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Sara Long
Lung Lab
4/28/2019
Lung Lab

Introduction

Accurate dose modeling in the treatment planning system (TPS) is imperative to

understanding the precise effect a radiation plan will cause in a patient.1,2 The modeling of dose

in a patient is a complex process, and parameters related to the deposition of energy into tissue

can be modeled many different ways. In addition to dose modeling algorithms, patient tissue data

retrieved from CT imaging can be very different due to patient tissue characteristics. Ultimately,

the use of tissue heterogeneity correction factors within the TPS determines how patient data will

be interpreted by the dose models.

Tissue heterogeneities are tissues of varying density within a patient that a beam must

traverse.1 Tissue homogeneity is an area of the patient where the beam traverses tissue that is

similar in density. As the beam encounters different density tissues it changes behavior. Tissues

with a density similar to water may create more scatter.2,3 Very dense tissue such as bone creates

less scatter and contributes to higher beam attenuation2,3; and low density tissue such as lung

allows more beam transmission and creates less scatter than soft tissue.2 The scatter,

transmissive, or absorptive behavior of the beam as it loses energy in the body contribute to

target dose as well as critical organ dose. While the human body is composed largely of water, it

does contain areas of low density such as air pockets (in the bowel, stomach, and sinuses) and

lung tissue. It also contains dense tissue such as compact bone. Modifications to the body may

result in the addition of very high density objects such as metal prosthetics, tissue expanders, and

dental work. Tissues of drastically different density may abut one another creating a tissue

interface. An example of such an area is where soft tissue meets rib. An interface adds

complexity to beam modeling because the density of some tissues, like bone, creates electronic
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backscatter which increases dose to the local soft tissue surrounding the bone on the entrance

dose side.2 Additionally, tissue on the other side of the bone may also receive higher dose due to

forward electronic scattering.2 An area of soft tissue surrounded by bone is the spinal cord. The

cord may actually receive a high scatter dose due to forward and back scattering of electrons

from the surrounding boney anatomy. Heterogeneity corrections applied within the TPS can

account for dose contributed by some forms of scatter in addition to dose from the primary beam.

Prior to the use of CT imaging in radiation oncology, dose modeling was based solely on

the behavior of the beam within a homogenous medium such as water.4,5 Improvements were

made in dose modeling once the tissue density of the patient’s actual anatomy could be inferred

through the use of CT imaging. Improvements in modeling have been vitally important because

the precision of treatment delivery has resulted in an increase of dose escalation studies.4 In

modern radiotherapy the improper account of scatter or beam transmission may increase

treatment complications.

The first step in dose modeling is to understand how dose is deposited into the body. TG

65 explains dose deposition occurs in two phases. The first phase is the conversion of energy loss

from the photon beam to electronic particles in the tissue (ie. electrons and nuclei). The cascade

of energy loss can be quickly summarized as TERMA > KERMA > KERMAc; where TERMA

(total energy released per unit mass) is of greater energy than KERMA (kinetic energy released

per unit mass), which is of greater energy than KERMAc (kinetic energy released per unit mass

locally through collisional interactions).6 The second phase, called the dose step, results in

energy deposited via coulomb interactions.2,6 Coulomb interactions slow Compton electrons and

electron-positron pairs from pair production events. The slowing of electrons results in energy

deposition and path deflection where local slowing is given by the metric mass collisional
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stopping power.6 It is important to keep in mind that every path deflection results in reduced

energy of the deflected electron and thus results in energy deposition into tissue. Many methods

exist to model dose within the TPS. The Monte Carlo method models local deflections and

energy depositions, but it is impossible to know exactly the path an electron takes; this method

makes predictions using statistical modeling. Dose modeling within TPS’s make use of Monte

Carlo predictions to varying degrees and some do not use it at all.

Several dose modeling methods are in use clinically.3,4,6 The modified Batho pencil beam

correction is a model which uses a table array of homogenous water phantom measurements.

