Alyssa Olson

Dos-523: Treatment Planning

Heterogeneity Correction
March 12, 2016

Introduction: Heterogeneity corrections (HC) are an important concept for consideration in

treatment planning dosimetry. The presence of vital organs and tissues with varying electron
densities within the beams path will alter the isodose distribution through the principle of
attenuation and scatter.1 Tissues of greater density, such as muscle or bone, will attenuate more
of a radiation beam in comparison to tissues of low density such as lung and air.2 As a result,
beam interactions with higher density materials shift the isodose lines towards the heterogeneity
while low density materials push the isodose lines further into the medium. While historical
isodose data was gathered using mediums of homogenous density, it can be argued that the
utilization of the HC will more accurately display the projected isodose distribution in a patient
plan.1 The objective of this project is to understand how HC can impact the isodose distribution
and its role in treatment planning through design and assessment of a lung tumor data set.
Methods and Materials: A simulation planning CT was completed on a patient who presented
with a stage 1B T2a N0 small cell carcinoma lesion in the right posterior lung. Their plan was
imported from DICOM into the Eclipse treatment planning system (TPS) workstation. Organs at
risk (OR) segmentation was performed on all pertinent structures which include the body, right
lung, left lung, spinal cord, tumor, and heart. The isocenter was established in the middle of the
tumoror gross tumor volume (GTV). Two treatment planning fields were created and oriented
in an antero-posterior, postero-anterior fashion using an energy of 6 MV and a field size of 8.2
cm2 by 8.4 cm2. To account for internal motion and set-up error inconsistencies, custom multileaf collimation (MLC) blocking was added to each field and fit to the GTV using a margin of 2
cm. The prescription requested a total dose delivery of 6000 cGy in 30 fractions to the planning
target volume (PTV), delivering 100% of the prescribed dose to 100% of the target volume. The
plan was normalized to the GTV and equal weighting was applied. Keeping all parameters the
same, the plan was copied and the dose was calculated twice: HC on, and HC off. The plans
were evaluated and differences were compared.

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Results: Noticeable differences can be observed when comparing the two treatment plans. As
shown in the treatment summaries of Figure 1 and 2, the total number of monitor units (MU)
required to deliver 180 cGy to the GTV is greater without the application of HC versus with HC,
with 298 MU and 273 MU respectively. In addition, while the PA MU contribution of both
plans is relatively similar, the most significant modification is the MU contribution from the AP
field; the plan without HC yields 173 MU while the HC plan yields 141 MU.
Obvious variances of the isodose distribution can be observed in the axial, coronal, and
sagittal views in Figures 3-5. The HC plan displays many perturbations in the isodose lines, as
they are non-uniform, contain inward bowing near midline at the tissue-lung interface, and are
irregularly-shaped. In contrast, the non-HC plan displays smooth, uniform, and evenly spaced
isodose lines throughout. Finally, hot spots of 130% are present within both plans, however, it is
more pronounced in the non-HC plan at the anterior surface. A hot spot of 115% on the
posterior aspect of the patient is present in the HC plan which is absent in the non-HC plan.
An analysis of the DVH for both plans was conducted by comparing the minimum GTV
dose, maximum GTV dose, mean GTV dose, and overall maximum dose present in the plan.
The non-HC DVH displayed 5,946 cGy, 6,198 cGy, 6,084 cGy, and 7,890 cGy respectively
(Figure 6). Likewise, the HC plan displayed 5,850 cGy, 6,576 cGy, 6,300 cGy, and 7,236 cGy
respectively (Figure 7). A final discrepancy can be noted with the amount of the right lung
receiving over 100% of prescription dose: approximately 16.5% in the non-HC plan versus 15%
in the HC plan.
Discussions: This project provided validation that heterogeneity corrections significantly alter
the isodose distribution when treating near tissue interfaces of varying density, such as the lung.
A drastic difference was noted in both plans with regard to the number of MU in the AP fields.
In comparison to water, there are less electrons per unit area in the lung; this correlates to a
decreased probability of interaction with the interacting radiation beam.1 More power is needed
to provide prescription dose coverage to the GTV in the plan without HC due to the TPSs
assumption that the beam is traversing through a homogenous medium of water rather than lung.
Therefore, more of the primary beam is transmitted to the GTV if the beam traverses through the
lung versus water (Figure 3 and Figure 4).

