1

Phillip Lin
DOS 523 Treatment Plan in Med Dos
4/23/17
Heterogeneity Corrections in Dose Calculations
Modern linear accelerator based radiation therapy requires the correct input of
monitor/machine units (MUs) in order to deliver a daily prescribed dose to a target. MUs are the
language that the treatment machine understands in place of dose. Linear accelerators are
generally calibrated to deliver at a rate of 1.0 cGy per 1 MU at a reference depth with a reference
field size at a source to calibration point distance (10cm depth, 10x10 field size, 100 SSD by TG-
51 recommendations).1 Factors that affect that ratio of cGy/MU include field size, distance,
treatment depth, energy, machine head scatter, and factors derived from structures within the path
of the beam. These measurements acquired in a homogenous water volume, which acts as a
tissue equivalent material. In order to accurately calculate what MU settings are needed to
achieve the amount of dose prescribed for a patients treatment plan, dose calculations in
radiation therapy require precise input of patient data.

Location of the target volume has increased in specificity due to the widespread use of
computed tomography (CT) scans in capturing patient data. This allows for visualization and
data calculations based on electron density (number of electrons/cm3) of different structures
within the body as well as obtaining a surface body contour. In classical radiation therapy, tools
such as soldering wire or calipers were used to obtain a surface body contour and tissue
inhomogeneities within a patients treatment field were at best estimated through treatment port
x-ray films.2 Accurate tissue inhomogeneities corrections are a very important factor to consider
in order to prevent under or overdosing the target volume at depth.

To demonstrate the effect of tissue inhomogeneities within a patients treatment plan, two
plans have been created in Eclipse TPS (Varian Medical Systems) with one accounting for
inhomogeneities and the other without. These plans consist of an AP/PA treatment field
arrangement to a tumor volume within the lung. As one can observe, the shift in isodose lines on
the heterogeneity plan are attributed to inhomogeneities in the surface body contour and tissue
density within that body. Whereas in the plan without heterogeneity corrections, the isodose line
 2

shifts are in response to changes on the body surface contour alone. Please see Figures 1 through
3 below to review the differences:

Figure 1-1. Axial view at isocenter of a 6X AP/PA plan displaying isodose lines with
heterogeneity corrections. Isodose lines react to the different tissue densities within the body
contour.
 3

Figure 1-2. Axial view at isocenter of a 6X AP/PA plan displaying isodose lines without
heterogeneity corrections. This was achieved in Eclipse by assigning the volume inside the body
contour to a homogenous tissue equivalence (Hounsfield unit = 0).

Figure 2-1. Coronal view at isocenter of plan with heterogeneity corrections.

Figure 2-2. Coronal view at isocenter of plan without heterogeneity corrections.

 4

Figure 3-1. Sagittal view at isocenter with heterogeneity corrections. Note how the 100% isodose
line (yellow) is significantly altered once the beam encounters lung tissue.

Figure 3-2. Sagittal view at isocenter without heterogeneity corrections. Isodose lines are more
uniformly predictable as the beam traverses through the patient separation as opposed to Figure
3-1.
 5

The heterogeneity correction in this plan was calculated with an analytical anisotropic algorithm
(AAA) through Eclipse. AAA is a computerized treatment planning algorithm and was
developed to improve dose calculation accuracy in heterogeneous volumes.3 Computerized
treatment algorithms use acquired beam data from the treatment machines and break down
beams into primary and secondary components; taking into account scatter due to beam shape,
intensity, patient geometry, and also tissue inhomogeneities.4 In classical radiation therapy,
inhomogeneities were calculated based on an isodose shift method, attributing tissues
inhomogeneity correction factors for air, lung, and bone in relation to tissue. For example, in
trajectories where the beam traverses encounters bone, a buildup of occurs and isodose lines are
shifted shallower whereas in the air within lung tissue, isodose curves would be shifted deeper. If
we refer to the axial view in Figure 3-1, we can observe that principle applied once air in the
lung tissue is encountered. This is highlighted in Figure 3-1a below:

