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Benjamin Smith

DOS 523: Treatment Planning

May 2, 2020

Treatment Planning Project: Heterogeneity Corrections

As a medical dosimetrist, there are several factors that must be considered when

designing a treatment plan. Everything from tumor location in comparison to organs at risk

(OAR) as well as varying tissue densities, including metal implants, all can significantly impact

the treatment plan. When the planning target volume (PTV) is near an OAR such as the

brainstem, a more complex treatment technique such as intensity modulated radiation therapy

(IMRT) or stereotactic radiosurgery (SRS) may be employed to treat the target while sparing

dose to the OAR as much as possible. Likewise, when the tumor is midline within the pelvis, a

higher energy such as 18MV would be selected to treat through a higher density of tissue in

contrast to a tumor in the neck where a lower energy such as 6MV would be sufficient to treat

with optimum dose coverage. The human body is not a water phantom with uniform density but

instead consists of tissues that vary in density. This inhomogeneity of tissue densities plays a

major factor when selecting energies as well as beam orientation, all of which affect the dose

distribution which is displayed on the dose volume histogram (DVH). When the inhomogeneity

of tissue is significant, as within lung tissue, more consideration needs to made when designing

the treatment plan.

With planning a lung tumor case, it is important to understand how dose distribution is

displayed within lung tissue. When treating through lung tissue to reach a target, higher energies

do not favor as well.1 This is due to the low density within lung tissue. The electrons naturally
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travel farther in lung tissue as compared to normal tissue and by doing so, their lateral spread is

extended which increases the width of the penumbra, ultimately resulting in less lateral electron

scatter which in turn equates to loss of dose along the beam’s axis.1 This is more significant for

higher energy beams (15MV, 18MV) as compared to ones of lower energy (6MV). 1 The beam

must also go through a second build up as it traverses through air in lung and re-enters a higher

density tumor volume.  Higher energies will require a greater buildup region and therefore will

cause a lower dose along the tumor periphery.1

One way around this tissue inhomogeneity is by turning off the heterogeneity correction

on the treatment planning system (TPS). By doing so, the TPS will assume all the tissue within

the patient is uniform and will not account for the varying densities. I created two plans for the

same lung tumor case: one with the heterogeneity correction on and the other with the

heterogeneity correction turned off. For both plans, I chose an AP/PA beam orientation with a

2cm auto margin around the PTV to be shaped with the leaves from the multileaf collimator

(MLC). I chose 6MV for the energy with the dose prescription being 2Gy x 30 fractions which

equates to 60Gy for the plan. The plan normalization mode was 100% in Reference Point

Calc_Point_ISO. I placed this reference point in the center of the PTV and used Anisotropic

Analytical Algorithm (AAA) for my calculation method.

After the TPS calculated the dose distribution for the plan with heterogeneity correction

on, we can observe how the dose distribution resembles an hourglass shape through the axial

view listed below. The dose is concentrated at anterior and posterior surface of the patient but

dips inward as it passes through the lung. The dose then extends laterally as it encompasses the

PTV. This middle region of the patient receives scatter from both beams thus giving the

hourglass shape.
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When displaying the PTV coverage on the DVH without normalization, we see that only

17.7% of the PTV is covered by 100% of the prescription dose.

We would need to normalize to the 94.9% isodose line to have 95% of the PTV covered

by 100% of the prescription dose. Displayed below is the DVH after normalization showing the

PTV coverage along with OAR doses including: right lung, left lung, spinal cord, and heart.
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Here is the dose distribution after normalization. The yellow line represents the

prescription dose of 6000cGy or 60Gy.

Listed below is the monitor unit (MU) printout for the treatment plan with heterogeneity

correction on.
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Now let us look at the treatment plan with the same parameters except this time we will

turn off the heterogeneity correction and observe the results. After the initial calculation, the

once observed hourglass is practically gone when looking at the dose distribution though the

axial, sagittal, and coronal views found below. The main factor that is influencing the dose

distribution is the sloping of the chest. The inhomogeneity of tissues is not an issue due to the

fact that by turning the heterogeneity correction off, we are telling the TPS to assume all tissue

within the body is the same density. This is why the dose distribution is fairly uniform

throughout the field. As we will observe later, this will affect the total MU needed to treat

through this “uniform” tissue.

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When displaying the PTV coverage on the DVH without normalization, we see that

65.5% of the PTV is covered by 100% of the prescription dose.