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Variances in the isodose distributions occur for specific reasons. As Kahn and Gibbons1
state, Compton scatter is the predominate interaction to occur in therapeutic energy ranges; it is
independent of atomic number but dependent on electron density. Therefore, as shown in the
HC plan in Figure 3, almost all of the 120% isodose line is attenuated in the chestwallan
electron dense materialwhile the homogenous plan disregards that tissue interface. In
addition, absorbed dose within a tissue heterogeneity influences the secondary electron fluence.1
The inward bowing of the 105% isodose line in the HC plan can be attributed to a reduction in
secondary electrons due to increased lateral scatter away from the central axis (Figure 3).
Similar findings were noted in a study by Ellen and colleagues3 which examined the
benefits of HC when treating the breast. The inclusion of lung in the breast tangent field
impacted the isodose distribution to the breast tissue through the process of attenuation. The
increased attenuation of the beam in the chestwall decreased the overall mean dose to the breast
by approximately 1.4% in comparison to a homogenously-generated breast plan. In addition, the
homogenous plan resulted in a higher lung dose due to its inability to account for such tissue
changes. While the TPS is a mere estimation of the delivered dose, an underdose of 1.4% to the
target could actually be greater during treatment delivery.
Hot spot size and location are critical in a plan evaluation. In this project, a noticeable
hot spot of 115% was present in the HC plan on the posterior aspect of the patient. The rationale
to this finding is due to the location of the hot spot: beyond the tissue inhomogeneity. According
to Kahn and Gibbons,1 areas beyond a heterogeneity will be predominantly affected by the
primary beam rather than secondary electron fluence. Because the lung does not absorb as much
of the primary beam in the HC plan, more radiation is present beyond the lung-tissue interface,
creating a larger hot spot at the posterior side.
Hot spots to ORespecially the lungwere a main concern voiced in a study conducted
by Nakayama et al4 for treatment of the esophagus. The studys results demonstrated a 6.5%
increase in the lung dose received when planning homogeneously rather than with HC. Because
the lung is so radiosensitive, a small percent variance can cause the patient detrimental and
critical complications.
Finally, a daily task of any medical dosimetrist is to critically assess the plan DVH to
ensure proper target and OR coverage or avoidance. Overall, the homogenous plan demonstrated

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a higher maximum dose to the right lung, a lower maximum dose to the GTV, and a lower GTV
mean dose in comparison to the HC plan. Again, this can be primarily attributed to the inability
to account for tissue changes when HC is turned off.2
A study, conducted by Ueki et al, evaluated the impact of heterogeneity correction using
3 types of dose calculation algorithms for treatment of lung lesions using stereotactic body
radiation therapy (SBRT). Variances in overall target coverage were foundespecially between
Batho power law (BPL) versus no HC correction. While keeping all geometric parameters the
same, the mean dose to the PTV using BPL was 9.6% greater than without HC applied. These
findings could underdose the tumor and drastically impact the treatment outcome if HC is not
considered in regions which include portions of the lung.
Conclusions: Since the implementation of HC in the treatment planning system algorithm, the
projected dose delivery accuracy has been significantly improved.3-5 Even in soft tissue areas
with moderate homogeneity, such as the breast, HC proved to provide a more accurate dose
projection.3 This aspect should be of great consideration due to the studys claim that
inhomogeneous breast plans can adversely impact cosmetic outcome. While it is still possible to
plan without using HC it is not recommended in areas of the body with high density variations,
such as treatment of the lung or esophagus.4,5 Whether the treatment goal is for a curative intent
or a sustenance of a high quality of life, these findings should help to drive treatment centers to
create the best treatment plan possible for patients. HC was created for a specific purpose of
achieving the most accurate replication of the isodose distribution during treatment planning.
Utilization of this feature only serves to benefit the patient.

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Figure 1. Dose-volume histogram of lung treatment plan without heterogeneity correction
applied

Figure 2. Dose-volume histogram of lung treatment plan with heterogeneity correction applied

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Figure 3. Axial view of a lung treatment plan demonstrating the impact of heterogeneity
correction on the isodose distribution to GTV

Heterogeneity Correction Off

Heterogeneity Correction On

Figure 4. Plan comparison of isodose distribution in sagittal view of lung treatment plans with
and without the heterogeneity correction factor

Heterogeneity Correction Off

Heterogeneity Correction On

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Figure 5. Plan comparison of isodose distribution with heterogeneity correction in coronal view

Heterogeneity Correction Off

Heterogeneity Correction On

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Figure 6. Dose-volume histogram (DVH) of lung plan without heterogeneity correction

GTV
GTV
LeftLung
Lung
Left
SpinalCord
Cord
Spinal
RightLung
Lung
Right
Heart
Heart

Figure 7. Dose-volume histogram (DVH) of lung treatment plan with heterogeneity correction

GTV
Left Lung
Spinal Cord
Right Lung
Heart

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References
1. Kahn FM, Gibbons JP. Kahns The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.
2. Stanton R, Stinson D. Applied Physics for Radiation Oncology. Madison, WI: Medical
Physics Publishing; 1996.
3. Ellen MM, Hogstrom KR, Miller LA, Erice RC, Buchholz TA. A comparison of 18-MV and
6MV treatment plans using 3D dose calculation with and without heterogeneity correction.
Med Dos. 1999;24(4):287-294. doi:http://dx.doi.org/10.1016/S0958-3947(99)00022-9
4. Nakayama M, Yoshida K, Nishimura H, et al. Effect of heterogeneity correction on
dosimetric parameters of radiotherapy planning for thoracic esophageal cancer. Med Dos.
2014;39(1):31-33. doi:http://dx.doi.org/10.1016/j.meddos.2013.09.001
5. Ueki N, Matsuo Y, Shibuya K, et al. Differences in the dose-volume metrics with
heterogeneity correction status and its influence on local control in stereotactic body
radiation therapy for lung cancer. J Radiat Res. 2013;54(2):337-343.
doi:http://dx.doi.org/10.1093/jrr/rrs084