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Nick Piotrowski Teletherapy Heterogeneity Correction As this field moves forward, the knowledge about radiation effects on human anatomy becomes more extensive. All of this information that we obtain continues to help make this a more accurate and safe field for our patients. In more recent years, the attempt to correct for tissue density differences has become a hot topic. While it was common knowledge that the density of tissues within the body were not all the same, it was important to determine the effect this played on a radiation beam. When creating a treatment plan, the calculated dose distribution is depicted in isodose lines. Before an algorithm was determined to take density changes into account, all calculations were based off of phantoms.1 While these phantoms do in fact provide an accurate representation of tissue, they never took into account structures like bone and air. With an extreme change in density brings about change in the attenuation of the radiation beam. If a treatment beam is attenuated more or less than calculated, there will be an inaccurate representation of the dose. With treatments today being more precise than ever, this change in distribution could lead to both an underdosage of the tumor, as well as an overdosage of critical structures.2 To avoid this complication, a homogeneity correction factor was developed to more accurately display the isodose distributions. The treatment of a lung tumor provides the most apparent changes when correcting for inhomogeneity. Filled with air, lungs have a much lower density than normal tissue. As the computer calculates the distribution of dose, it recognizes the drop in density and corrects for it. Without this correction factor, the software would overestimate the attenuation factor and lead to an overdosing of the lung.2 While the primary beam and photon scatter create this overdosing in and beyond the lung, there are other regions where underdosing may occur. The other effect, changing of the secondary electron fluence, will lead to this decrease in dose near the beam edges.3

In order to visualize the difference that the correction makes, two plans were created, one homogenous, and the other heterogeneous. As both energy and field size effect the process, it was important the plans be identical.4 Using anterior posterior/ posterior anterior (AP/PA) beams, and an 18 megavolt (MV) energy, the plans were prescribed 39.6 Gray (Gy) to the tumor volume with a 2 centimeter (cm) margin. The images in Figure 1 show the dose distribution, hot spot, and dose volume histogram (DVH) when the heterogeneity factor was turned on. As a comparison, Figure 2 depicts these same outcomes when the heterogeneity factor was not taken into account.

Figure 1: Heterogeneity factor on

Figure 2: Heterogeneity factor off The most notable thing that occurred when taking the heterogeneity into account was the increase in the hot spot. As the dose in the lung went up, the hot spot followed as the plan pushed to reach adequate coverage around the planning target volume (PTV). While 87.1centigray (cGy) isnt a severe increase, it does make the plan less acceptable. To attempt to decrease the heterogeneity hotspot from 104.6%, and keep my coverage the same, the monitor units (MU) would have to be decreased. In addition, moving the weight point and potentially weighting the fields could help make this plan more acceptable. Looking at this plan provides an excellent comparison of past and present. While some centers continue to use the old method, using the heterogeneity correction is much more common. While both plans can become acceptable, it wasnt an easy transition for many people. In a case such as this one, the physicians had to make the decision if they wanted to have excellent coverage, or decrease their target dose. Although the plans may not always have been better, they were without a doubt more accurate. With that being the ultimate goal in this field, its safe to say having the heterogeneity factor has once again pushed this profession forward.

References 1. Mackie TR. Treatment planning algorithms: model-based photon dose calculations. In: Khan FM. Treatment Planning in Radiation Oncology 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2012:93-109. 2. La Fuente-Herman TD, Gabrish H, Herman TS, et al. Impact of tissue heterogeneity corrections in stereotactic body radiation therapy treatment plans for lung cancer. Journal of Medical Physics. 2010;35:170-173. Available at: http://www.jmp.org.in/article.asp?issn=09716203;year=2010;volume=35;issue=3;spage=170;epage=173;aulast=Herman. Accessed March 12, 2013. 3. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996:101. 4. Khan F. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2010: 220-229.