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Jonathan Gonzales
DOS 523 Treatment Planning
March 8, 2015
Lung Plans: A Comparison with and without the use of Heterogeneity Corrections
Introduction: Standard isodose charts and depth tables assume homogeneous, unit density
(water) media.1 However, within a patient are fat, bone, muscle, and air, which attenuate and
scatter the beam differently than does water.1 All these mentioned structures alter the isodose
distribution because each has its own unique electron density. Beam interactions within varying
electron density material give rise to what is called the Compton effect. The Compton effect is
the predominant mode of interaction1 and is what gives rise to the necessary scatter radiation to
effectively deliver prescription dose to a target. Accounting for these changes in electron density
materials are crucial to the treatment planning process. Targets located in the lung, for example
introduce great variations in electron densities all along the path of the beam. The purpose of this
project is to analyze the effects of heterogeneity corrections on a treatment plan for a lung tumor
and see what would happen if the heterogeneity correction was not considered.
Experiment: For this project, an anonymized CT dataset of a patient with right lung cancer was
used. The reconstruction of an image in CT is a complex mathematical algorithm that generates
the CT numbers, which are related to the attenuation coefficients.2 The attenuation coefficients
vary from tissue to tissue but there is a linear relationship between them and the CT number.
A treatment plan was then created for this data set using Eclipse treatment planning
software (TPS). The location of the tumor was in the lower lobe of the right lung and was sitting
just posterior to midline. A gross tumor volume (GTV) was contoured around the visible tumor.
A margin of .5 centimeters was expanded around the GTV and was labeled the planned target
volume (PTV). A dose was then prescribed to the PTV with 95% isodose line (IDL) coverage
with +/- 5% none uniformity. The organs at risk (OR) that were contoured were: the body, right
lung, left lung, spinal cord, and heart. An anterior-posterior (AP/PA) beam arrangement was used
and the isocenter was placed in the center of the PTV. A beam weighting of 55/45 was assigned
to the AP/PA fields. Using multi-leaf collimation (MLC), a block margin of 1.5 centimeters was
given around the PTV. Utilization of 6-megaelectron volts (MV) was chosen. With the

heterogeneity correction on, the TPS then calculated the monitor units necessary to deliver the
prescription dose to the isocenter using a Anisotropic Analytical Algorithm with a .25cm
calculation grid. A second plan was then created, without adjusting any of the treatment
parameters, the heterogeneity correct was turned off and then dose was again calculated. A
comparative analysis was then performed on the two treatment plans by observing both the
changes in IDL distribution and changes in the dose volume histograms (DVH).
Results: The generated plan with the heterogeneity correction delivered 159 monitor units (MU)
from the AP field and 105 MUs from the PA field. The isodose distribution showed less than
optimal PTV coverage with the 95% IDL. (Figure 1). For best PTV coverage the plan generated
a 130%-145% hotpot region on the anterior chest wall of the patient. With AP/PA beam
arrangements and the given location of the target, the only OR that was of concern was the right
lung. The dose to the right lung was receiving a mean dose of 22.9% of the prescription. (Figure
1)
The plan without heterogeneity correction would deliver 216 MUs from the AP field and
120 MUs for the PA field. The isodose distribution displayed complete coverage of the PTV with
the 95% IDL. (Figure 2). The hotpots that were formed were increased to 160%-175% on the
anterior chest wall. The right lung was receiving a mean dose of 25.1% of the prescription.
(Figure 2)
Analysis: The resulting IDL distribution in the plan with the heterogeneity correction is a result
of the variations in electron densities as the beam traverses through the body. As you will see,
from Figures 1 and 2, the beam will initially pass through fat, then muscle/rib, then lung, and
some heart before reaching the target. These tissues have different absorption characteristics; the
radiation beam is attenuated when passing through the body, the various tissues have different
physical and radiological properties.3 You will notice an initial buildup region close to the surface
with isodose lines bunched together just within the chest wall, this is due to increased scatter
occurring within the tissues of the chest wall. This sudden increase in dose from the surface to
depth is called the buildup region and it is where electron equilibrium occurs. The beam will then
enter into the lung which has a much lower electron density to that of water. You will now notice
the isodose lines begin to spread out and the dose begin to fall off because absorption and less
interactions within that portion of the beam path. Finally, once the beam hits the target you will
see a second re-buildup region forming. This secondary buildup is occurring at the interface