This method divides the incident beam into beamlets and calculates the dose contributed by

them. A heterogeneity scaling correction to each beamlet (also called a “pencil”) is made to

account for differences in attenuation.4 Adjacent beamlet dose is not considered in this model

which means scatter is not accounted for in it, and dose is only considered along the beam path.

Anisotropic Analytic Algorithm (AAA) is a pencil beam model which uses Monte Carlo

simulations. AAA pencil beams are point spread doses (this is like a point spread function where

signal, or dose, has a taper of intensity, like penumbra, around the point dose). The algorithm is

called a “superposition convolution algorithm with pre-convolved pencil beams.”4 This

calculates a lateral scatter component from adjacent tissues. Dose is calculated from primary and

secondary photon sources as well as electron contamination sources. Scaling of Monte Carlo pre-

calculated scatter kernels with the pencil beam data results in the heterogeneity correction.

Collapsed Cone Convolution (CCC) is used in Pinnacle (Philips Medical Systems,

Milpitas, CA). CCC is also a superposition convolution model but takes into account TERMA

and KERMA for every point in the CT density data.4 Monte Carlo point dose kernels are again

used but with the patient’s CT data to determine dose through the entire patient volume. It is
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called a collapsed cone because dose is calculated in a sphere from a point forming a cone shape.

The conical data is then reduced to a 2D plane to create a dose distribution of heterogeneity

correction.4 This method accounts for lateral scatter like the AAA method but is more beneficial

in planning because it uses actual patient data.

The gold standard for dose determination in heterogenous tissue is Monte Carlo

simulation.2,4 This method traces the likely interactions of particulate radiation through dose

deposition path length where all products of these interactions are followed as well. The

calculation for this method is very time consuming and is not often used in clinical planning

TPS. CCC modeling is the planning algorithm most aligned with Monte Carlo dose predictions.4

CCC is the dosimetric modeling algorithm used in Pinnacle and therefore used in this lung lab.

The use of heterogeneity corrections is not always desired. The RTOG 0117 (2001) study

required submission of heterogeneity uncorrected and corrected plans because different

institutions have different heterogeneity algorithms which makes for difficult comparison among

institutions.7 However, in clinical use, the algorithms are important to aid in the understanding of

dose to the target and to critical organs.

Lab Procedure

A left upper lobe lung tumor was planned with heterogeneity correction turned on and

turned off. Both plans used 6MV AP and PA static beam configuration. The plans were

compared to understand the effect heterogeneity correction has on the dose distribution

calculation. The patient body, right lung, left lung, spinal cord, and heart were contoured for

OAR comparison; the tumor target was contoured for coverage comparison. The isocenter was

placed in the middle of the PTV and a 2 cm margin was placed around the target. The target is
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surrounded entirely by lung tissue and was planned to 50Gy. No artifacts were noted within the

CT scan. In clinical practice the heterogeneity correction would be turned on since this mode

most accurately models dose distribution. The treatment planning system is Pinnacle which uses

CCC modeling. Dose calculation with heterogeneity turned off would result in dose distribution

modeled from a solid water phantom.

Lab Results

The homogenous tissue plan shows 100% PTV coverage, cord max dose of 2084 cGy,

mean heart dose of 19.7 cGy, and left lung V20 of ~18%. The dose distribution appears robust in

the lung with only a slight hourglass shape at the center. The monitor units (MU) for both the AP

and PA beams is 754 MU.

