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Kevin Kocos
4/23/2017
Homogeneity vs. Heterogeneity in Lung Treatment Planning
Introduction: Effective dosimetry techniques will be able to deliver the correct dose to the
correct location within the patient. This is no exception when it comes to lung treatments in
radiation therapy (RT) that require special considerations in order to obtain accurate dose
delivery. Heterogeneity correction factors (HC), in most clinical situations, are the best option to
achieve accuracy for lung dose models. The use of standard isodose models assumes
homogeneity across all of the tissue. This can result in significant miscalculations within
treatment which have the potential to compromise optimal patient outcomes.1 In reality, radiation
beams must pass through several types of heterogenous tissues such as muscle, bone, fascia, air
and water. Interactions between radiation beams and the previously mentioned tissues is
primarily due to the Compton effect which is heavily influenced by the electron density of a
material. In order to explore how lung plans are affected by HC and homogeneity, this paper will
discuss the differences in each type of planning method.

In order to correctly account for the varying tissue densities, HC are available in most
modern treatment planning systems (TPS).2 A retrospective study by M.D. Anderson looking at
the lung treatments of 30 patients with homogeneity was re-planned with HC. Fourteen of the 30
patients were found to have less than 90 percent coverage of the planning target volume (PTV)
while at least 95% coverage was obtained with homogeneity. This decrease in coverage is due to
the fact that loss of electronic equilibrium from the low density lung tissue decreases the amount
of attenuation from the primary radiation beam within the lung.1 This loss of electronic
equilibrium will cause an associated drop in dose in the immediate layers before and after the
lung. In addition to the dose reduction in the immediate layers, dose buildup behind the lung
tissue then causes an abrupt increase in dose. This dose increase is equal to approximately 2
percent per centimeter for high megavoltage (MV) beams (> 6 MV).

