Lisa Spanovich

Treatment Planning Project

Spring 2017

Heterogeneity VS. Homogeneity Correction

INTRODUCTION

The history of treatment planning has evolved tremendously over the years, and one huge
advancement in radiation treatment planning is the development of calculation algorithms that
are able to correct for tissue inhomogeneities. In the past, radiation therapy treatments were
calculated as though the patients anatomy was all the same density, a soft tissue or a water
equivalent material. Realistically, the body is made up of many different densities such as
muscle, fat, bone, and air.1 When a radiation beam transverses through tissues of different
densities, the dose computation is altered. The degree of alteration is dependent on the tissue
type, position of the tissue in the path of the radiation beam, and on the energy of the radiation.2
For this project, a lung tumor plan will be assessed with heterogeneity correction and without
heterogeneity correction.

METHODS AND TECHNIQUES

I utilized the Eclipse Treatment Planning System (TPS) to develop parallel-opposed

(POP), anterior to posterior (AP) and posterior to anterior (PA) treatment fields for the treatment
of a right lung tumor. The fields were equally weighted, and the lowest energy available was
used: 6 megavoltage (MV). The field size was derived from a 2.0 CM margin around the PTV.
The prescription for this plan was 200 cGy daily, in 30 fractions, for a total dose (TD) of 6000
cGy. The following structures were contoured on the CT scan: external (body), right lung, left
lung, lungs, spinal cord, PTV (tumor), and heart.

The initial plan was calculated using the Anistropic Analytical Algorithm (AAA). Eclipse
gives the option to disable the heterogeneity correction. After this plan was complete, the
heterogeneity was disabled, and a second plan, with the same parameters, was calculated.
Pictures of the axial, coronal, and sagittal views of each plan were obtained, along with the final
treatment plan that includes the monitor units (MU), and dose volume histograms (DVH).

RESULTS AND DISCUSSION

Comparing the heterogeneous plan and the homogeneous plan, we must first understand
what is happening within the patients body when the radiation interacts with tissue. The dose to
lung tissue is primarily governed by its density, because the lung has a low density, it gives rise
to higher dose within and beyond the lung. High energy photon beams are typically not used for
lung patients due to the problem of loss of lateral electronic equilibrium. Because of the lower
density of lung, an increasing number of electrons travel outside the geometric limits of the
beam, which causes the dose profile to become less sharp.1

When analyzing the axial, coronal and sagittal views of the heterogeneous and
homogeneous plans, there are stark differences in regards to the isodose lines. Looking at the
isodose lines on the homogenous plan, they are not skewed depending on where the radiation
beam transverses bone or an air cavity. The isodose lines look similar to the classic hourglass
shape that we see in our textbooks, and those isodose lines are obtained by using a homogenous
water phantom. When looking at the heterogeneous plan, specifically the sagittal view (Figure
3), the isodose lines take on a curvature depending on the different tissues densities that the beam
transverses.

Next, we can compare the amount of monitor units of both plans, and analyze what we
know about radiation and its beam path. The homogenous plan had more monitor units than the
heterogeneous plan (specifically on the AP field); it is more noticeable in this project because we
are comparing lung plans. The monitor unit calculation difference would be as less skewed if we
compared the heterogeneity and homogeneity of, for example, a whole brain treatment. It is
known that the body is made up of many different types of tissues that have different equivalent
depths. The equivalent depth is a method used for calculating dose through different mediums,
where you assign a correction factor for tissue types based on their electron density.3 Tissue
inhomogeneity is something that must be accounted for when calculating doses for radiation
treatments.
 Figures 5 and 10 show the treatment plans of the heterogeneity and homogeneity plans,
respectively. Lets focus on the AP beam of these 2 plans, due to the large amount of lung tissue
that the AP beam transverses. The AP beam is going through 18.9 CM of tissue, 14.9 CM of
which is lung tissue, and 4.0 CM of soft tissue (Figure 11). In order to determine how much
tissue the beam must go through in order to treat the tumor, the equivalent depth (or equivalent
path length) must be determined. Because lung tissue is less dense than water, the thickness of
the lung tissue is multiplied by a number less than 1.0 (usually in a range of 0.25-0.35).3

