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Patrick Melby
DOS 523 Treatment Planning
March13th, 2016
Heterogeneity vs. Non-heterogeneity Corrections
Introduction
The human body is comprised of many different types of tissues. These tissues have a
large range of electron densities going from tissues of very low densities like lungs, to tissue like
bone which have very high densities. In radiation therapy, as the photon beam passes through
the patient, it will interact differently when it interacts with each tissue. With heterogeneity
corrections factored in the radiation therapy plan, the dose distributions will take into account the
different electron densities of the various tissues. Without it, the patient is assumed to be a
homogeneous tank of water.1 The standard isodose charts are based on these homogeneous
models that are solely based on the electron density of water.
Before the 1970's radiation treatment were solely based on these homogeneous models.
It was the emergence of computer tomography (CT) that allowed for the heterogeneity of the
human body to be evaluate.2 The CT machines were able to calculate the electron density
information from the patient that would later be included in the dose calculations. Because of
the need for further computer advances along with the historical data on homogeneous
treatments, heterogeneous corrections were not immediately accepted by the field. Today,
because of the advancement of computers, these issues no longer apply.
To validate the need for heterogeneity corrections, we first look at the main type of
interaction of megavoltage (MV) photon beams: the Compton effect.3 The Compton effect is
when an incoming photon interacts with an electron and transfers enough energy to free it from
its binding energy and emit it from the atom. This transfer of energy will alter the path of the
photon by scattering it at a different angle. The amount in which the Compton effect occurs is
based off the electron density of the target.4 This shows that incorporating the electron density
obtained by the CT could affect the distribution of the dose.
Looking at the influence of Compton's scattering on the photon, we can see that the
change in angle from the interactions will alter the path of the primary photon. With a change in
electron density the number of interactions of the Compton effect will be different. So areas past
an inhomogeneity will be affected, resulting in a less accurate estimation of the dose
distribution.3 Also, since the number of secondary electrons created from the Compton effect
will be affected by the inhomogeneity, the dose within the inhomogeneity will also be altered.

Another topic in which incorporating the heterogeneity correction would affect the dose
distribution would be when assessing the dose to the lung-tissue interface. In these interfaces,
there is a large change in electronic density. The difference causes a loss of electronic
equilibrium within the lung tissues. Once the radiation reaches soft tissue, the dose then needs to
build back up and potentially miss parts of the tumor close to the surface.5 Certain algorithms
are better at detecting these changes at the tissue interface. For example according to the Eclipse
reference guide, "When a beam traverses lung tissue, the AAA tends to overestimate dose at the
lung-soft tissue interface, where the beams exits the lung and enters soft-tissue again. The effect
is more pronounced as the interface depth increases."6 Because of this, for the observations of
heterogeneity corrections, Acuros XB was used.
Heterogeneity corrections have become the standard in radiation therapy. Specifically
lung treatments are where the heterogeneity corrections will be examined. This paper will
review the findings of other research along with a personal investigations on how much
heterogeneity corrections can change the dose distribution of the plan.
Methods
To test the affects of the heterogeneity correction factors on the dose distribution, two
separate plans were made on a test patient. The difference between these two plans was only that
the heterogeneity correction was turn-off. The plans consisted of a patient with diseased tissue
within her right lung. Contours were created for the patient as a whole, right lung, left lung,
spinal cord, tumor, heart. Two 6MV beams were placed as opposing beams with one coming
directly anterior (AP) and the other from the posterior (PA). A 2cm margin was created around
the PTV to count for any movement or errors associated with the patient set-up. The algorithm
used to create both plans was the Acuros XB. The plans were assessed by visually comparing
the dose distribution throughout the treated area along with analyzing the cumulative dosevolume histogram. Additionally, a third plan was created to compare monitor units (MU) of
plans with and without heterogeneity corrections. This plans had similar dose coverage of the
target as the previous plan made without heterogeneity corrections.
Results
The results show that there was a significant difference between plans with and without
the heterogeneity corrections. Figure 1 show the digital reconstruction of the AP field to
visualize the beam's eye view for all plans. The plan without heterogeneity corrections was first

created and the dose was prescribed to isocenter. In order to get 100% of the dose to 95% of the
volume, I deceased my prescribed percentage to 98.3 %. The prescribed percentage kept the
same for the plan with heterogeneity corrections to evaluate the change in dose coverage. The
dose distributions for both plans can be seen in Figures 2 and 3.

Figure 1. Anterior DRR of both plans

Figure 2. Axial, sagittal, and coronal slices of the patient with no heterogeneity corrections

Figure 3. Axial, sagittal, and coronal slices of the patient with heterogeneity corrections
By comparing the dose distribution within the 3-dimensional images, it is observed see
that there is difference between the two. First, noting that the max dose for the plan without
heterogeneity corrections is 7791.7cGy as compared to the 8176.7cGy in the heterogeneity
corrected plan. Second, in the plan with no heterogeneity correction the hot spots are located
near the patients surface, with the hotter spots located superiorly which is caused by the decrease
in thickness of the patient. As for the heterogeneity corrected plan, the hotspots are located also
near the surface of the patient, but they are also in areas in which the beam travels through more
lung tissue. These areas are located more medial and inferiorly. And third, the heterogeneity
corrected plan has a difficult time getting dose to the lateral edge of the tumor. This underdose
can be easily assessed in the dose-volume histogram (DVH).
As for dose distribution, as previously mentioned, the plan with no heterogeneity
correction was purposely set to have 100% of the target dose going to approximately 95% of the
target volume. As for the plan with heterogeneity corrections, with the same conditions applied,
100% of the dose was only going to 79% of the target volume. The DVH and a close-up of the

DVH is displayed in Figures 3 and 4, respectively with printouts of the MU sheets for each plan
in Figures 6-9.

