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Bianca Tester
Treatment Planning Project
4/23/18

Heterogeneity vs Homogeneity in Lung Cancer Treatments

Objective: To determine the changes in isodose line dose distribution for a simple lung cancer
case with and without heterogeneity corrections.
Introduction: Cancer is a terrible disease that continues to plague the human population. Lung
cancer in particular, is the number one cause of cancer deaths in both men and women in the
U.S. and worldwide.1 In fact, lung cancer takes more lives than colon, prostate, and breast cancer
combined.2 The signs and symptoms of lung cancer include: chronic cough, shortness of breath,
coughing up blood, hoarseness, or no symptoms (typical until more advanced). The prognosis of
lung cancer tends to be poor due to the patient not being diagnosed until the disease is at an
advanced stage. The five-year survival rate is around 54% for early stage, while survival is
around 4% in advanced, inoperable lung cancer.1
Treatment options for lung cancer depends on many factors including: staging, histology,
type (Non-Small Cell Lung Cancer versus Small Cell Lung Cancer), if the tumor can be resected,
and the patient’s overall condition.2 Options for treating lung cancer include surgery,
chemotherapy, radiation therapy and most commonly, a combination of modalities. It’s
estimated that >60% of lung cancer cases require radiation therapy at least once, with about 45%
receiving radiation as part of their initial treatment.2 Treatment planning for lung cancer is not as
straightforward as other parts of the body. When using standard isodose charts and depth dose
tables, the tables assume a homogenous unit density medium, even though human bodies consist
of inhomogenous densities. These tissue inhomogeneities will cause a change in the dose
distribution, which depends on the density of the tissue, the amount of tissue, and the intensity of
the radiation energy.3 Since lungs are mostly filled with air, it’s harder for radiation to interact
with the tumor volume, to cause an area of dose buildup. In the past, patients were planned with
a homogeneous correction (ie: all tissue densities were assigned the same value). Today plans
are typically planned using a heterogenous correction, however there is an option to change it to
a homogenous correction. If you wanted to still do a heterogenous plan but needed to correct the
density of contrast in the bowel (as an example), because the contrast mimics the same density as
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bone, there is an option in the Pinnacle treatment planning system (TPS) called “density
override,” where you can select the contoured organ at risk (OAR) and override the density to ‘1’
so the Hounsfield values now associated with that structure are calculated to a soft tissue density.
Regardless of how it’s achieved, it’s important to account for differing tissue densities.
Methods and Materials: A 3D treatment planning CT was performed for a patient with stage
T2aN2M0 adenocarcinoma lung cancer. The patient was scanned, head first, supine, with both
arms up above her head using a wingboard, “B” head holder, a mattress underneath her back,
from the waist down, knee sponge, and foot holder. The CT scan was transferred to the Pinnacle
TPS to begin planning. The radiation oncologist drew a planned target volume (PTV), while the
dosimetrist drew normal OAR. PTV is defined as the clinical target volume (CTV) plus internal
target volume (ITV) plus a setup margin.4 The necessary OAR for planning a lung include: both
lungs, the heart, and spinal cord. The isocenter was placed within the middle of the PTV
volume, and a 2.0 cm margin was placed with multi-leaf collimators (MLC) to account for
motion and setup error. An anterior and posterior beam was placed using 6 megavoltage (MV).
A dose of 200 centigray (cGy) for 30 fractions was calculated to 100% isocenter. The beams
were equally weighted and the first plan was calculated as a heterogeneous calculation. The plan
was then calculated with a homogeneous calculation. The two plans were assessed and
compared.
Results: The two plans reflect different dose distribution throughout the treatment volume,
shown in Figures 1-3 (A&B). With the heterogenous correction turned off, the treatment
planning system (TPS) acts like the patient is a solid water phantom and the radiation is able to
penetrate further throughout the patient’s body. The isodose distribution for the homogenous
plan has an hourglass appearance at the level of the isocenter (shown in Figure 1B). Although
the homogenous plan shows better PTV coverage (seen when reviewing Figures 4A and 4B), this
isn’t an accurate representation of dose distribution because the differing tissue densities aren’t
taken into consideration (looking at Figure 1A dose distribution versus Figure 1B - the sternum
is shown having no effect on the dose distribution for the homogenous plan, as well as the
pectoralis muscles.)
When planning lung cancer, it’s important to choose the ‘correct’ beam energy.
Generally, 6 MV is the energy of choice for lung cancer, to provide better PTV coverage in the
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border of the high-density tumor and low-density lung tissue.2 “The imbalance of secondary
electron flow between the high density and low density structures induces dose loss in the
boundary region – the higher the photon energy, the greater the effect.”2 The dose distribution
for the heterogeneity plan looks less uniform and more jagged due to the TPS taking the differing
tissue densities into consideration. Heterogeneity corrections can differ from -10% to +30% in
the dose distal to the lung, depending on the size of the treatment field and the thickness of the
lung.2 In fact, an RTOG survey in 2004 found that the majority of health institutions didn’t take
the effects of lung density into consideration when doing lung treatment plans. Researchers from
M.D. Anderson replanned 30 lung cases, this time using the heterogenous correction (with a
commercial TPS, with convolution-superposition algorithm). The researchers found out that out
of the 30 cases replanned, 14 of them had less than 90% of the PTV coverage when the
heterogeneity correction was turned on.2 The researcher went on to explain that in order to
achieve 95% PTV coverage, 8/30 cases required <2% increase of monitor units, while 13/30
cases required >5% monitor unit increase, with a maximum increase of 25%.2 When evaluating
the monitor unit discrepancy between the heterogenous and homogenous plan, there was an
increase in the monitor units for the homogenous plan by about 10%, seen in Figures 5A and 5B.
The increase in monitor units is due to the fact that the TPS thinks that the density of the lungs is
more dense than what it actually is, therefore it needs more monitor units to push the proper dose
to the PTV.
Conclusion: Cancer is a very complex disease, but luckily radiation therapy is always changing
and evolving as more data comes out – tissue tolerances are adjusted, treatment techniques
improve, and patients generally experience less side effects. One advancement on the TPS side
is the use of heterogeneity corrections. As stated earlier, treatment plans in the past were done
using a homogeneity correction, so regardless of if the beam passed through air, or bone it was
all calculated to the same density of “1.” It’s imperative as a dosimetrist to understand how
radiation reacts as it passes through different tissue densities, so when analyzing a plan, the
dosimetrist can understand why the dose is being deposited the way it is. Lung inhomogeneity
must be accounted for to ensure the treatment plan being produced is an accurate representation
for how dose will be deposited in the patient’s body as well as ensuring proper PTV coverage.
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Figures

