Fuller 1

Keenan Fuller
DOS: 523 – Treatment Planning
Treatment Planning Project

Introduction
Radiation is constantly interacting with varying densities as it passes through normal
tissues traveling toward a target. Traditionally, in radiation therapy, dose has been predicted by
testing the prescription to a homogeneous water phantom, which assumes that the patient’s body
is also a homogenous medium.1 This is not the case, as it is known that body tissue is made of
many different densities and such differences in tissue, or heterogeneities, which need to be
accounted for and then analytically calculated in a way which corrects for the changes in density
within the patient. During a simulation computed tomography (CT) scan, objects of differing
densities are assigned specific electron densities based off a matrix which is derived from a CT
value known as a Hounsfield unit (HU). Electron densities representing these tissue values are
then used to create a heterogeneity correction factor, which is used by the treatment planning
software (TPS) to generate the dose distribution charts, depth dose tables, and isodose
distribution lines for the plan.1 Having a particular TPS algorithm that can adequately
compensate or correct for tissue inhomogeneities becomes more important in areas such as lung
or air cavities because of the many different types of tissues that the beam must pass through to
reach the target.
Patient History
The patient data used for this planning project was a 66-year-old male that presented with
a history of pancreatic cancer and non-small-cell lung carcinoma (NSCLC) (adenocarcinoma).
There is a new growing nodule in the right middle lobe, which was initially diagnosed in 2012
during a routine surveillance scan for his pancreatic cancer. Relevant history included a right
upper lobectomy and lymph node dissection on February 6, 2012 for pT1a (1.5cm) pN0M0
NSCLC, well-differentiated adenocarcinoma. After the lobectomy and dissection, all margins
were negative with no further treatment given for his lung cancer at that time. Due to the location
of the new nodule recurrence, the option of biopsy was determined to be too morbid. The plan is
to treat the site of NSCLC recurrence with a course of radiotherapy: 60 Gy (6000 cGy) in 30
fractions.
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Methods and Materials