Equivalent Depth of AP beam

0.35 (electron density of lung) X 14.9 CM (of lung tissue) = 5.22 CM

1.0 (electron density of soft tissue) X 4.0 CM (of soft tissue) = 4.0 CM

5.22 CM + 4.0 CM = 9.22 CM

The equivalent depth according to the actual treatment plan is 9.6 CM, which gives a 4%
deviation from our rough hand calculation of 9.22 CM. The equivalent path length can be found
in Figures 5 and 10, below the monitor unit calculation. This calculation shows the tremendous
difference that treating through lung tissue can make. The AP beam for the homogeneous plan
was calculated using an 18.9 CM depth to CAX. When using heterogeneous calculations with the
lung tissue, our equivalent depth is half of that measurement (9.6 CM). Because of this
difference, it made a huge impact on the amount of monitor units that were needed to treat this
lung tumor. The AP field of the homogeneous plan required 244 MU, while the AP field of the
heterogeneous plan only had 174 MU.

When comparing the DVH for the heterogeneous and homogeneous plans (Figure 12), it
is apparent that the DVH for the homogenous plan yields more coverage of the PTV. This is
because of the electronic equilibrium occurring at the boundaries of low density material or air
cavities.1 I like to think of the tumor coverage in regards to a flashlight. When I use my flashlight
to see what is outside my door step, lets say its a squirrel thats sitting across the yard, there is
nothing in the air that is blocking the light, so I have a full, uninterrupted view or coverage
(homogeneous). If I used my flashlight to look up into a tree, the light would be partially blocked
by the branches, and all of the light would not be getting to the object in question
(heterogeneous).

CONCLUSION

Heterogeneity correction is an important accessory when calculating a radiation treatment

on any part of the body, but has a profound effect when treating areas within the chest cavity.
Because lung is the most inhomogeneous site in the body, it is necessary to account for the
differences in tissue densities in the dose computation and to consider the secondary electron
transport accurately. The use of heterogeneity correction and different types of algorithms have
been reported to significantly influence the accuracy of the absolute dose.4 Sometimes using
homogenous techniques in treatment planning is still acceptable, depending on what and where
we are treating. Water phantoms are a staple in the radiation therapy department, and that is
something that will never be exempt, due to needing baseline dose measurements.
Figure 1: Heterogeneous axial scan

Figure 2: Heterogeneous coronal scan

Figure 3: Heterogeneous Sagittal view

Figure 4: Heterogeneous DVH

Figure 5: Heterogeneous Treatment plan
Figure 6: Homogeneous Axial View

Figure 7: Homogeneous Coronal View

Figure 8: Homogeneous Sagittal View

Figure 9: Homogeneous DVH

Figure 10: Homogeneous Treatment Plan
Figure 11: Measurement of Axial CT Scan at Isocenter

Figure 12: Heterogeneity/Homogeneity DVH

Heterogeneity plan is shown as Homogeneity plan is shown as

 REFERNCES

1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams and Wilkins. 2014.
2. Lim M. Principles and Practice of Clinical Physics and Dosimetry. Madison, WI:
Advanced Medical Publishing, Inc, 2006.
3. Washington CM, Leaver DT. Physics, Simulation, and Treatment Planning. St. Louis,
MO: Mosby, Inc. 1996.
4. Takahashi W, Yamashita H, Saotome N, et al. Evaluation of heterogeneity dose
distributions for Stereotactic Radiotherapy (SRT): comparison of commercially available
Monte Carlo dose calculation with other algorithms. BioMed Central.
https://doi.org/10.1186/1748-717x-7-20