Ashley Smelko

DOS 523 Treatment Planning in Medical Dosimetry 2017

This project is designed to compare and contrast the differences in treatment plans utilizing a
heterogeneity correction and a plans without a heterogeneity correction. The patient has a large
tumor in the left lung. She has been simulated in the supine position with her arms above her
head. The prescribed dose is 200cGy for 30 fractions for a total dose of 6000cGy. The isocenter
was placed in the center of the PTV. The right and left lung, spinal cord, tumor, and heart have
been contoured.
The beam energy used in this plan is 6MV. The beams have been arranged AP/PA. Due to the
tumors posterior position in the body, I decided to weight the beams 3:1. The AP beam holds
25% of the weight while the PA holds 75%.
The GTV has been expanded by 1.0cm to create the PTV. The blocks that were created have a
2cm margin around the PTV. The TPS created these blocks based on the PTV volume.

Right Lung-Dark
Green

Left Lung-Orange

Heart-Red

Spinal Cord-Green

PTV-blue
colorwash

Tumor-Yellow

Figure 1: Supine patient position. Three-pane view showing contours.

The heterogeneity correction accounts for the differences in tissue densities assigned to the data
set from the CT scan. Each pixel in a CT image requires a numerical gray-scale value for display
which is known as Hounsfield units or CT#. Most CT units are capable of associating a range of
4000 different values with each pixel. In order to apply heterogeneity corrections, the
Hounsfield units have to be converted into electron density.1
There are a number of dose correction methods. One-dimensional methods account for electron
density information along a ray path from the source to the tumor volume. These methods are
the ratio of TAR (rTAR) and the power law method. This method does not account for scatter
nor does it account for scatter produced by a nearby inhomogeneity. Three-dimensional
corrections use 3-D density data acquired from CT simulation. Known as the as equivalent tissue
air ratio (ETAR) method, these methods perform a ray trace to determine the change in primary
photon fluence and calculate the scatter dose.1
McDermott explains how the presence of inhomogeneities is more important at low energies
because lower-energy beams are attenuated more rapidly and because the scatter contribution to
the dose is more important at low energy.1 When referring to the image below (Figure 2), the
dose lines appear to follow the shape of the patient in the RIGHT image. The densities are
homogenous and have been assigned an electron density of 1g/cm^3. All tissues are absorbing
the radiation energy at the same rate. The dose distribution is very similar to an isodose
distribution characterizing beam energy. The only factors shaping the isodose lines is the beam
traveling in free space before it strikes the body and the dose that is attenuated by the depth
traversed. The image on the LEFT has the heterogeneity correction applied. The 95% line barely
encompasses the gray tumor volume. The 90% line is being attenuated at the medial portion of
the posterior beam by the vertebrae and ribs. The 80% line is affected by the vertebral bodies as
well as the density of the heart.

tum
Figure 2: (Left) Plan with heterogeneity correction applied. (Right) Plan without
heterogeneity correction applied.

The images above (Figure 2) display the stark differences between isodose distribution when the
correction is applied and when it is not applied.

Tumor

rib

Figure 3: (Left) Heterogeneity correction applied. (Right) No Heterogeneity correct (homogeneous

calculation).

The picture above (Figure 3) shows the sagittal view of the beam passing into the thorax. The
picture on the LEFT shows the dose being attenuated by the density of the tumor volume and it
also is demonstrating hotspots of 110% on the ribs or areas of high density. Kahn explains there
is a dose enhancement in the soft tissue layer adjacent to bone on the entrance side of the photon
beam. This enhancement has shown to be due to backscatter and is approximately 8% for
energies 6MV -24MV.2 Once the beam has passed through the bone the dose at the interface is
initially less but then slightly increases beyond the interface. The image on the right doesnt
reflect these affects due to the homogenous composition caused by the absence of a
heterogeneity correction. After the beam has passed through the ribs and enters the lung, the
lower density allows higher dose within and beyond the lung but it also results is a greater loss of
laterally scattered electrons which reduces the dose on the beam axis. The image on the left
displays how the beam continues to travel much further into the lung after it passes through the
rib and after it overcomes the perturbation of that bone-tissue interface. The dose to tissue
beyond lung tissue increases 3%/cm of lung it travels through for 6MV energies.2
Figure 4: Coronal view. (Left) Heterogeneity correction applied with hotspot. (Right) Absence of
correction.

