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Taisa Polishchuk
DOS 523 Treatment Planning in Medical Dosimetry
March 5, 2015

Treatment Planning Project

Process:
The project involved comparing planning of a lesion in the posterior aspect of the left
lung with heterogeneity corrections turned on and with heterogeneity corrections turned off. The
physician prescribed 180 cGy in 25 fractions to the total dose of 4500 cGy. The isocenter was
placed in the center of the tumor and the dose was calculated to that point utilizing anterior (AP)
and posterior (PA) fields. The blocks were created with an auto margin of 1.5 cm around the
planning target volume (PTV). The following contours (Image 1) were required for the plan:
body, right lung, left lung, spinal cord, tumor (PTV), and heart. 18 MV energy was utilized on
both AP and PA fields, weighted 45% (AP) and 55% (PA). In addition, 15 degree wedges were
utilized in attempt to push the dose towards the medial aspect of PTV and achieve better
coverage.
Findings:
Heterogeneity corrections were turned on for the first plan. Looking at the isodose images
provided in the image 2, the 95% isodose line was selected to deliver radiation dose to the tumor.
The breaking up of the higher isodose lines is due to the difference in tissue attenuations. Density
of bone is larger than the density of air. Having different densities, these tissues affect the
penetration of the beam and the scattering characteristics differently.1 Filled with air, lung tissue
has a lower density than muscle or bone and attenuates the photon beam less than an equal
thickness of soft tissue. On another hand, the attenuation of the photon beam is higher for the
bone with the higher density than lung or soft tissue.
Heterogeneity corrections were turned off for the second plan. Isodose lines (image 5)
look more homogeneous when comparing to the first plan with the heterogeneity corrections
turned on. The structures that are in the path of the beam have the same density and therefore
attenuate radiation the same way. Due to this fact, it takes more MUs to deliver the same dose of

radiation to the tumor when comparing to the first plan (compare MU sheets of two plans, image
4 and image 7). AP MU increased from 116 MU to 136 MU (17% increase). PA MU however did
not change due to the tumor being more posterior in the thorax and the beam not traveling
through as big of a distance and through as many of different structures as with AP.
Research:
Beam data for treatment planning systems are obtained from measurements in water
phantoms.2 This data represent dose distributions in a homogeneous phantom. However, in a
patient the beam transverses heterogeneous layers of tissue such as fat, bone, muscle, lung, and
air.3 Each of these structures have their own density, and therefore interact with radiation in a
different way producing changes in the dose distributions, depending on the amount and type of
material present and on the quality of radiation. The change in dose due to the presence of tissue
inhomogeneities is related to the transmission of the primary and scattered photons and
secondary electrons set in motion from photon interations.4 Depending on the inhomogeneities in
the path of the beam, the change in dose can be substantial. Therefore it is essential to account
for such heterogeneities, and heterogeneity corrections must be utilized when treating a patient.
Due to the greater attenuation of the bone, the beam will not travel as deep as it would when
penetrating though the lung tissue. The lung tissue with its lower attenuation will cause deep
penetration of the beam and the isodose lines will shift away from the surface of the patient.
As described previously there is a change in dose distribution when comparing the plan
with heterogeneity on and the plan with heterogeneity off. In addition there is an increase of MU
when treating with the heterogeneity corrections off due to the beam traveling only through
tissue the entire time versus being attenuated when traveling through bone, tissue and air in the
case of the plan with heterogeneity on. In order to make non-heterogeneous plan look similar to
the heterogeneous we would need to adjust the MUs. We can notice an increase in overall dose
to all of the structures and an increase in the dose to the PTV (image 8). Accounting for
inhomogeneity is important in order to have the correct representation of the dose delivered
within the patient, and is clearly seen when comparing two plans in the image 8.
Summary:
With the advancement in treatment planning and computing algorithms it is essential to
include heterogeneity corrections in treatment plan.

The oncology team at the Virginia Commonwealth University Health System Massey
Cancer Center (VCUHS) uses heterogeneity corrections during treatment planning.5 The
outlining of inhomogeneities and determining the density within the volume can be easily
achieved with the use of computed tomography (CT).
There are some occasions when homogeneity correction is utilized instead of
heterogeneity. VCUHS uses homogeneity correction when planning for heterotopic ossification.
The metal hardware in the area of interest can cause artifacts on the CT image and significantly
change the true representation of the radiation dose in that area. Turning on the homogeneity
correction helps account for metal density and create a better-represented treatment plan. In
addition, sometimes homogeneity is used in protocols. VCUHS participated in a couple of
protocols requiring utilization of homogeneity. Breast protocol RTOG 0413 (NSABP B-39), as
well as pediatric lymphoma protocol AALL0434 are just some of the examples.6 These protocols
were set up almost a decade ago when using homogeneity was more common in clinics, and
therefore the requirement had to be followed on all cases submitted to radiation therapy oncology
group. Homogeneity corrections helped maintain standardization of data nation-wide and
conduct a good research.

Images:

Image 1. Contoured structures utilized in the treatment planning.

Image 2. Isodose distribution in axial, sagittal, and coronal views with heterogeneity corrections
turned on.

Image 3. Dose Volume Histogram of the plan with the heterogeneity corrections turned on.

Image 4. Monitor Unit sheet of the plan with the heterogeneity corrections turned on.

Image 5. Isodose distribution in axial, sagittal, and coronal views with heterogeneity corrections
turned off.

Image 6. Dose Volume Histogram of the plan with the heterogeneity corrections turned off.

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Image 7. Monitor Unit sheet of the plan with the heterogeneity corrections turned off.

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Image 8. Dose volume histogram of plan with heterogeneity on and heterogeneity on with
adjusted MU.

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References:
1. Bentel GC. Radiation Therapy Planning. 2nd ed. Columbia: McGraw-Hill; 1996.
2. Prado KL, Prado CM. Photon dose distributions. In: Washington CM, Leaver D, eds.
Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010:
527-549.
3. Khan FM. Treatment planning II: patient data, corrections, and setup. In: KhanFM, ed. The
Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2010:
201-240.
4. Purdy JA, Emami B, Graham MV, Michalski J, Perez CA, Simpson J. Three-dimensional
treatment planning and conformal therapy. In: Levitt SH, Khan FM, Potish RA, Perez CA, eds.
Technological Basis of Radiation Therapy. 3rd ed. Baltimore, MD: Lippincott, Williams, and
Wilkins; 1999: 104-127.
5. Discussion with Keith Neiderer, Medical Dosimetrist at the Virginia Commonwealth
University Health System Massey Cancer Center. March 4, 2015.
6. Discussion with Ruth-Ann Good, Medical Dosimetrist at the Virginia Commonwealth
University Health System Massey Cancer Center. January 20, 2015.