1

Savannah Coleman
DOS 523: Treatment Planning
Planning Project
Comparison of Lung Treatment Planning with and without the use of Heterogeneity
Corrections
Objective: The purpose of this project is to evaluate the impact of heterogeneity correction on
the treatment planning system’s dose calculation for a 3-dimension (3D) conformal lung case.
Introduction: Treatment planning has changed drastically in the last half decade. Treatment
planning before the 1970’s was conducted in 2-dimension.1 Anatomy was defined with the aid of
solder wires, projection x-rays, and contouring devices. A single field’s dose distribution was
often calculated manually. Heterogeneity in this time was largely unaccounted for, and plans
were created on the basis of measurements taken in water. Mini-computers were eventually used
to calculate dose to a point or dose distributions in a single plane, and to combine multiple fields.
The advent of computed tomography (CT) and the progression in computer speed led to the
development of 3D conformal radiation therapy. Computer programs that were first created used
algorithms that were semiempirical.2 These types of algorithms primarily used measured data
obtained in a water phantom and attempted to apply corrections for differing variables such as
contour irregularities and inhomogeneity of tissue. Inhomogeneity was corrected for using
techniques such as the TAR method, the ETAR method, and the generalized Batho method.
These methods had various limitations in accuracy regarding extreme tissue interfaces and in
situations of unstable electronic equilibrium.
Algorithms that are used currently in treatment planning are model based.2 These
algorithms compute dose distribution using a model that allows them to simulate the transport of
radiation. The Monte Carlo algorithm is widely considered the reference algorithm as far as
accuracy.3 This method uses the physics of photon and electron transport to consider the paths of
individual particles. During this method millions of histories are traced for each particle and dose
distributions are achieved by summing the energy deposition for each particle’s history.2 Many
commercial TPS systems use model-based convolution/superposition algorithms, which perform
calculations with comparable accuracy to Monte Carlo, but require less time for calculation.3
Convolution-superposition methods separately consider the path of and energy deposited by the
primary photons and those of scatter photons and electrons. There are various forms of this type
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of algorithm that exist. For example, the Pinnacle TPS system uses a collapsed cone convolution
(CCC), and Varian Eclipse TPS uses an anisotropic analytical algorithm (AAA).4 Inhomogeneity
is accounted for slightly differently based on what type of convolution-superposition method is
used.
Methods/Materials: Both treatment plans used for comparison were calculated using Eclipse
treatment planning system (TPS). A CT was chosen from a retrospective patient pool, which
demonstrated a patient case in which the gross tumor volume (GTV) was located in lung tissue.
The previous physician-designated planning target volume (PTV), located in the left anterior
lung, was used for the planning comparison (Figure 1). Organ at risk (OR) structures contoured
included the patient body, right and left lung, spinal canal, and heart.
Plan 1 was planned using the standard Eclipse TPS heterogeneity correction. The plan
consisted of two parallel opposed AP/PA fields at 0 and 180. Fields were structured for a
Varian Trilogy linear accelerator with 6 MV and 23 MV capacities. Both fields were assigned 6
MV energy, and multi-leaf collimator (MLC) blocking with a 2 cm block margin on the PTV
(Figure 2). A prescription dose of 30 Gy in 10 fractions was used. Isocenter was aligned to the
PTV structure (Figure 3), and a point used for calculation was aligned with the isocenter. Fields
were calculated and upon calculation were assigned a weighting of 0.66 and 0.34 to the anterior
and posterior respectively, in order to achieve a more homogeneous dose distribution due to the
anterior location of the calculation point. No other planning techniques were utilized to adjust the
target coverage or maximum point in the plan. Plan 1 was copied to create plan 2. All parameters
were left as denoted in plan 1, with the exception of the heterogeneity correction. For plan 2, the
standard heterogeneity correction in the TPS was switched off, and then recalculated. The two
plans, along with their paired dose volume histograms (DVH), were then compared in terms of
isodose line appearance, coverage, and DVH values.
Results: The differences in isodose line dose distribution can be visually examined in figures 4
through 9. In plan 2, the isodose lines present in a somewhat uniform and equal distribution.
Each isodose line is squared out in shape and is smooth, with no ballooning of any particular
point. The 95% isodose line fully connects the anterior and posterior portions of the dose
distribution, and fully encompasses the PTV. There is a large section of 110% isodose in the
patient’s posterior body. In plan 1, the lines are not uniform. There is curvature of the lines in the
lung tissue, and the lines located in the soft tissue have a triangular appearance that follows the
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curve of the tissue/lung interface. The higher 105% isodose pools in the soft tissue of the
patient’s anterior and posterior body. The 95% isodose line does not connect the anterior and
posterior portions of the patient, and does not encompass the PTV fully. The 110% isodose is
relatively equally distributed between the anterior and posterior soft-tissue sections of the
patient.
A dose volume histogram (DVH) is a graphic representation of the relationship between
structure volume and dose received by that volume. The DVH graph for plan 1 (Figure 10)
demonstrates that approximately 42% of the PTV volume is receiving 100% of the prescribed