We would need to normalize to the 97.8% isodose line to have 95% of the PTV covered

by 100% of the prescription dose. Displayed below is the DVH after normalization showing the

PTV coverage along with OAR doses including: right lung, left lung, spinal cord, and heart.
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Here is the dose distribution after normalization. The yellow line represents the

prescription dose of 6000cGy or 60Gy.

Listed below is the MU printout for the treatment plan with heterogeneity correction off.
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After reviewing both plans, we are able to see how the heterogeneity correction affects

the plan and the overall dose distribution which reflects in the MU printout. When the

heterogeneity factor was on, the TPS accounted for all the various tissue densities which led to

the hourglass shape and less initial coverage of the PTV. After turning off the heterogeneity

correction, the dose distribution was more uniform as the TPS assumed homogenous tissue

throughout the body. The MUs for the plan with the heterogeneity correction on were less for

both AP/PA fields in comparison to the plan with heterogeneity correction off. This is due to the

fact that the TPS assumed more MUs were needed to push the dose through the uniform dense

tissue to reach the PTV with heterogeneity off. It is important to account for these heterogeneity

factors when treating lung tumors in order to accurately calculate the dose distribution and
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coverage of the PTV along with dose to the OAR. Chang et al2 studied heterogeneity correction

factors for lung dose and concluded, “a high degree of correlation exists between heterogeneity-

corrected and heterogeneity-uncorrected dosimetric parameters for lung and the risk of

developing pneumonitis.” This is one example as to why is it crucial to accurately represent all

the tissue densities when calculating a treatment plan.

Not only do we see the impact of tissue inhomogeneities with lung tissue compared to

surrounding tissue, but also with metal prosthesis or implants, both of which can greatly affect

how the dose is distributed. Alves et al3 researched the impact metal hip prosthesis affect

treatment planning and if the TPS accurately displays the dose distribution. Based on their study

using multiple dosimeters in phantoms with metal hip prosthesis, they concluded that the TPS is

accurate at recognizing the heterogeneity and accounting for it with the dose distribution and

MUs needed for treatment.3 Whenever you have any metal in a patient such as dental fillings or a

breast tissue expander, this can cause streaking on the CT scan during simulation. This CT

artifact can impact how the TPS accurately reads the heterogeneous tissues. The artifact displays

as black streaks in the CT slices which can be read as the density of air if not corrected. This is

often the case when planning a breast patient with a tissue expander. Due to the high attenuation

of the expander, the CT scan displays the surrounding area around the expander as black air

space instead of breast tissue. If this was not corrected, the dose distribution would not be

accurate. To correct this, the dosimetrist can utilize the image thresholding tool and find the

range that encompasses solely the tissue expander, labeling it accordingly as a separate contour.

Next, the dosimetrist can create another structure and highlight the breast tissue in all slices that

is affected by the CT artifact and assign it a HU value of breast tissue. One important step is to
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make sure that the expander is excluded from the newly assigned HU value as its heterogeneity

factor still needs to be accurately accounted for in the dose calculation.

As seen in the lung treatment plans, plans with metal implants, and plans with varying

tissue densities in general, it is important to account for these heterogeneities. Every patient

must receive the most accurate treatment that can be allotted for them. In order to do so, several

steps must be taken. From patient immobilization and detailed contouring to actual treatment

planning, it is important to utilize the most optimum treatment technique that will obtain

appropriate dose coverage to the target while sparing as much normal tissue as possible. During

this process, the dosimetrist must have the TPS account for tissue inhomogeneities in order to

accurately display the dose distribution and calculate the appropriate MUs needed for the

treatment.
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References

1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia:

Lippincott Williams & Wilkins; 2014.

2. Chang DT, Olivier KR, Morris CG, et al. The Impact of heterogeneity correction on

dosimetric parameters that predict for radiation pneumonitis. Int J Radiat Oncol Biol

Phys. 2006;65(1):125–31. http://dx.doi.org/10.1016/j.ijrobp.2005.09.047

3. Alves GG, Kinoshita A, Oliveira HF, Guimaraes FS, Amaral LL, Baffa O. Accuracy of

dose planning for prostate radiotherapy in the presence of metallic implants evaluated by

electron spin resonance dosimetry. Braz J Med Biol Res. 2015;48(7):644–649.

http://dx.doi.org/10.1590/1414-431X20154367