For this treatment planning project, the patient case will be evaluated in order to
demonstrate the effect the use of heterogeneity corrections has on a basic right lung tumor plan.
The patient first had a simulation CT scan of the thorax which was transferred and loaded to
MIM version 6 for organ and tumor volume contouring. In this case, the tumor was located
within the medial right lung and was given a planning target volume (PTV) margin to be treated
by the attending physician which is displayed with magenta in the planning Figures 1-6. Also
contoured were the heart, right lung, left lung, combined lungs, and spinal cord. A two-field
beam arrangement was created utilizing a basic anterior-posterior/posterior-anterior (AP/PA)
plan setup with the isocenter at the center of the PTV lung volume. At Froedtert Hospital –
Milwaukee, Wi the lowest photon energy available is 6 MV, which was assigned to both beams
and a 1 cm margin was placed around the PTV. In order to balance the dose to the tumor
location, the AP beam was weighted at 3100 cGy / 30 fx and the PA beam was weighted at 2900
cGy / 30 fx for a 6000 cGy total prescription dose. Since the purpose of this project is not to
necessarily obtain a clinically acceptable plan but to show the effects of heterogeneity
corrections within the lung, no other changes were made to the treatment field parameters.
In order to properly show the effects of heterogeneity corrections within this treatment
plan, the Xi0 TPS superimposition algorithm for pixel heterogeneity correction will first be left
in the default mode which is on. The treatment plan will then be re-calculated, this time with the
pixel heterogeneity correction turned off. Keeping all other factors the same, both treatment
plans will then be compared with any differences and observations noted.
Results
The isodose distribution differences between the plan with heterogeneity corrections
turned-on versus turned-off are quite substantial and are demonstrated visually by the axial,
sagittal, and coronal views in Figures 1-6 as well as in the dos-volume-histograms (DVH) in
Figures 9 and10. With the axial slices, it can be seen that the plan with heterogeneity corrections
turned-on that the distribution of isodose lines is more irregular and has a greater concentration
of dose laterally as the beam energy passes through lung and heart tissue, compared to that of
plan with heterogeneity turned-off which shows a fairly even distribution both in uniformity and
in spacing between the isodose lines. The most prominent difference between the two plans can
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be viewed within the sagittal images from the TPS. These images show that in the plan with
heterogeneity tuned-on the dose will first build up within the soft tissue and then slope inward
toward the tumor volume as it approaches the isocenter. Given that the patient tissue is defaulted
to a water-equivalent, an even dose distribution in the sagittal image is once again seen when the
heterogeneity correction is turn-off, in this case the isodose lines follow the external patient
contour, creating a greater amount of full prescription amount superiorly. This effect on the dose
distribution can be seen on the coronal images as well, which show a greater amount of dose
superiorly and when heterogeneity corrections are turned-on a significantly greater amount of
dose to the lateral aspect of the PTV.
There was not a great difference in the global maximum dose (hotspot) point between the
plan with heterogeneity turned-on verses turned-off. With heterogeneity corrections turned-on
the max hotspot point dose was 7432.2 cGy and with heterogeneity corrections turned-off the
max hotspot point dose was 6870.6 cGy, so a difference of only 561.6 cGy. Similarly, the
location of the max hotspot dose did not change much, as it was located within the anterior chest
wall of the patient for both plans, with shifting local max dose depending on the CT slice chosen
for comparison. Another point to note was that the monitor units (MU) for the two plans varied
to some extent with the AP field for the plan with heterogeneity corrections turned-on requiring
135.42 MU while the AP field for the plan with heterogeneity corrections turned-off requiring
133.95 MU. The PA fields had a greater difference between the plans – the plan with the
heterogeneity correction turned-on and the plan with the heterogeneity correction turned-off
requiring 125.23 MU and 131.64 respectively. This shows that there is was a little to no change
in the MU needed on the for the AP fields, however an increase in MU needed for the PA fields
indicating that more MU would be needed when a radiation beam is passing through water-
equivalent rather than air. The plan printout, including the MU data, can be seen in Figures 7 and
8.
At Froedtert Hospital – Milwaukee, WI plans are also evaluated based on a wish-list from
the attending physician, which provides a list of volumes of interest and PTV with corresponding
dose constraints for each. For a lung plan the typical structures on this wish-list will include the
PTV, lung_R + lung_L – ITV, spinal cord, heart, and esophagus. Given the tumor location, this
6000 cGy AP/PA arrangement will obviously fail the normal constraints, so just the PTV volume
is examined in this project. The plan with heterogeneity corrections turned-on provided full
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prescription dose coverage to 46.44% of the PTV, with the right lung receiving a max dose of
6669.0 cGy, a mean dose of 2590.0 cGy, and a min dose of 37.0 cGy. The plan with
heterogeneity corrections turn-off provided full prescription dose to 25.02% of the PTV, with the
right lung receiving a max dose of 6360.0 cGy, a mean dose of 2455.0 cGy, and a min dose of
35.0 cGy. These results prove that the PTV would be underdosed if heterogeneity corrections
were turned off.
Discussion
Having inhomogeneity corrections turned-on can be useful to display proper dose
distribution when treatment planning, especially when the target volume is within lung tissue or
another area of low-density such as an air cavity. This is important because when inhomogeneity
corrections are turned-off, the isodose curves do not account for the effect the various layers of
fat, bone, muscle, lung, and air that have on the radiation beam travelling through to reach the
intended target.2 Depending on the quality or energy of the radiation and the type and thickness
of material that is passed through, the inhomogeneity factors will change. The two major effects
of tissue inhomogeneities are classified as: changes in the absorption of the primary beam with
the related pattern of scatter, and changes in secondary electron fluence.2 The inhomogeneities