dose. The DVH graph for plan 2 (Figure 11) demonstrates that approximately 52% of the PTV
volume is receiving 100% of the prescribed dose. With heterogeneity correction for lung tissue
not being taken into consideration, plan 2 shows a 19.2% increase in the prescription coverage
allotted to the PTV. The DVH for plan 2 shows that 100% of the PTV volume is receiving 95%
of the prescription dose, with only 97% of the volume receiving this same percentage in plan 1.
Other DVH statistic for each plan can be examined in table 1. There was a marked increase in all
OR mean dose values for plan 2 as compared to plan 1. Plan 2 showed increased maximum doses
for the spinal canal and left lung, and decreased maximum doses in the right lung and heart.
Plan parameters and monitor unit (MU) printout can be seen in figures 12 and 13. Plan 1
and plan 2 produced similar MU for the anterior field, at 219 MU and 220 MU respectively. The
MU values were considerably different for the PA field. Plan 1 allocated 143 MU, whereas plan
2 allocated 193 MU.
Discussion: The AAA calculation algorithm used by Varian Eclipse is a variation of a pencil
beam convolution technique. Inhomogeneity is accounted for by scaling of the dose deposition in
direction and scaling of the scatter based off of the electron density.3 This type of algorithm, as
with all 3D model based algorithms, applies heterogeneity corrections using data obtained from
CT. When CT data is reconstructed, the reconstruction algorithm divides each plane into small
volume elements called voxels.2 Ct numbers, otherwise known as Hounsfield numbers, are
calculated based on the attenuation of each voxel. Departments are then able to establish electron
densities that correlate to the specific Hounsfield values for their CT scanner. These electron
densities are then used by the TPS algorithm to establish dose distribution and to correct for
inhomogeneity in planning calculations.3
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Without the use of heterogeneity corrections, dose distributions are calculated as if the
entire sector of the body was a uniform electron density value, equivalent to water. As shown
when comparing plans 1 and 2, dose is much more uniform and it appears that PTV coverage is
better when the heterogeneity correction is not used. This is because the correction accounts for
the density of lung tissue, which has an approximate electron density of 0.3 g/cm3 as compared
to water with a standard density of 1 g/cm3.2 For this reason the TPS will also produce different
MU with and without the heterogeneity correction in place. With the anterior PTV location, plan
2 required 193 MU for the PA beam, as compared to the 143 MU calculated for plan 1. This is
understandable because the plan calculated without the use of correction uses the electron
density for water, rather than the density of lung. Higher electron density results in more
attenuation of the beam, thus more MU will be required to deliver the same dose for the plan that
assumes homogeneity.
The difference in the accuracy of the electron density used in the calculation also affects
OR doses. Plan 2 showed an increase in mean dose for all organs examined. Max dose was also
greater for organs that were directly within the field. Organs not directly within the field saw a
decrease in maximum dose. This is likely due to the inaccuracy of the scatter component of the
calculation.3 Calculation through an electron density equivalent to water will be different as
compared to a calculation that accurately depicts the secondary photon and electron path
demonstrated in the electron density of lung.
Conclusion: When producing treatment plans without the use of heterogeneity corrections, the
TPS calculates dose distribution as if the entire patient was a homogeneous structure with an
electron density equivalent to water. This produces a more aesthetically pleasing distribution
with smooth isodose lines and better target coverage, but is not an accurate portrayal of the dose
that will be received by the patient. This is especially true when planning in areas in which large
differences in electron density exist within the treatment field, a prominent example being lung
cases. The plan produced without heterogeneity correction increased the amount of MU that was
allotted to be delivered to the patient, and showed a 19.2% increase in prescription coverage of
the PTV. The use of planning without heterogeneity correction could result in overdosing of
critical structures with the use of additional MU, and may lead to target underdosing due to the
inaccuracy of coverage displayed. Rare instances exist in which it may be beneficial to
manipulate heterogeneity corrections, such as in cases of scatter correction, but in general,
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utilizing heterogeneity corrections provides a more accurate depiction of dose distribution. Thus,
the use of corrections allows the production of a treatment plan that is optimal for the patient.
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References
1. Van Dyk J, Barnett RB, Battista JJ. Computerized radiation treatment planning systems. In:
Van Dyk J. The Modern Technology of Radiation Oncology: A Compendium for Medical
Physicists and Radiation Oncologists. Madison, Wisconsin: Medical Physics Publishing;
1999:231-286. https://medicalphysics.org/documents/VanDyk1_Ch8.pdf. Accessed April 20,
2018.
2. Khan FM, Gibbons JP. The physics of radiation therapy. 5th ed. Philadelphia, PA: Lippincott,
Williams, and Wilkins; 2014.
3. Chen WZ, Xiao Y, Li J. Impact of dose calculation algorithm on radiation therapy. World J
Radiol. 2014; 6(11):874-880. http://dx.doi.org/10.4329/wjr.v6.i11.874
4. Zhen H, Hrycushko B, Lee H, et al. Dosimetric comparison of Acuros XB with collapsed cone
convolution/superposition and anisotropic analytic algorithm for stereotactic ablative
radiotherapy of thoracic spinal metastases. J Appl Clin Med Phys. 2015;16(4):181-192.
http://dx.doi.org/10.1120/jacmp.v16i4.5493
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Figures