The coronal view is displayed in Figure 4. The hotspot is shown on the rib in the left image.
The dose is lower on the medial portion of the beam due to the higher attenuation by the higher
density bone of the spine. The image on the right shows a homogenous dose throughout the
field. The dose is only being attenuated as it traverses the volume with an equivalent density to
water throughout.
Figure 5: Block shape and orientation of MLC around PTV. GTV in red surrounded by blue PTV
expansion.

The beams eye view (BEV) in Figure 5 allows the dosimetrist to see the different densities or
critical structures which may need to be avoided. It also enables the planner to see that the entire
volume is within the field of treatment.

Figure 6: heterogeneous correction plan with image progression through the tumor volume. The
images outlined in ORANGE show interface effects.

Absorption of the primary beam is changed when in the presence of an inhomogeneity. Nearby
inhomogeneities will affect scatter radiation contributing to dose. Electrons are sent into motion
by a photon with in tissue. As shown in Figure 6, there is a loss of charged particle equilibrium
and at the end of the lung cavity the dose has to build up again as it re-enters tissue. This is
referred to as interface effects.1
 PT
Heart

Left

Cord

Right

Figure 7: Cumulative DVH displaying dose comparison between the two plans. The heterogeneous
Correction plan is represented by a solid line. The Homogenous Calculated plan is represented by the
dashed line.

The DVH shows better PTV coverage when the plan does not use a heterogeneity correction
factor. In this example, the dose to critical structures is higher with the homogenous calculation.
In a study performed by Franks et al, there were significant decreases in target coverage (V100)
for heterogeneous vs homogenous calculated plans. The plan used in this paper shows the same
results. Heterogeneous plans showed increases in 60Gy and 30Gy dose spillage which resulted
in an increase in the mean OAR doses when compared to the homogenous plans. The results of
this study suggested lowering prescription doses when planning without heterogeneous
calculations to achieve similar toxicity levels.3 The standard beam arrangement in the study, by
Frank et al, was a total of 9 beams. Although the plan used for this paper shows the homogenous
plan has lower dose levels to OARs, if there was a different beam arrangement we would see that
the dose would travel further to different OARs due to the differences in densities. This is
shown, again, by the hotspots created near the ribs due to beam perturbation and the higher dose
at the air-tissue interface after passing through the lung.
Figure 8: Hetero MU data

Figure 9: Homogenous MU data

Notice that there are less MUs calculated in the heterogeneous calculation. This is due to the
different correction factors applied by the treatment planning system. The approximate change
in dose through lung is +3%/cm travelled while bone decreases by 2%/cm.2 Since the
homogenous calculation assumes that the patient is a uniform density it doesnt account for the
scattering, interface effects, or attenuation by different densities. These factors reflect the
differences in MU for each plan. The lower amount in MU in the heterogeneous plan from the
AP beam is due to the amount of air the beam is traversing at the central axis. There is less for
the beam to interact with as well as less scatter contributing to dose. In contrast, the
homogenous calculation has higher MU to account for the 1cm/g density it is calculated to
traverse through as opposed to the .25cm/g the heterogeneous plan travels through.

Figure 10: Dose computation parameters to change to homogeneous calculations and homogenous
scatter.
 References
1. McDermott PN, Orton CG. The Physics and Technology of Radiation Therapy.
Madison, WI: Medical Physics Publishing; 2010.
2. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014:220.
3. Franks KN, Purdie TG, Dawson LA, et al. Incorporating heterogeneity correction and
4DCT in lung stereotactic body radiation therapy (SBRT): The effect on target coverage,
organ-at-risk doses, and dose conformity. Med Dosim. 2010;35(2):101-107.
doi:10.1016/j.meddos.2009.03.007
4. Michalski J, Fowler J, Johnstone D, et al. A Phase II Trial of stereotactic body radiation
therapy (SBRT) in the treatment of patients with medically inoperable Stage I/II Non-
Small Cell Lung Cancer. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?
action=openFile&FileID=13767. September 2009. Accessed April 15, 2017