can be given a value based on their properties and then a shift or correction can be determined in
order to create a more accurate isodose distribution chart. Since lung tissue is filled with air, it is
substantially less dense than normal body tissue as well as the tumor volume to be treated.
Without turning on heterogeneity corrections a plan would be created which could potentially
overdose the target because the TPS alters beam isodose line assuming that there is more
attenuation taking place than actually occurs.1
Numerous methods have been created to correct for inhomogeneities, one such example
being the isodose shift method. This method, is used to correct isodose charts for points beyond
the inhomogeneity and takes into consideration the amount the isodose curve is shifted.2 This
amount is equal to n times the inhomogeneity thickness as measured parallel to the central axis
and through the point of interest.2 The shift created around air cavities and/or lung tissue will be
away from the skin and the shift for bone will be toward the skin, which is demonstrated in
Figures 1-6 below. Data from the shift method can be calculated and isodose shift factors can be
created for different types of inhomogeneities. These inhomogeneity corrections and dose shifts
are evident by viewing two plans, one with the homogeneity corrections turned-on and then
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turned-off. An example of this can be seen well in Figures 1-4. The isodose lines in the plan
where inhomogeneity was turned-on, appear more jagged and irregular as they are corrected for
the various densities being passed through, especially the low density in the lung, while the plan
with inhomogeneity turned-off the isodose lines remain uniform following the external patient
contour.
Heterogeneity corrections will also have an impact on a plan in cases where there is metal
artifact within the area to be treated. Opposite of the low density within lung tissue and air
cavities, high density implants (such as those used for prosthetic hips and dental fillings) will
attenuate more of the beam energy leading to beam hardening, noise, scatter, and photon
starvation causing artifacts, which result in inconsistencies within the CT raw data.3 When the
patient has a simulation CT, the high density nature of these implants will lead to incorrectly
reconstructed HU in the CT images, this results in a streaking affect on the planning CT which
will cause a loss of accuracy in the dose calculations in the plan.3 The affect that the metal causes
in the planning CT can be accounted for in the TPS by first contouring the artifact and then
assigning it to a specific electron density that corresponds to its metallic composition. The
streaking seen in simulation CT scans with metal can also be accounted for. This is done by
contouring the area affected by the streaking and then assigning it a value similar to the
surrounding tissue then adjusting the heterogeneity correction factor so that the TPS treats it as
normal tissue. It is very important to use heterogeneity corrections for plans that involve metal
because planning based on images that contain artifacts have been shown to lead to a dose error
at isocenter of up to 8.4%.3
Similarly, it is important to use heterogeneity corrections for plans using contrast media
in the simulation CT, such as prostate and rectal cancers, because the contrast can influence the
TPS dose calculations. For example, contrast within the small bowel at the time of the simulation
CT will create artifact on the scan. When seen by the TPS, this contrast artifact will be accounted
for and calculated as such. Therefore, treatments planned on contrast images will usually show a
lower amount of radiation dose to both the target volume and the organs at risk (OAR) because
the TPS is compensating for increase in attenuation due to the high density contrast.4 For this
reason, heterogeneities caused by the contrast should be corrected for since the contrast will not
be there at the time of treatment. Recent research has shown that the radiation dose differences
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between plans for CT scans with and without contrast artifact are not significant after it has been
corrected for.4
An important factor to note in lung treatment planning, and really any plan, is the use of
proper algorithms. Many algorithms have been fashioned in an attempt to accurately display the
isodose lines and the corresponding curves created by inhomogeneity interaction. In radiation
therapy, these algorithms play a vital role in verifying that the proper treatment planning dose is
reaching the target while sparing normal structures with an expected accuracy of 5% or
less.5 With a wide array of algorithms used in the clinical setting, it is important to know the
effectiveness and limitations with the accuracy of each. Another important consideration for lung
treatment planning is the beam energy. Since dose within the lung is mainly ruled by its density,
specifically lower lung density will give rise to a higher dose inside of and beyond the lung
tissue however, there is a slight decrease in dose to the tissue just beyond and in front of the lung
cavity.2 This is due to a loss in electronic equilibrium as the high-energy photon beam passes
through the lung, meaning that as the beam goes through an area of lower density, an increasing
number of electrons travel outside the geometric parameters of the beam, thus reducing the dose
along the central axis.2 This leads to the reasoning behind using 6 MV photon energy, when
applicable, for lung cases instead of a higher energy such as 18 MV because of the dose build-up
needed at the tumor site is greater for higher energies. This build-up causes a decrease in the
dose just beyond the air cavity – most notably at the surface, in this case being the tumor volume
beyond the lung tissue.2
Conclusion
When planning lung treatments, there are many factors which affect the dose distribution
and plan constraints that need to be taken into consideration, one of the most important being
heterogeneity corrections. The goal with any plan is to create a treatment which will deliver the
proper dose to a specified volume with minimal dose to surrounding tissue. Without
heterogeneity corrections turned-on there is a risk for inaccuracies and a potential to over or
under dose the patient, depending on location of the volume of interest. This project has proven
that, within the scope of lung treatment planning, the use of heterogeneity corrections will create
a superior plan which is both more accurate and effective at treating lung tumor volumes.
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Figure 1: Axial slice of plan with heterogeneity corrections turned-on, yellow isodose line
represents the 6000 cGy prescription dose

