In medical dosimetry, the delivery of radiation dose correlates heavily to the density of the

material the beam traverses. The physical density of tissue is proportional to the
absorption/attenuation of the X-ray beam.1 Density values are assigned to various tissue types
within the body. Anatomic variables may occur within the targeted region of an individuals’
treatment plan that must be accounted for when planning. Materials that are comprised of
elements having high atomic numbers significantly increase radiation absorption properties,
[such as dental implants, hip replacements, surgical wires, clips, and staples].2 Treatment
planning systems calculate with the densities identified from the images and compute radiation
dose delivery based in part from these values. In megavoltage photon beams, these materials
have the potential to greatly affect the dose delivered to the prescription point and to tissue
shielded by the prosthesis.2 If, the densities recorded to the adjacent tissues from the CT scanner
are incorrectly assigned due to image artifact produced by metallic objects within the body, then
the treatment planning systems calculations will also result with inaccurate dose parameters,
creating an alteration in dose distribution.

Planning pelvic treatment fields that include beams traversing through metal hip prosthesis,
results in an undesirable isodose distribution. The density of the prosthesis material absorbs a
considerable amount of the dose from the lateral fields. The absorbed dose within and beyond
metallic prostheses dropped significantly due to beam attenuation.3 In a four-field conformal
plan, this results in cold areas of insufficient dose to the PTV as well as throughout the areas of
multiple beam intersections. The dose distribution is concentrated to the anterior and posterior
fields leaving these areas to be hot, while the distribution is cold in the lateral beams creating an
isodose curve that outlines the prosthetic but is cold within the center. I have recreated a four-
field pelvis with bilateral hip prosthesis to aid in the visualization of the isodose outcome if
treatment planning were to occur through the hardware.

To improve the accuracy and homogeneity of dose distribution in patients with unilateral or
bilateral hip prosthesis, several techniques may be used alone or in combination to achieve the
best plan outcome. Dosimetrists could consider alternate beam arrangements that avoid the
prothesis and maintain dose levels at tolerance to adjacent structures and organs at risk. If the
treatment planning system has the capabilities, inputting heterogeneity corrections for the
prothesis material is possible if the composition of the prothesis is known, allowing for more
accurate calculations within the plan. With IMRT, making the prosthesis a critical structure to
avoid with dynamic multileaf collimators or placing a dose constraint on the structure, can result
in favorable planning.2 Physical compensators can also be used that are customized to the
patient’s prosthesis dimensions. Orthopedic hardware continues to be a common challenge
within dosimetry. However, creating and comparing different treatment techniques and
combinations is often the necessary approach to produce the best prescription dose outcome in
this circumstance.

References:

1. DenOtter T, Schubert J. Hounsfield Unit. Ncbi.nlm.nih.gov.

https://www.ncbi.nlm.nih.gov/books/NBK547721/. Published January 2020. Accessed February
14, 2021.

2. Reft, C, Alecu R, Das I, et al. Dosimetric considerations for patients with hip prostheses
undergoing pelvic irradiation. Report of the AAPM Radiation Therapy Committee Task Group
63. Med. Phys.2003;30(1162-1182). https://doi-org.libweb.uwlax.edu/10.1118/1.1565113.
Published May 30, 2003. Accessed February 13, 2021.

3. Mahuvava C, Du Plessis FCP. Dosimetry Effects Caused by Unilateral and Bilateral Hip Prostheses: A
Monte Carlo Case Study in Megavoltage Photon Radiotherapy for Computed Tomography Data without
Metal Artifacts. J Med Phys. 2018;43(4):236-246. doi:10.4103/jmp.JMP_70_18. Published October 2018.
Accessed February 16, 2021.