between the lung and tumor, or GTV. At this target depth, you will see a drastic bowing in of
isodose lines because of the lack of lateral side scatter contributions from the adjacent tissue, or
lung. This results in very poor 95% IDL coverage of the PTV. (Figure 1) The right lung is the
only OR and because of the small irradiated volume within the irradiated area, the doses are kept
well below dose tolerances.
The resulting IDL distribution in the plan without the heterogeneity correction shows a
plan that is considering everything along the path of the beam to have a density of water. The
resulting isodose lines are now very homogenous in distribution because there are no longer
variations in electron densities along the beam. The isodose lines look much like those that you
would see in standard beam profiles, with an initial build up region to Dmax and then a gradual
fall off dose at depth. The 95% IDL is now offering complete coverage of the PTV because it is
now factoring contributions from scatter radiation from water equivalent tissue from all around
the tumor. (Figure 2) There is now an increase in hotspot because the beam now has to traverse
more material of electron density, primarily because of the deduction of the lung volume. You
will notice that most of the irradiated volume is of lung. By now attributing that lung volume a
density of water you are now required to increase the MUs to achieve the prescription dose at
depth.
Conclusion: The Eclipse TPS offers this heterogeneity correction as a way to account for all the
variations in electron densities along the beams path. Eclipse has a tool to actually measure the
water equivalent depth (WED) along a path. WED measuring tool sums up all the electron
densities along the area of interest and assigns it a cumulative water equivalent depth. For the AP
field, the WED measured 6.36 cm but had an actual distance from surface to isocenter of 18.81
cm. (Figure 3) The PA field had a WED measuring 5.13 cm and an actual distance of 10.14 cm.
(Figure 4). This data is a way to further analyze the results of my two plans. The plan with the
heterogeneity correction on, essentially is delivery dose through a WED of 6.36 cm from the AP
and 5.14 cm from the PA. In the plan without heterogeneity correction, the TPS now considers
the WED from the AP to measure 18.18 cm and 10.14 cm from the PA. This increase in supposed
depth is what results in the increase in hotspots because of requirement of more monitor units to
penetrate at those depths.
If this non-corrected plan were to be used on a patient, you would essentially be over
dosing the patient. A simple way to test this would be to run the first plan with heterogeneity

correction but input the monitor units of the second non-corrected plan. The results do show
coverage of the PTV with 95% IDL but with hotspots nearing 200%. With dose escalations like
this, you can cause serious and irreversible damage to healthy tissue. This additional test further
shows the importance of why we should always account for tissue inhomogeneities when
creating treatment plans.
For future treatment planning, we have to be aware of the effects of scatter radiation
contributions and how to achieve best target coverage without irradiating too much healthy
tissue. We must also understand that tumor lung interfaces can pose difficulties when trying to
achieve coverage. There is an increase dose buildup in the interfaces between muscles than in
less dense lung tissue (air cavity) and the corresponding builddown, where under dosage can
occur.4 Having an understanding of how inhomogeneities alter isodose distribution can aid the
dosimetrist in figuring out the most optimal beam angles to use to achieve.

Figures

Figure 1: Isodose distribution/DVH/Structure dose statistics of the plan with heterogeneity

correction

Figure 2: Isodose distribution/DVH/Structure dose statistics of the plan without heterogeneity

correction

Figure 3: The AP distance and the water equivalence depth (WED)

Figure 4: The AP distance and the water equivalence depth (WED)

References
1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. Mosby,
Inc; 2010.
2. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2012
3. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections for
megavoltage photon beams. AAPM report no.85. American. Assoc Phys Med. Published
August, 2004. https://www.aapm.org/pubs/reports/rpt_85.pdf . Accessed March 8, 2015.
4. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996