1

Aubrie Rice
Treatment Planning Project
April 23, 2017
Effect of Heterogeneity Correction on Lung Planning
Introduction
Treatment planning in radiation therapy has greatly advanced in previous decades with progress
not only in imaging procedures and beam modulation techniques but also with the introduction of
heterogeneity correction algorithms. Before the 1970s, standard isodose charts and dose distributions
assumed tissue was homogeneous and were calculated assuming the patient composition was made up
exclusively of water.1,2 In reality though, the human body is made up of a variety of tissues and air
cavities which affect dose distribution in different ways. With the introduction of computed tomography
(CT), determining the electron density of tissue became possible and allowed for the creation of
heterogeneity correction algorithms.1 This project will explore the effects that different heterogeneities
have on dose distribution by evaluating and comparing a treatment plan with heterogeneity correction to
an uncorrected plan while also comparing these results to the literature.
Methods
A lung cancer patient was scanned on a CT simulator in setup position. The patient was
positioned supine, a t-grip and vacbag were used to immobilize the patient arms overhead and a knee
sponge was used for patient comfort. Organs at risk were contoured which included the heart, right lung,
left lung, and spinal cord. The patient had been injected with IV contrast during the simulation. This was
overridden to 40 Hounsfield units. The physician drew a gross tumor volume (GTV), clinical target
volume (CTV), internal target volume (ITV) and planning target volume (PTV). Two treatment plans
were created for the patient using the Eclipse Treatment Planning System. Isocenter was placed in the
center of the PTV and for the first plan (NoCorrection), an anterior and a posterior beam were added with
equal weighting and an energy of 6 megavoltage (MV). A 0.7 cm margin was placed around the PTV for
both the anterior and the posterior beam. Prescription dose for the plan was 66 Gy to be delivered in 33
fractions (200 cGy/fraction). The first plan was calculated with AcurosXB dose calculation algorithm
with heterogeneity correction turned off. A verification plan (Correction) was then created on a duplicate
structure set for this patient and calculated with the same MU from the previous plan with heterogeneity
correction turned on. Both plans had a normalization value of 100%.
Results
These plans were created for the purpose of comparing dose distribution, not for optimal target
coverage and due to this, percentages will be used to compare areas of interest. The treatment plans
NoCorrection and Correction generated considerably different dose distributions, different target
coverage, and dose to organs at risk (OARs). For the NoCorrection plan, 95% of the dose covered 96.2%
 2
Aubrie Rice
Treatment Planning Project
April 23, 2017
of the PTV and had a max point dose of 104.9%. The Correction plan on the other hand, resulted in a
much higher dose to the PTV with 95% of the dose covering 98.3% of the PTV and a max point dose of
117.8%. OARs mainly varied in max point doses and their variations can be seen on in the comparison
DVH provided in Figure 1. The max point dose to the spinal cord for the No Correction versus
Correction plan was 97.1% and 96.4%, respectively. The max point dose to the heart for the NoCorrection
versus Correction plan was 109.8% and 116.3%, respectively. The max point dose to the Lung Total
CTV structure for the NoCorrection versus Correction plan was 114.4% and 123.8%, respectively. A
treatment plan summary for each plan can be found in Figures 2a & 2b. Axial, coronal and sagittal views
of the plan at isocenter are provided in Figures 3a, 3b, and 3c.
Discussion
The different dose distributions, target coverage and dose to OARs with the plan corrected for
heterogeneity compared to the uncorrected plan are a result of the varying tissue density in the patients
body. The dose distribution in plan NoCorrection resembles standard isodose charts and a comparison can
be seen in Figure 4. The isodose lines only deviate as a result of the body contour and varying patient
thickness, sloping along with the outline of the patient. The Correction plan on the other hand, has a very
different look. The isodose lines in this plan are affected by the varying tissues in the patients body. In
the lung tissue for example, the isodose lines constrict as they travel through the lung tissue. This effect is
noted by Khan and is due to the loss of lateral electronic equilibrium as the beam traverses through lung
tissue. Due to the lower density of lung, a larger number of electrons travel beyond the beam limits,
resulting in a less sharp dose profile and constriction of the isodose lines.2 Figure 5 shows the effect of
lung on the Correction plans dose distribution. The effects of bone can also be seen on the Correction
plan. Bone, which has a much higher density than water/soft tissue, has several effects on the isodose
distribution. In megavoltage photon beams like the ones in this plan, electron backscattering due to the
increased density of bone causes an increase in dose in the soft tissue that is adjacent to the bone.2 This
effect is illustrated in Figure 6. The backscattered photons have a very limited range of only a few
millimeters which limits the region of dose escalation.2 On the opposite side of the bone though, there is a
dip in the isodose lines, noting a decrease in the soft tissue beyond the bone. As mentioned by Khan, the
forward scatter of electrons on the transmission side of the bone combined with the electron build up in
soft tissue results in a decreased dose beyond the bone for energies up to 10 MV.2 This effect is illustrated
in Figure 7 for the Correction plan.
The effects that these heterogeneities have on the dose distribution result in differing target and
OAR doses for each plan. Both plans were calculated with the same MUs and normalization values. Due
 3
Aubrie Rice
Treatment Planning Project
April 23, 2017
to this, the increase in dose to the target in the Correction plan shows that if a patient were planned
without heterogeneity, the target would be overdosed. This is also noted in a study by Herman et al3 that
examined the impacts of tissue heterogeneity corrections in SBRT lung treatments. The author reports
that failure to use heterogeneity would overdose the target due to assumption of more attenuation than
what actually occurs by the treatment planning system.3 Their results showed higher doses to targets on
plans corrected for heterogeneity compared to uncorrected plans. For 15 plan comparisons, their study
showed an average of 10% higher minimum, an 8% higher mean and a 6% higher maximum dose.3
Conclusion
The results of previous studies and the ones found during this project show the importance of
using heterogeneity corrections when planning lung treatments. As shown by Herman et al3, planning
without heterogeneity can result in overdose to targets and increased dose to OARs. Although Herman et
al discussed these effects with SBRT plans, the same held true in this study when comparing parallel
opposed fields. When considering this, it is clear that planning with heterogeneity correction is of great
benefit to the patient in order to reduce the possibly of overdosing the target or normal tissue.
 4
Aubrie Rice
Treatment Planning Project
April 23, 2017
References
1. Papanikolaou N, Battista JJ, Boyer AL et al. AAPM Report No. 85: Tissue Inhomogeneity
Corrections for Megavoltage Photon Beams - Report of Task Group No. 65 of the Radiation
Therapy Committee of the American Association of Physicists in Medicine. Madison: Medical
Physics Publishing; 2004.
2. Khan, FM. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2014.
3. Herman Tde L, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of tissue heterogeneity
corrections in stereotactic body radiation therapy treatment plans for lung cancer. J Med Phys.
2010;35(3):170-3. http://dx.doi.org/ 10.4103/0971-6203.62133
 5
Aubrie Rice
Treatment Planning Project
April 23, 2017
Figures

