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Yasmin Ahmed
Treatment Planning Project
March 8, 2015

Cancers of the lung and related areas account for the most common invasive
malignancies in the United States. These cancers account for 29% of cancer deaths and 15% of
new cancers diagnosed.1 In the United States, lung cancer is the leading cause of cancer deaths
amongst men and women. This may be due to the fact that the prognosis for lung cancer is
generally poor, since it is often discovered at an advanced stage. For cancers that are early stage,
the five-year survival rate is about 40%-50%. However, for inoperable lung cancer tumors, this
number drops significantly to only 1%-5% survival. The treatment options for lung cancer
include surgery, chemotherapy, and/or radiation therapy.2
When treating lung cancers with radiation therapy, the easiest technique used is that
which uses anterior and posterior parallel opposed fields. The primary organs at risk (OR) to
consider while treating lung cancer include the heart, spinal cord, and normal lung. Care must be
taken to keep the dose to these organs as low as possible. In general, if 60% of the heart receives
4500-5500 cGy, pericarditis and other complications may arise. For the spinal cord, extra care is
taken to try to keep the dose to no more that 4500 cGy, although this may be challenging while
treating lung cancer. For the normal lung, the physician generally tries to keep the dose at no
more than 2000 cGy for 20% of the lung. Complications that may arise in the patient may
include dyspnea and pneumonitis.1
When lung tumors are planned at my clinical site, it is common practice to use
heterogeneity corrections. Heterogeneity corrections are corrections that account for the
presence of irradiated media other than water.1 Since the human body is comprised of different
tissues with varying densities, the way the radiation beam traverses through each tissue will also
be different. For example, since lung tissue is mostly comprised of air, it exhibits a lower density
than muscle. As a result, it attenuates the photon beam less than muscle or soft tissue.3 Hence, it
is imperative to use heterogeneity corrections to account for the differences between tissues.
At my clinical site, in the Pinnacle treatment planning system, under dose comp parameters, the
default selection is heterogeneous density correction. This corrects for the densities of different
structures, such as bone, air, and soft tissue. For example, since bone attenuates more than soft

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tissue, it is important to distinguish the difference between structures, since this is what is
actually happening in the patient. The beam and tissue that it goes through will also act different
depending on the energy. The electron fluence will vary and the primary beam will also be
absorbed and scattered differently in various tissues. Dose in the lung however is mostly
determined by its density. A lower density usually yields higher dose within the lung. However,
a slight decrease in dose may be evident in the first layers of soft tissue after a large lung
thickness due to secondary electron loss. This is referred to as loss of lateral electronic
equilibrium. Due to the lung having a lower density, many electrons travel beyond the limit of
the beam, causing a loss of scattered electrons. This in turn causes the dose to be reduced.4 The
density of the lung can be anywhere from 0.25 to 1.0 g/cm3 and the effects of inhomogeneities
are in the absorption of the primary beam and in the scatter.3
For this project, I planned a lung tumor case using the Pinnacle treatment planning
system (TPS) version 9.6 with heterogeneity correction first and then without it. I used an
anterior beam at a gantry angle of 0 and created an auto surround block with a margin of 2 cm
around the tumor volume. I then copied and opposed this beam. My posterior beam was
therefore at a gantry angle of 180. The prescription dose was 180 cGy daily for 34 fractions.
The total dose was equal to 6120 cGy. Each beam was set at an energy of 15 MV photons. I
calculated the entire plan, as it generally would be done with the heterogeneity turned on. The
images for the dose distribution for this plan in three planes may be seen in Figures 1-3. I then
made a copy of the plan and calculated it with heterogeneity turned off. The isodose distribution
for this homogeneous plan may be seen in Figures 4-6. The difference in isodose lines compared
to the first plan can be clearly seen from the figures.
In the plan with heterogeneity on, the blue 95% isodose line is clearly bowing in since the
planning system is taking into account the different tissues. Scatter contribution is smaller in the
heterogeneity plan, resulting in the bowing shape of the lines. The coverage is clearly reduced in
the heterogeneity corrected plan. In the homogeneous plan however, the 95% isodose line is
covering the tumor fully since the system is treating all of the tissue as if it has a single density.
The homogeneous plan however is not a true depiction of what will actually happen since the
patients body is comprised of different tissues with varying densities. Therefore, the beam
behaves differently as it goes through each section, such as tissue, muscle, and air. Besides the
difference in isodose distribution, I noticed a difference in monitor units (MU). For the

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heterogeneous plan the MUs were 97 and 105 (Figure 7); for the homogeneous plan the MUs
were 107 and 114, respectively (Figure 8). This makes sense since the TPS is treating the
homogeneous plan as if everything is tissue; hence more MUs are needed to penetrate. The dose
volume histogram (DVH) also shows the difference between both plans for the lung planning
tumor volume (PTV), heart, spinal cord, and right and left lung (Figure 9). The major differences
seen on the DVH are for the PTV and left lung. The tumor, as depicted by the red line on the
DVH, has a sharper drop off for the homogeneous plan (dotted line) as compared to the
heterogeneity corrected plan (solid line). The left lung, depicted by the green line on the DVH, is
getting a higher maximum dose overall for the homogeneous plan (dotted line). One way to get
the homogeneous plan to look similar to the heterogeneity corrected plan may be to use a lower
energy. Below are my hand calculations to second check the monitor units. Using the equivalent
square and depth from the plan, I was able to determine the TMR and output factor for each
beam by interpolating using a table from my clinic for 15 MV.