Methods and Materials: The patient was seen for a non-small cell lung cancer (NSLC) of the
upper and inferior lobe of the right lung and it was agreed that radiation therapy would be the
best treatment. This patient was status post right lung middle lobectomy and right upper lobe
resection due to a history of bronchio-alveolar carcinoma, 5 years prior. The patient was given a
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computed tomography (CT) simulation (sim) by the Toshiba Aquilion CT machine which was
then imported by the Philips Pinnacle3 Version 9.10 TPS. It has been demonstrated that Pinnacle
TPS is able to correctly identify inhomogeneities within a 5% error.3 The physician placed the
isocenter during the CT sim and the dosimetrist was then responsible for contouring the organs at
risk (OR) which included the right and left lung, the heart and the spinal cord. The physician
then contoured the gross tumor volume, clinical tumor volume and PTV.
The patient was prescribed 6000 cGy to the tumor isocenter for 30 fractions of 200 cGy.
Anterior/posterior (AP) and posterior/anterior (PA) beams were used with a 6 MV energy and the
beams were equally weighted at 50 percent each. The beams were setup with a 1 cm margin
around the PTV. This was done by utilizing the auto-block function of the TPS as well multi-leaf
collimators to achieve the proper blocking. The fields were calculated using the collapsed cone
convolution algorithm. Although Monte Carlo has been shown to be the most accurate algorithm
while calculating complex inhomogeneities, long calculation times prevent their use in many
clinical situations. In their place, convolution based algorithms can be used with confidence to
accurately predict tissue heterogeneity.4 MUcheck was then used to verify the monitor units
(MU) the patient was receiving. Two trials were completed for this lung tumor, one being with
HC and one with homogeneity. The two trials were then used to compare against one another to
show the differences of the treatments.
Results: Valuable information can be obtained from the cumulative dose volume histogram
(DVH) that allows us to evaluate several factors of each plan on the same page. The DVH
demonstrates that PTV coverage is significantly higher for the homogeneous plan, which is
47.55% compared to 18.97% with HC (Figures 1,2). Maximum dose to the right lung is also
significantly lower for the right lung with HC plan at 6684 cGy as compared to 7022 cGy for the
homogeneous plan (Figures 1,2). Maximum dose to the spinal cord was 1456 cGy for the HC
plan as compared to 2042 cGy for the homogeneous plan (Figures 1,2). Heart dose was shown
to be a maximum of 5828 cGy for the HC plan, where the homogeneous plan demonstrated a
6052 cGy maximum (Figures 1,2). The left lung dose proved to be the smallest as the HC plan
was a maximum dose of 299 cGy compared to the homogenous plan which was 381 cGy
(Figures 1,2).
The monitor units (MU) were evaluated for each plan and were found to be significantly
higher in the HC plan than for the homogeneous plan. The AP beam for the heterogeneous plan
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was calculated to give 124 MU while the AP beam for the homogeneous delivered 140 MU to
the patient (Figures 3,4). The PA beam for the HC plan was found to give 127 MU while the PA
beam for the homogeneous plan was calculated to deliver 151 MU (Figures 3,4).
Evaluation of the hot spots in both the plans demonstrated the plan with HC had a hot
spot of 7294 cGy which equals approximately 122% of the prescription dose. The lung plan with
homogeneity demonstrated a hotspot of approximately 130% of the prescription dose (Figure 5).
Both of these hot spots were positioned in nearly identical positions at the posterior surface of
the patient in the middle of the right lung. Accurate monitoring of the treatment hot spot is
crucial as this has the potential to cause severe morbidity to the patient if underestimated.
Discussion: The most striking differences that can be observed are within the comparison of the
isodose curves. These curves show that PTV coverage from the 100%, 98%, 95% and 90%
isodose are significantly less when HC is applied to the plan as they bow inwards toward the
center (Figures 6,7,8) . Comparatively, the transverse and sagittal views of homogeneous plan
shows uniform isodose lines that resemble an hourglass (Figures 6,7). The previously mentioned
loss off electronic equilibrium can also be observed in the transverse and sagittal views of the
plan with HC. Here it shows the 105% and 102% isodose lines are reduced significantly near the
entrance points of the lung for both of the primary beams (Figures 6,7).
The PTV in the HC plan was alarmingly under-dosed by almost 30% due to the fact of
low density lung tissue causing a lack of lateral electronic equilibrium.1 This in turn will cause a
significant reduction of dose in throughout the primary beam. It becomes evident with this
exercise that by not using the HC with the lung plan, the practitioner has the potential to
significantly under-dose the tumor, doing a great disservice to the patient.
Administration of MU to the patient must also be closely monitored during RT
treatments. The MU given to the patient for the anterior beam was 13% higher for the
homogenous plan compared to the HC. MU for the posterior beam was 19% higher for the
homogeneous plan. This is in part due to the fact that the HC plan uses an adjusted effective
depth as part of the calculation for the MU. In the adjusted effective depth, the air cavities in the
lungs are essentially looked at as a depth of 0, decreasing the effective depth. The longer
effective depth for the beams in the homogeneous plan, makes it necessary to use a greater
amount of MU in order to deliver the prescription dose to the PTV (James Schmitz, CMD, oral
communication April 2017).
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Conclusions: When comparing both of these plans, it becomes evident that incorporating HC in
for adjacent regions that have vastly different densities will help to accurately account for the
dose and MU being administered to the patient. This becomes most crucial at the lung-tissue
interfaces where homogeneous planning, fall short of accurate modeling.4,1 Its also important to
know that not all HC are effective as the others, the accuracy of the HC will depend on the
conditions used during the radiation process. Typical correction factors such tissue air-ratio,
effective tissue air-ratio and bathos power law have been commonly used but fail to achieve the
accuracy of convolution methods or Monte Carlo methods.1,5 This is most often due to areas of
outside of the tumor that lack electronic equilibrium.4 The practitioner must analyze the benefits
of including HC into the treatment plan versus the downsides of not including HC. I believe that
in most cases, including HC will prove beneficial to the patient. When used correctly HC can be
a method that helps us to attain our overall goal in radiation oncology, to deliver the greatest
amount of dose the tumor, safely, while minimizing exposure to OR.
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References
1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams and Wilkins. 2014.
2. Khan F, Gerbi B. Treatment Planning in Radiation Oncology. 3d ed. Philadelphia, PA.
Lipincott Williams and Wilkins. 2012.
3. 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.
4. Engelsman, M, Damen E, Koken P, vant Veld A, van Ingen K, Mijnheer B. Impact of simple
Tissue inhomogeneity correction algorithms on conformal radiotherapy of lung tumours.
Radiotherapy and Oncol. 2001; 60(3): 299-309.
http://dx.doi.org/10.1016/S0167-8140(01)00387-5.
5. Ueki N, Matsuo Y, Shibuya K, et al. Differences in the dose volume metrics with
Heterogeneity correction status and its influence on local control in stereotactic body radiation
Therapy for lung cancer. J Radiat Res. 2013; 54(2): 337-343.
http://dx.doi.org/10.1093/jrr/rrs084.
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Figures

Figure 1: Heterogeneous lung plan DVH

Figure 2: Homogeneous lung plan DVH

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Figure 3: MUcheck printout for heterogeneous lung plan

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Figure 4: MUcheck printout for the homogeneous lung plan.

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Heterogeneity Plan Homogeneity Plan

Figure 5: Hot spots and their doses

Heterogeneity Plan Homogeneity Plan

Figure 6: Isocenter placement in the transverse plane.
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Heterogeneity Plan Homogeneity Plan

Figure 7: Isocenter placement in the sagittal plane.

Heterogeneity Plan Homogeneity Plan

Figure 8: Isocenter placement in the coronal plane.
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