Figure 2: Axial slice of plan with heterogeneity corrections turned-off, yellow isodose line
represents the 6000 cGy prescription dose
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Figure 3: Sagittal slice of plan with heterogeneity corrections turned-on, yellow isodose line
represents the 6000 cGy prescription dose

Figure 4: Sagittal slice of plan with heterogeneity corrections turned-off, yellow isodose line
represents the 6000 cGy prescription dose
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Figure 5: Coronal slice of plan with heterogeneity corrections turned-on, yellow isodose line
represents the 6000 cGy prescription dose

Figure 6: Coronal slice of plan with heterogeneity corrections turned-off, yellow isodose line
represents the 6000 cGy prescription dose
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Figure 7: MU printout for plan with heterogeneity corrections turned-on

Figure 8: MU printout for plan with heterogeneity corrections turned-off

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Figure 9: Cumulative DVH for plan with heterogeneity corrections turned-on, illustrating the
volume to dose relationship of the contoured structures.

Figure 10: Cumulative DVH for plan with heterogeneity corrections turned-off, illustrating the
volume to dose relationship of the contoured structures.
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References
1. Herman Tde L, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of tissue
heterogeneity corrections in stereotactic body radiation therapy treatment plans for lung
cancer. J Med Phys. 2010;35(3):170–173. doi:10.4103/0971-6203.62133.
2. Khan FM, Gibbons JP. Corrections for tissue inhomogeneities & Electron beam therapy.
In: The Physics of Radiation Therapy, 5th ed. Philadelphia, PA: Wolters Kluwer; 2014,
214-291.
3. Ziemann C, Stille M, Cremers F, Buzug TM, Rades D. Improvement of dose calculation
in radiation therapy due to metal artifact correction using the augmented likelihood image
reconstruction. J Appl Clin Med Phys. 2018;19(3):227–233. doi:10.1002/acm2.12325.
4. Heydarheydari S, Farshchian N, Haghparast A. Influence of the contrast agents on
treatment planning dose calculations of prostate and rectal cancers. Rep Pract Oncol
Radiother. 2016;21(5):441–446. doi:10.1016/j.rpor.2016.04.004.
5. Asnaashari K, Nodehi MR, Mahdavi SR, Gholami S, Khosravi HR. Dosimetric
comparison of different inhomogeneity correction algorithms for external photon beam
dose calculations. J Med Phys. 2013;38(2):74–81. doi:10.4103/0971-6203.111310.