Figure 1A. Transverse image at isocenter reflects dose distribution with heterogeneity
correction.

Figure 1B. Transverse image at isocenter reflects dose distribution with homogeneity
correction.
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Figure 2A. Coronal image at isocenter reflects dose distribution with heterogeneity correction.

Figure 2B. Coronal image at isocenter reflects dose distribution with homogeneity correction.
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Figure 3A. Sagittal image at isocenter reflects dose distribution with heterogeneity correction.

Figure 3B. Sagittal image at isocenter reflects dose distribution with homogeneity correction.
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Figure 4A. Dose volume histogram with heterogeneity correction.

Figure 4B. Dose volume histogram with homogeneity correction.

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Figure 5A. Monitor units calculated for heterogenous plan.

Figure 5B. Monitor units calculated for homogenous plan.

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References

1. Stöppler M. Lung Cancer. MedicineNet.com Web site.

https://www.medicinenet.com/lung_cancer/article.htm. Updated January 30, 2018.
Accessed April 18, 2018.
2. Khan FM, Gerbi BJ. Treatment planning in radiation oncology. Philadelphia: Wolters
Kluwer/Lippincott Williams & Wilkins Health; 2012.
3. Khan FM, Gibbons J. The Physics of radiation therapy. Philadelphia: Wolters
Kluwer/Lippincott Williams & Wilkins Health; 2014.
4. Lenards, N. Dose Specifications and Prescriptions: Teletherapy Treatment Planning.
[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2016.