Figure 3-1a. Region where isodose lines are shifted on the axial view.
Dose-volume histograms (DVH) can be displayed and are based on calculated dose delivered to
the structures defined on the CT scan.5 This allows one to compare different treatment plans and
evaluate them based on target coverage and dose delivered to organs at risk. Inhomogeneity
corrections allow for these graphs to be more precise in their evaluation and could mean the
difference between choosing a high quality vs a poor quality plan in respect to therapeutic ratio.
 6

This is especially critical in IMRT planning where a plan is constructed based on dose-volume
constraints. Please refer to Figures 4-1 and 4-2 for DVH comparison of the heterogeneity and
non-heterogeneity corrected plans.

Figure 4-1. Dose-volume histogram (DVH) of plan with heterogeneity corrections. PTV
coverage shows it is being underdosed (with goal of 100% of prescription dose covering 95% of
volume)
 7

Figure 4-2. Dose-volume histogram (DVH) of plan without heterogeneity corrections. Overall
PTV dose coverage is increased but the projected ipsilateral lung (right) erroneously shows an
increase in dose delivered. This is a result of not correcting for lung tissue electron density. More
dose buildup in the lung tissue is falsely recorded.
Looking at the MU calculated from each plan (Rx: 300 cGy per fraction was used). There is a
gross difference in the calculated MU from the AP field of the plan without heterogeneity
corrections (Figures 5-1, 5-2). In the case of this plan, the target volume was positioned more
posteriorly in regards to the patient mid-sagittal. This is due to the fact that the majority of the
beam path from the AP field needs to traverse is calculated as tissue, and a greater number of
monitor units are required to deliver the minimum amount of dose to the target volume. This
resulted in a difference in AP MU of 186/223 = 0.834 1 = 16.5% difference in AP MU!

Figure 5-1. Monitor units of plan with heterogeneity corrections. AP: 186, PA: 182

Figure 5-2. Monitor units of plan without heterogeneity corrections. AP: 223, PA: 184
 8

To observe the effect of this on a more complex plan, a study conducted by Herman TDLF,
Gabrish H, Herman TS et al6 displayed the effects of heterogeneity corrections in high dose
stereotactic body radiation therapy (SBRT) to lesions in the lung. Fifteen treatment plans were
constructed using pencil beam convolution algorithms in conjunction with the Modified Batho
Power Law to account for tissue heterogeneity in Eclipse. Plans were calculated with these
models and then a copy of the plan was created and calculated without. What was found was that
the non-heterogeneity corrected plans were under dosed with a lower average min (by 13%),
mean (8%), and max (6%) compared to the corrected plans. This study highlights the importance
of taking tissue inhomogeneities into account. Calculation errors can be made that can
significantly affect adequate treatment for patients.
 9

Reference List and Works Cited

1. Almond PR, Biggs PJ, Coursey BM, et al. AAPMs TG-51 protocol for clinical reference
dosimetry of high-energy photon and electron beams. Medical Physics. 1999;26(9):1847-1870.
doi:10.1118/1.598691.
2. Khan F. The Physics of Radiation Therapy. 4th Philadelphia, PA: Lippincott Williams &
Wilkins; 2010.
3. Van Esch A, Tillikainen L, Pyykkonen J, et al. Testing of the analytical anisotropic
algorithm for photon dose calculation. Med Phys 2006;33:4130-48.
4. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
5. Evans MDC. Computerized Treatment Planning Systems for External Photon Beam
Radiotherapy. International Atomic Energy Agency Publication. Montreal Quebec, Canada;
2006.
6. Herman TDLF, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of tissue
heterogeneity corrections in stereotactic body radiation therapy treatment plans for lung
cancer. Journal of Medical Physics / Association of Medical Physicists of India. 2010;35(3):170-
173. doi:10.4103/0971-6203.62133.