Organ at Plan 1 Plan 2 Percent Plan 1 Plan 2 Percent

a
Risk Max Dose Max Dose Difference Mean Dose Mean Dose Difference

Spinal 157.8 cGy 234.8 cGy +32.8% 49 cGy 102.1 cGy +52%
Canal
Lung Rt 220.5 cGy 188.4 cGy -14.6% 17.9 cGy 28.3 cGy +36.7%
Lung Lt 3309.8 cGy 3394.7 cGy +2.5% 1218.2 cGy 1249.6 cGy +2.5%
Heart 3036.1 cGy 2928.6 cGy -3.6% 335.6 cGy 374.1 cGy +10.3%
a
Percent difference + indicates percent increase, - indicates percent decrease.
Table 1. Dose-volume histogram values for plan 1 and plan 2 with percent difference

Figure 1. Transverse view of PTV and GTV delineated by the physician for planning.
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Figure 2. Multi-leaf collimator blocking allotted for the PTV structure.

Figure 3. Digitally reconstructed radiographs showing isocenter placement.

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Figure 4. Axial view of plan 1 isodose distribution.

Figure 5. Sagittal view of plan 1 isodose distribution.

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Figure 6. Coronal view of plan 1 isodose distribution.

Figure 7. Axial view of plan 2 isodose distribution.

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Figure 8. Sagittal view of plan 2 isodose distribution.

Figure 9. Coronal view of plan 2 isodose distribution.

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Figure 10. Dose volume histogram calculated for plan 1.

Figure 11. Dose volume histogram calculated for plan 2.

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Figure 12. Treatment plan parameters and MU information for plan 1.

Figure 13. Treatment plan parameters and MU information for plan 2.