in the path of the beam before the lung, however, is covered entirely by the 100%
isodose line and is receiving in some areas over 110% of the prescription dose, with a Dmax of
113.2%.
Below is a view of the isodose distributions, field monitor units (MU), and cumulative
dose volume histogram for the Non Heterogeneity-Corrected (NHC) plan.
 Upon viewing the isodose distribution of the NHC plan, one can see that the
heterogeneity no longer plays a role in the shaping of the dose, and that the depth of the tumor
has the greatest effect on coverage of the PTV. The 100% isodose line connects through the
center of the body and according to the DVH now encompasses 53.8% of the PTV, a remarkably
higher volume than the roughly 11% observed in the HC plan. Inferiorly, and seen in the sagittal
view, there is a decrease in coverage due to the sloping of the chest and greater volume of tissue
in the path of the beam. A similar effect is observed in the axial plane, as the sloping increases
patient thickness towards midline, thus decreasing dose coverage medially in the PTV. The DVH
now displays that 100% of the PTV volume is covered by 93.8% of the prescribed dose, and the
maximum dose received by the PTV is 103%. Once again, proximal to the source in the soft
tissue, there are large volumes covered by the 105% and 110% isodose lines, and the Dmax was
hotter at 116.1%. If this had truly been a plan with little heterogeneity, a higher energy beam
would have been used to increase skin sparing while providing greater deep coverage. In
addition, wedges would likely have been used to account for the sloping of the anatomy.1
Overall, it was observed that the NHC plan had significantly better PTV coverage with
the 100% isodose line (53.8% vs. 11.1%), and a higher dose encompassed the entire PTV
volume (93.8% of prescription vs. 84.7%). Nevertheless, the NHC plan was hotter than the
corrected, with a Dmax of 116.1% as opposed to 113.2%, and an average dose received by the
PTV calculated at 99.8% rather than a mean of 96.5% in the HC plan. There was also an increase
in MU’s from the corrected to not corrected plans. The MU’s increased 116% from 128 to 148
for the AP beam, and 121% from 117 to 141 for the PA beam, as a result of the significant depth
of the tumor and the greater density tissue traveled through.
In a study by Xiao et al.2 similar results were recorded when analyzing 20 HC and NHC 6
MV treatment plans from multiple institutions submitted to be part of the protocol RTOG 0236:
Stereotactic Body Radiation Therapy of Inoperable Stage I/II Non-Small Cell Lung Cancer. A
requirement of the protocol was to create one treatment using homogenous water density, and
another calculated with heterogeneity corrections but using the same monitor units by altering
beam weighting. Upon comparison of corrected versus non-corrected plans, it was found that the
volume receiving full prescription dose dropped on average by 10.1% in the HC plans.2 This was
nearly the same result as the current plans in comparison, however, it should be noted that the
MU’s of the above NHC plan were not adjusted to match those of the HC.
On the contrary, a 2003 publication by Frank et al.3 with a similar interest in comparing
HC and NHC plans for 30 patients undergoing treatment for non-small-cell lung cancer
concluded an opposing outcome. When using heterogeneity corrections, the coverage of the PTV
was proven significantly higher than when treated as homogenous, and no significant differences
were recorded amongst maximum doses.3 Though two similar studies yielded conflicting results,
it is important to recall the case-by-case nature of treatment planning before drawing official
conclusions, as variation is often dependent of location of the tumor and beam geometry.4
While heterogeneity corrections have a dramatic effect in the thoracic region, they also
play a significant role in correcting for other forms of heterogeneity, such as artifact.2,5 Artifact
may come in the form of dental work or a prosthetic body part, and it often causes streaking in
the CT images. This streaking is inaccurate and will be read as a higher density material able to
cause greater attenuation than is physically present in the body, causing an inaccurate calculation
by the treatment planning system.5 When this occurs, it is in the best interest to include any high
density material that truly remains, yet carefully alter the density on the image only in the areas
where the streaking arises. Air in the bowel at the time of scan may also inaccurately portray the
density of the tissue to the treatment planning system. To prevent this and any calculation
inaccuracy that may result, a bowel prep may assist in cleaning and emptying the intestine.5 All
steps, including fusion of other diagnostic imaging to the CT, should be taken to yield the most
accurate representation possible of the exact patient’s anatomy.
Given an accurate representation of a patient’s anatomy, complex heterogeneity
correction calculations are able to predict the interaction of a radiation beam throughout the
various tissue densities found in the body. In doing so, the program may accurately estimate the
dose received by targets and surrounding structures despite any complex variation in anatomy.
The benefit of being able to view these dose distributions is invaluable, and has a profound effect
on the efficacy of the treatment and quality of life for the patient. For these reasons,
heterogeneity corrections are now an indispensable feature of any advanced treatment planning
system.
References
1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th Ed. Philadelphia, PA:
Lippincott Williams & Wilkins. 2014:179, 221-223.
2. Xiao Y, Papiez L, Paulus R, et al. Dosimetric evaluation of heterogeneity corrections
for RTOG 0236: Stereotactic body radiotherapy of inoperable stage I-II non–small-
cell lung cancer. Int J Radiat Oncol Biol Phys. 2009;73(4):1235-1242.
doi:10.1016/j.ijrobp.2008.11.019.

3. Frank SJ, Forster KM, Stevens CW, et al. Treatment planning for lung cancer:
Traditional homogeneous point–dose prescription compared with heterogeneity-
corrected dose–volume prescription. Int J Radiat Oncol Biol Phys. 2003;56(5):1308-
1318. doi:10.1016/s0360-3016(03)00337-7.

4. Ding GX, Duggan DM, Lu B, et al. Impact of inhomogeneity corrections on dose

coverage in the treatment of lung cancer using stereotactic body radiation
therapy. Med Phys. 2007;34(7):2985-2994. doi:10.1118/1.2745923.

5. Williams G, Tobler M, Gaffney D, Moeller J, Leavitt DD. Dose calculation errors due
to inaccurate representation of heterogeneity correction obtained from computerized
tomography. Med Dosim. 2002;27(4):275-278. doi:10.1016/s0958-3947(02)00147-4.