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Alecia Eliason
April 13, 2017
DOS 523 Treatment Planning Project
Inhomogeneity Consideration in Treatment Planning for Primary Lung Cancer
Introduction. The information provided in standard depth dose tables and isodose charts is with
the assumption that the tissue traversed by radiation is of a uniform density.1 This, of course, is
not the case in regards to patient tissue, as the beam must pass through varying densities of
tissues which may include fat, bone, muscle, lung, or air. As a result of this inhomogeneity
within patient tissue, the dose distribution of an incident radiation beam will be affected. Both
the attenuation of the primary beam and secondary scattering of electrons are influenced by
heterogeneous material.2 For this reason, modern treatment planning systems have complex dose
calculation algorithms considering the different densities of patient tissue through which the
beam passes. Particularly, heterogeneity corrections may be one of the most significant factors
affecting treatment planning for tumors in and near the lung due to the range of densities through
which a radiation beam may pass and the interfaces between these tissues.3
Methods and Materials. A relatively simple lung plan was created to evaluate the effects of
heterogeneity on dose distribution. First, a chest structure set was obtained via CT simulation.
Contours were drawn in MIM Maestro Version 5.4 and included the right and left lungs, heart,
spinal cord, patient, and GTV. The structure set and contours were then sent to Xio, where the
treatment plan was created. A prescription of 4500 cGy, delivered in 25 fractions at 180 cGy per
fraction, was chosen for this plan using a superposition dose calculation algorithm. Isocenter was
placed mid-GTV. Beams used for the plan were equally weighted AP and PA fields with a 1 cm
margin around the GTV, and 6 MV photon energy was used for each beam. It should be noted
that the creation of a realistic treatment plan was not the goal of this project, so beam energies,
weighting, and field parameters may not be ideal for treatment of this patients disease.
By default, Xio takes into account tissue heterogeneity when the superposition algorithm
is chosen for treatment planning. However, this feature can be disabled, and the planning system
will then assume all tissue to be water-equivalent. To evaluate dose distribution affected by
heterogeneity corrections within a treatment planning system, the treatment plan discussed was
planned both with and without heterogeneity corrections, referred to from now on as Plan W and
Plan WO, respectively. All other factors remained the same between the two plans.
Results. Visual isodose line variations between Plans W and WO are obvious and are
represented in the axial, sagittal, and coronal planes in Figures 1-6. Plan W contains isodose lines
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which curve inwards midplane, and well as shaped conically nearer to the central ray, as is
clearly shown in Figures 1 and 3. The isodose lines in Plan W are jagged and irregular when
passing through lung tissue. Plan WO, in contrast, has very smooth isodose lines, although they
also bow inwards midplane. The isodose lines in Plan WO retain the shape of the external patient
contour as the beam travels through the patient until reaching isocenter and appear to be more
evenly spaced than those of Plan W.
A notable difference between Plan W and Plan WO is the hot spot point dose, 5755 cGy
and 7256 cGy, respectively. The hot spot in each plan was similarly located in the anterior chest
wall of the patient. Relative to the high hot spot dose in Plan WO is the large amount of MU for
the AP field per fraction as compared to Plan W, with 181 MU required for Plan WO and 127
MU required for Plan W. The dose contribution from the PA field was relatively similar, differing
by only 5 MU per fraction. These MU values are displayed on the treatment plan verbose in
Figures 9 and 10.
As shown in Table 1, an evaluation of Plans W and WO revealed differences in hot spot
dose and GTV coverage. Additionally analyzed were doses to the right lung, including the
maximum dose, the mean dose, and the volume of lung receiving 2080 cGy. This volume was
chosen as a comparative figure due to the QUANTEC recommendation of less than 30% of the
lung to receive greater than or equal to 2080 cGy when delivering fractional doses of 180 cGy.4
These values did not vary significantly, with a difference of only 0.05% between the two plans.
Plan WO revealed greater GTV coverage at 42.3% as compared to 10.2% GTV coverage in Plan
W. Undesirably, Plan WO not only had a high hot spot dose as discussed previously, but both the
maximum and mean lung doses were also notably higher than those in Plan W. The DVHs for
both plans portray in graphical form the volume of each structure of interest receiving a
particular dose or higher, as is shown in Figures 7 and 8.

Table 1.

Structure of Interest Plan W Plan WO

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Mean dose 1275 cGy 1408 cGy

Right lung Maximum dose 5276 cGy 6573 cGy
V20.8 Gy 27.2% 27.7%

Hot spot 5755 cGy 7256 cGy

Volume GTV
receiving prescribed 10.1 % 42.3%
dose

Discussion. Comparing Plan W with Plan WO revealed significant differences in dose