Figure 1. Cumulaive DVH for Correction plan and NoCorrection plan.

 6
Aubrie Rice
Treatment Planning Project
April 23, 2017

Figure 2a. Treatment plan summary for NoCorrection Plan.

Figure 2b. Treatment plan summary for Correction Plan.

 7
Aubrie Rice
Treatment Planning Project
April 23, 2017

Figure 3a. Axial view at isocenter for NoCorrection (left) and Correction (right) plans.

Figure 3b. Sagittal view at isocenter for NoCorrection (left) and Correction (right) plans.
 8
Aubrie Rice
Treatment Planning Project
April 23, 2017

Figure 3c. Coronal view at isocenter for NoCorrection (left) and Correction (right) plans.

Figure 4. Isodose distribution from Khan2 for a 4 MV beam (left) compared to the NoCorrection plan
(right).
 9
Aubrie Rice
Treatment Planning Project
April 23, 2017

Figure 5. Axial views of the parallel opposed dose distribution for Correction plan showing the
constriction of the isodose lines as they travel through lung tissue.

Figure 6. Axial view of the Correction plan with arrows indicating the dose enhancement region caused
by electron backscatter from the sternum.
 10
Aubrie Rice
Treatment Planning Project
April 23, 2017

Figure 7. Axial view of Correction plan demonstrating the reduction of dose (dipping isodose line) in the
soft tissue behind the sternum.