MU = __prescribed dose per field_


ISF x FSF x TMR
Heterogeneous plan (using effective depth):
AP = _____85.7 cGy____ = 97.3 MU (% difference from plan = 0.3)
1 x 0.991 x 0.889

PA = _____94.1 cGy____ = 102 MU (% difference from plan = -2.9)


1 x 0.991 x 0.933

Homogeneous plan (using reference depth):


AP = _____86.3 cGy____ = 105 MU (% difference from plan = 1.9)
1 x 0.991 x 0.830

PA = _____93.9 cGy____ = 112.5 = 113 MU (% difference from plan = -0.88)


1 x 0.991 x 0.842

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Whether or not to use heterogeneity corrections when planning a lung case is still highly
debatable, and some facilities still choose to treat without the correction. Traditionally, lung
tumors have been treated with a homogeneous setting. The Radiation Therapy Oncology Group
(RTOG) protocol for any thoracic tumor also requires that the treatment plan be homogeneous.
This is because of worries that the primary tumor volume may be underdosed when correcting
for heterogeneity. In a study by Frank et al.5 lung plans were compared by planning them with
and without heterogeneity correction. The results indicated that there was no significant
difference in the dose maximum and minimum to the PTV. It was also found that the plans with
heterogeneity correction had substantially better PTV dose coverage. The study concluded that
when compared to homogeneous plans, heterogeneous plans produce equivalent doses while
providing excellent PTV coverage.
According to the American Association of Physicists in Medicine (AAPM) report 85 of
task group 65 (TG-65), since the body consists of various tissues with different properties, it is
essential that the dose given during radiation delivery be accurately predicted while taking into
account inhomogeneities. The report reviewed the need for inhomogeneity corrections and
reviewed the current algorithms being used for planning. The task group recommended that
heterogeneity corrections be used in treatment plans, as long as the TPS algorithms have been
tested and approved by a medical physicist.6 Ultimately though, the decision to use heterogeneity
correction lies with the physician and/or physicist as it pertains to each individual case.

Figure 1: Axial view of dose distribution for heterogeneity corrected plan. The red line
represents the 100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

Figure 2: Sagittal view of dose distribution for heterogeneity corrected plan. The red line
represents the 100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

Figure 3: Coronal view of dose distribution for heterogeneity corrected plan. The red line
represents the 100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

Figure 4: Axial view of dose distribution for homogeneous plan. The red line represents the
100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

Figure 5: Sagittal view of dose distribution for homogeneous plan. The red line represents the
100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

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Figure 6: Coronal view of dose distribution for homogeneous plan. The red line represents the
100% isodose line (6120 cGy) and the blue represents the 95% line (5814 cGy).

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Figure 7: Beam parameters and Monitor Units for heterogeneity corrected plan.

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Figure 8: Beam parameters and Monitor Units for homogeneous plan.

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Figure 9: DVH for heterogeneous and homogeneous plan. The solid line represents the
heterogeneous plan and the dotted line represents the homogeneous plan.

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References
1. Washington C, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis,
Missouri: Mosby Elsevier; 2010.
2. Lung Cancer. Medicine Net website.
http://www.medicinenet.com/lung_cancer/article.htm. Accessed March 6, 2015.
3. Bentel G. Radiation Therapy Planning. 2nd ed. New York, New York: McGraw-Hill;
1996:41.
4. Khan FM. The Physics of Radiation Therapy. 4th ed. Philadelphia, Pennsylvania:
Lippincott Williams & Wilkins; 2010.
5. Frank SJ, Forster KM, Stevens CW, et al. Treatment planning for lung cancer: traditional
homogeneous point-dose prescription compared with heterogeneity-corrected dosevolume prescription. Int J Radiat Oncol Biol Phy. 2003;56(5)1308-1318. doi:
http://dx.doi.org/10.1016/S0360-3016(03)00337-7.
6. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections for
megavoltage photon beams. AAPM report no. 85. American Association of Physicists in
Medicine website. https://www.aapm.org/pubs/reports/rpt_85.pdf. Published August
2004. Accessed March 7, 2015.