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Madeline Doberstein

Treatment Planning

April 28, 2019

Objective: The objective of this paper is to identify the differences in a lung treatment plan with
and without heterogenity corrections.

Purpose: The goal of treatment planning for radiation therapy is to maximize tumor control
propability (TCP) while minimizing normal tissue complication probability (NTCP). Inadequate
coverage of a tumor can lead to reoccurance and an overdose to normal tissue or critical
structures can cause severe side effects. According to Washington et al,1 standard isodose charts
assume that the medium being irradiatited is of a uniform density of water. However, in an actual
patient we have bone, fat, muscle and air. When treating with photons, the majority of iteractions
of the x-rays in the body is Compton scatter, which reacts differently in various electron
densities. Therefore, to make sure an accurate respresentation of dose being delivered to the
patient, corrections for electron denisity differences must be made.

Materials and Methods: To complete this project, a patient with a tumor in the lung (excluding
any patient with a tumor located near the mediastinum) was chosen. Contours created were an
external skin contour, right lung, left lung, spinal cord, heart, gross tumor volume (GTV) and
planning target volume (PTV). An AP/PA plan was created using Pinnacle TPS (version 14.0)
with a 1 cm margin block around the PTV and equal weighting to the anterior and posterior
beam. Energy used for both beams was 6 megavoltage (MV). The dose prescribed was 200 cGy
in 30 fractions to the isocenter. The isocenter was placed in the center of the PTV, a plan was
then calculated and labeled as “heterogeneity”. The TPS default is to use heterogeneity
corrections. The plan was then copied to a new trial and all beams were turned to homogeneous
and the new plan was labeled “homogeneity”. The goal of this plan was to identify the
differences in a plan when using heterogeneity corrections so adequate PTV coverage and dose
to critical structures was not considered.

Results: Upon initial review of the plans it was clear that using heterogeneity corrections
delivered a much cooler plan (Figure 1-3). In the plan with the heterogeneity corrections the
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100% isodose line seems to drop off after entering the lung. In the coronal view of the lung
tumor, the 95% isodose line thourougly surrounded the PTV in the plan without the corrections
(Figure 3). In the plan with heterogenetiy corrections the PTV was receiving only 8.64% of the
prescription dose. In the plan without the corrections, the amount of PTV recieiving prescription
dose almost doubled to 15.1%. The point of maximum dose also increased from 6821 cGy in the
heterogeneous plan to 7394 cGy in the homogeneos plan. The monitor units of the AP beam
increased from 126.8 MU to 155.5 MU when the heterogeneity corrections were removed
(Figure 4 &5). The monitor units of the PA beam increased from 121 MU to 125.6 MU as well
in the”homogeneity” plan (Figure 4&5). Regarding changes in the dose volume histogram
(DVH), the plan labeled “homogeneity” showed the PTV to be given a much more uniform dose
with the DVH appearing to drop off in a straight line compared with the more gradual slope in
the heterogeneous plan (Figures 6 &7). Dose to the heart, spinal cord seemed to be
overestimataed in the homogeneous plan while the dose to the right lung was underestimated
(Figures 6&7).

Discussion:When heterogeneity corrections are not applied to a plan, all tissue is assumed to be
the same density. In reality, lung tissue is about 1/4 the denisty of tissue and bone is about 1.6
times the density of tissues.1 Khan staes that the differences primary beam and scattered photons
as well as the change in secondary electron fluence play a role in inhomogeneity effects. For
example, the electron fluence plays a big role in the different density interface. As results show,
dose dropos off as the beam enters the lung from the tissue due to the loss of electronic
equilibrium. The primary beam and scatter relate to how the beam attenuates beyond the
inhomogeneity which is shown in this case by the rebuild up region once the primary beam
reaches the tumor.2 Therefore, when differences in electron density are not accounted for, an
accurate plan can not be visualized. To apply heterogeneity corrections most commonly a
convolution/superposition algorith is used. This correction can lead to big differences in how a
plan looks depending on the differences in density. This change is most evident in a plan for a
lung tumor that is centrally located in the lung because of the large variations in electron density
as the beam travels through the patient.

This issue has been studied extensively when it comes to stereotactic body radiotherapy
(SBRT) plans as adequate tumor coverage is of great importance when a high dose is being
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delivered to a small target in a low number of fractions. In a study by Herman et al,3 when
keeping all factors (beam arragnement, weighting, energy and MU) the same between a SBRT
plan with heterogoeneous corrections and one without, it was shown that the the homogeneous
plan provided only an average of 70% coverage to the PTV while the heterogeneous plan
provided an average of 95% coverage, other studies were also referenced and provided similar
results. Overall, treatment plans that do not have a heterogeneity correction will need a higher
prescribed dose to provide acceptable coverage to the tumor but this will also increase dose to
surrounding normal tissue which can increase the event of adverse effects. Because the beam is
not attenuated as much in lung due to the decreased scatter in air, there is a region of build up
once the beam reaches the tumor in a centrally located lung tumor. If a heterogeneity correction
was not applied, the area of build up would not be accounted for an the treatment planning
system would show a higher dose to the outer edges of the tumor. If this was to get treated, the
tumor would be underdosed which would ultimately lead to recurrence of a tumor.4

Conclusion: In conclusion, lung tumors should always be treated with heterogeneity corrections.
Isodose distributions can vary greatly in different electron densities and in order to provide the
most effective treatment for a patient, these differences should be accounted for. These results
not only show the importance of correction for variations in tissue densities but also the
imporatnce of accounting for any artifact in treatment plans. Often times patients are simulated
with the use of radiopaque wires that must be contoured out and overriden to the correct tissue
density of air as these will not be there for the actual treatment. In the case of any metal implant,
streaking artifact must also be overriden as using heterogeneity corrections would read the
artifact as air when it should be tissue.

Figure 1: Comparison between heterogeous and homogeneous corrections in the transverse view.
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Figure 2: Comparison between heterogeneous and homogeneous corrections in the sagittal view.

Figure 3: Comparison between heterogeneous and homogeneous corrections in the coronal view.
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Figure 4: Monitor unit output for AP and PA beam with heterogeneity corrections.

Figure 5: Monitor unit output for AP and PA beams with homogeneity corrections.

Figure 6: DVH for heterogeneous plan.

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Figure 7: DVH for homogeneous plan.

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References

1. Washington C, Leaver D. Principles and practice of radiation therapy. 4th ed. St. Louis:
Mosby;2016.
2. Kahn F. The Physics of Radiation Therapy. 4th Ed. Philadelphia, PA: Wolters Kluwer;
2010.
3. Herman L, Gabrish H, Herman T, et al. Impact of tissue heterogeneity corrections in
stereotactic body radiation therapy treatment plans for lung cancer. J Med Phys.
2010;35(3):170-173. doi:10.4103/0971-6203.62133
4. Rutter C, Husain B, Mancini B. et al. The use of heterogeneity corrections and its impact
on delivered dose in patients treated with stereotactic body radiotherapy of the lung. J
Radiat Oncol. 2014;3:78-80