The heterogenous tissue plan shows 99% PTV coverage, cord max dose of 1936 cGy,

mean heart dose 17.2 cGy, and left lung V20 of ~18%. The dose distribution appears less robust

in the lung and has a more pronounced hourglass shape. The MU for both the AP and PA beams

is 716 MU.
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Dose Distribution for Homogenous Tissue Plan
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DVH for Homogenous Tissue Plan
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Monitor Unit Display for AP Beam of Homogenous Tissue Plan
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Monitor Unit Display for PA Beam of Homogenous Tissue Plan
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Dose Distribution for Heterogenous Tissue Plan
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DVH for Heterogenous Tissue Plan
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Monitor Unit Display for AP Beam of Heterogenous Tissue Plan
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Monitor Unit Display for PA Beam of Homogenous Tissue Plan

Dose Distribution Comparison with Heterogenous Plan on the Left and Homogenous Plan

on the Right
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DVH Comparison
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Discussion

Lung tissue is less dense than other soft tissues. A comparison of the dose distributions of

both plans reveals how the tissue density property of the lung determines the shape of the beam

and contributes to scatter production. When the heterogeneity correction factor is turned off all

tissue in the scan is treated as if it has the density of water. Water is more dense than lung and

creates more scatter than lung. The electronic scatter of the beam contributes to lateral dose and

the shape of the dose distribution.2 With the heterogeneity factor turned on, OARs received less

dose likely from the modeling of less scatter creation. Additionally, since lung tissue does not

create much scatter the lateral electronic scatter of the primary beam is reduced and the dose

distribution begins to diminish within the lung.2 The AP field in the Heterogenous Plan likely

contributed more dose to the tissue posterior to the lung. This is shown by the increased depth of

the 105% isodose line (IDL) from the posterior surface. This is likely also attributable to the low

density of the lung. More primary beam from the AP port was able to travel deeper before being

absorbed by the soft tissue behind the lung.

Summary

The density of tissue affects the way dose is absorbed in the body. Dose calculation in the

TPS can include a modifier to correct for these tissue effects. This modifier is the tissue

heterogeneity correction factor and it accounts for the absorptive, transmissive, and scatter

producing properties of different tissue types. It is important to plan with the correction factor on

because this gives the best prediction for how dose will distribute during treatment. Low density

tissues like lung and air cavities in sinuses will transmit more dose, absorb less dose, and create

less scatter than more dense tissues. Very dense tissue such as bone may contribute to higher
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dose to soft tissue structures surrounding it due to electronic back and forward scatter.

Modifications placed within the body such as metal prosthetics, dental work, and tissue

expanders are more dense than bone and absorb more dose than bone. These structures may also

contribute to electronic scatter dose to immediately adjacent tissue. These structures create

streaking artifacts on the CT used for planning. This is problematic because streaking appears as

less dense tissue in an area where that information is false. A high density scan may be selected

at the time of sim to reduce this artifact, or the planner may contour the streaks and correct the

density of the streaks to that of the surrounding tissue. Contrast used in imaging may also cause

streaking but this is more pronounced in hyper dense artifacts.

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References

1. Stanton R, Stinson D. Applied Physics for Radiation Oncology. 2nd ed. Madison, WI:

Medical Physics Publishing; 2009.

2. Khan FM, Gibbons JP. Khan’s The Physics of Radiation Therapy.5th ed. Philadelphia,

PA: Wolters-Kluwer; 2014.

3. Khan, FM, Gibbons JP, Sperduto PW. Khan’s Treatment Planning in Radiation

Oncology. 4th ed. Philadelphia, PA: Wolters-Kluwer; 2016.

4. Herrick AC. A comparative dosimetric analysis of the effect of heterogeneity corrections

used in three treatment planning algortihms [dissertation]. Toledo: The University of

Toledo; 2010.

5. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 4th ed. St.

Louis, MO: Elsevier, Mosby; 2016.

6. Task Group No. 65 of the Radiation Therapy Committee of the American Association of

Physicists in Medicine. Tissue Inhomogeneity Corrections for Megavoltage Photon

Beams. https://www.aapm.org/pubs/reports/rpt_85.pdf. Published August, 2004.

Accessed April 27, 2019.

7. Radiation Oncology Group, RTOG 0117. A Phase I/II Dose Intensification Study Using

Three Dimensional Conformal Radiation Therapy and Concurrent Chemotherapy for

Patients with Inoperable, Non-Small Cell Lung Cancer.

https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0117.

Accessed April 27, 2019.