distribution and overall patient dose for several reasons. Plan WO assumes all tissue to be water-
equivalent, thus possessing equal electron densities. Since the Compton effect is the dominant
type of interaction between photons and tissue with the megavoltage energy chosen for these
plans (6 MV), the attenuation of the beam is dependent upon electron densities of the irradiated
matter.1 Therefore, the incident beam, including primary and secondary scatter, will interact with
all tissue in the same manner when no heterogeneity correction is applied, which is evident in the
smooth isodose lines and curvature of the lines retaining the outer contour shape of the patient as
is displayed in Figures 2 and 4. Since Plan W considers all the different electron densities
through which the beam traverses, attenuating the beam more when passing through tissues of
greater electron density and less through those of lower electron density, the isodose lines are
more jagged. The isodose curves for Plan W also shift deeper into the patient and increase dose
in tissues beyond lung because of the decreased attenuation of the beam by low-density lung
tissue. Additionally, since the location of the GTV is within a large lung volume with low
density, the loss of lateral electronic equilibrium in the GTV was demonstrated visually by the
bowing in of isodose lines midplane, leading to poor overall GTV coverage of prescribed dose
for both plans.
The hot spot dose difference between Plans W and WO is directly related to electron
densities of the tissue through which the beam passes and the beam energy of 6 MV used for
both plans. At isocenter, the patients thickness is approximately 28 cm, with 18 cm of that
distance occupied by lung tissue. Plan WO demands the beams to travel through only water-
equivalent tissue and deposit 100% of the prescribed dose at isocenter. Since a 6 MV beam has a
dmax of 1.5 cm, a high hot spot developed at this point in the anterior chest wall of the patient in
Plan WO due to the large number of MU necessary to deliver the prescribed dose to the
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isocenter, which lies just posterior to midplane. More MU were needed from the AP than the PA
in order to achieve this. Conversely, Plan W took into account the low electron density of the
lung tissue, which correspondingly led to fewer interactions between the incident photon and
tissue before reaching isocenter. Therefore, compared to Plan WO, less MU were necessary from
Plan Ws AP beam in order to deliver 100% of the prescribed dose to isocenter.
An important factor to consider when creating treatment plans with vast differences in
electron densities of tissues as is seen in lung plans is the algorithm chosen for calculation of
dose. Ideally, heterogeneity corrections within a treatment planning system should be accurate
within 5%.2 This can prove exceptionally challenging for lung plans due to loss of lateral
electronic equilibrium, notably at interfaces between tissue types. Because lung tissue is of low
density, the amount of laterally scattered electrons is reduced when a beam traverses lung,
causing a build-up region when meeting water-equivalent tissue (i.e. GTV) and resulting in
possible peripheral dose coverage loss in the target volume.1 For this reason, correction-based
pencil beam models have proven to be inadequate for heterogeneity calculations.2 Contrarily,
superposition-convolution and Monte Carlo models are the algorithms of choice when planning
in tissues of differing densities because of their ability to more accurately depict dose distribution
via lateral electron scatter and interface characteristics in heterogeneous materials.
Dose calculations considering tissue heterogeneity were essentially nonexistent before
the 1970s.5 With advancements in technology and the capability of CT simulation to portray
patient anatomy in 3 dimensions, electron densities of materials could be ascertained and
accounted for in treatment planning. However, even with this knowledge at hand, some cancer
centers continued to use assumption of homogeneity within patients due to cost, access, and
inconsistencies of heterogeneous treatment planning. In order to promote accurate radiation
treatment planning, the AAPM took it upon themselves to form Task Group 65, whose mission
was to review and assess inhomogeneity correction methods and make recommendations for
clinical usage of inhomogeneity corrections. This report was published in 2004 and continues to
be the foundation for treatment planning with corrections based on tissue heterogeneity.
Conclusion. Accurate dose distribution representation within radiation treatment planning
systems is essential to creating safe and effective plans, necessitating the use of heterogeneity
corrections in order to achieve this. External beam radiotherapy plans targeting volumes within
or near the lung are especially susceptible to inaccuracies regarding dose distribution due to the
varying densities and corresponding interfaces of tissues if inhomogeneity is not considered.5
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Proper treatment planning algorithms and beam energies, as suggested and outlined by AAPM
Report 85,5 must be chosen to ensure adequate coverage to the target volume while limiting dose
to surrounding critical structures. Although heterogeneity corrections within treatment planning
algorithms do not perfectly represent dose, plans utilizing the corrections are far more accurate
than those which do not.
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Figure 1. Axial slice of Plan W, with the red isodose lines representing the prescribed dose of
4500 cGy.

Figure 2. Axial slice of Plan WO, with the red isodose line representing the prescribed dose of
4500 cGy.
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Figure 3. Sagittal slice of Plan W, with the red isodose lines representing the prescribed dose of
4500 cGy.

Figure 4. Sagittal slice of Plan WO, with the red isodose line representing the prescribed dose of
4500 cGy.
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Figure 5. Coronal slice of Plan W, with the red isodose line representing the prescribed dose of
4500 cGy.

Figure 6. Coronal slice of Plan WO, with the red isodose line representing the prescribed dose of
4500 cGy.
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Figure 7. Plan W cumulative DVH of target objective (GTV) and organs at risk as a function of
volume and dose, summarizing the dose distribution of each structure.

Figure 8. Plan WO cumulative DVH of target objective (GTV) and organs at risk as a function
of volume and dose, summarizing the dose distribution of each structure.
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Figure 9. Plan W verbose.

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Figure 10. Plan WO verbose.

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References:

1. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2014.
2. Saxena R, Higgins P. Measurement and evaluation of inhomogeneity corrections and
monitor unit verification for treatment planning. Med Dosim. 2010;35(1):19-27.
http://dx.doi.org/10.1016/j.meddos.2009.01.002
3. Nakayama M, Yoshida K, Nishimura H, et al. Effect of heterogeneity correction on
dosimetric parameters of radiotherapy planning for thoracic esophageal cancer. Med
Dosim. 2014;39(1):31-33. http://dx.doi.org/10.1016/j.meddos.2013.09.001
4. Marks LB, Bentzen SM, Deasy JO, et al. Radiation dose-volume effects in the lung. Int J
Radiat Oncol Biol Phys. 2010;76(3):S70-S76.
http:dx.doi.org/10.1016/j.ijrobp.2009.06.091
5. Papanikolaou N, Battista JJ, Boyer AL, et al. AAPM Report No. 85: Tissue
inhomogeneity corrections for megavoltage photon beams.
http://www.aapm.org/pubs/reports/RPT_85.pdf. Published August 2004. Accessed April
12, 2017.