Figure 4. DVH of both plans

Figure 5. A close-up of the DVH containing of both

Figure 6. The treatment plan printout for AP beam without heterogeneity corrections.

Figure 7. The treatment plan printout for PA beam without heterogeneity corrections.

Figure 8. The treatment plan printout for AP beam with heterogeneity corrections.

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Figure 9. The treatment plan printout for PA beam with heterogeneity corrections.
The monitor units (MU) displayed in Figure 6-9, were less for the heterogeneity corrected
plan which also had less tumor coverage. So next I wanted to compare the MU in a
heterogeneity corrected plan that covered 100% of the dose to 95% of the tumor volume just
like the plan without heterogeneity corrections. The DRR is the same as in Figure 1. The dose
distributions is displayed in Figures 6.

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Figure 10. Axial, sagittal, and coronal slices of the patient with no heterogeneity corrections
By comparing the dose distribution from Figure 1 and Figure 10, it can be seen that the
dose coverage of the lateral edge dips in more towards the tumor. Otherwise the tumor coverage
is similar. This was expected since the plans were prescribed to 95% coverage. The max of the
heterogeneity corrected plan is now 8252.7cGy as compared to the 7791.7cGy for the
homogeneous plan. The MU for the heterogeneity corrected plan, as seen in Figures 11 and 12,
were 155MU for the AP beam and 160MU for the PA beam. Looking at the homogeneous plan,
the MU for the respective AP/PA beams are 167MU and 168MU.

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Figure 11. The AP printout with heterogeneity corrections with 95% coverage.

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Figure 12. The PA printout with heterogeneity corrections with 95% coverage.
Discussion
By comparing the first two plans, it can see the true affects of the lung-tissue interface.
In the homogeneous plan, the dose distribution is based solely off of patient thickness. The hot
spots are along the surface, in the areas in which the patient is thinner. But once the
heterogeneity corrections were turned on using the same plan, it can seen that the dose has a
difficult time depositing itself with the lateral edges of the tumor. This can be explained since in
these areas, the beam did not have enough space to effectively build-up and reach equilibrium
within the tissue.3 Because of this, the dose was not able to affectively cover the tumor
depositing 100% of the dose to only 79% of the tumor. This is significantly lower than the
homogeneous plan, which deposited 100% of the dose to 95% of the tumor. Other things that
can be observed from the comparison is that the areas with increased lung tissue within the
beam's path displayed a higher dose to the soft tissues surrounding the lung. This increase in
dose is due to the fact that there are fewer interaction between photons and the lung tissue
because of the decreased electron density. Because of this, in areas in which the beam travels
through more dose the distal tissue will have an increased dose. An approximate increase of

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dose for tissues beyond healthy lung for a 6MV lung are estimated to be an increase of between
2-3% /cm of lung.4
With the second comparison, the MUs required for a heterogeneous and homogeneous
plan to obtain similar dose distributions within the tumor were evaluated. In this comparison it
is seen that the heterogeneity corrected lung plan required less MU's to achieve the same dose
restraints. Again, this can be attributed to the photon being more penetrating through the lung
tissue. If the MUs would have been the same for both the plans, it can be assumed that the plan
without the heterogeneity correction factors would be around 7% hotter because there would be
7% more MUs. This corresponds with the past studies that show that depending on the lungs
thickness, applying a heterogeneity correction can result in a -10% to +30% change in the dose
distal to the lung.1 In addition to this, the heterogeneity plan already had higher hot spots than the
homogeneous plan in areas that traversed through mostly lung tissue. These hot spots would be
even further increased. This assumption could be tested in a future observation that created both
plans with the same amount of MUs for each beam and compare the dose distribution. I assume
that if the MU were increased onto the plans with heterogeneity corrections to the amounts of
167 and 168MU that the actual hotspots that we would be creating would be much larger than the
plan without heterogeneity suggests.
Throughout my observations, it is determined that the heterogeneity corrections make a
significant difference within lung plans. This corresponds with other studies conducted in the
past that have determined that heterogeneity factors are significant for most lung patients, and
the uniformity in the lungs is worse when the dose distribution are corrected for heterogeneity.2
It has been shown that because of the changes in attenuation, along with the affects of tissue-lung
interfaces that applying the heterogeneity corrections to a lung will create a more accurate dose.

References
1. Mackie TR, Liu HH, McCullough EC. Treatment planning algorithms: Model-based photon
dose calculations. In: Kahn FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd Ed.
Philadelphia, PA. Lippincott Williams & Wilkins. 2012. 93-110

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2. Papanikolaou N, Battista JJ, Boyer AL, et al. AAPM Report No. 85: Tissue Inhomogeneity
Corrections for Megavoltage Photon Beams - Report of Task Group No. 65 of the Radiation
Therapy Committee of the American Association of Physicists in Medicine. Madison: Medical
Physics Publishing; 2004
3. Khan FM, Gibbons J. Khan's The Physics of Radiation Therapy. 5th Ed. Philadelphia, PA:
Wolters Kulwer. 2014.
4. Prado CM, Prado KL. Photon dose distributions. In: Washington CM, Leaver D. Principles
and Practice of Radiation Therapy. 4th Ed. St. Louis, MO: Mosby. 2016. 513-535
5. DesRosiers P, Moskvin V, DesRosiers C, Timmerman R, Randall M, Papiez L. Lung Cancer
Radiation Therapy: Monte Carlo Investigation of "Under Dose" by High Energy Photons.
Technology in Cancer Research & Treatment. 2004;3(3):289-294.
doi:10.1177/153303460400300306.
6. Varian Medical Systems. Eclipse Algorithms Reference Guide. Finland. Varian Medical
Systems. 2011