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1
Amanda Lisher
DOS 523: Treatment Planning
7 March 2015

Heterogeneity Correction Factors in Treatment Planning for Lung Carcinoma

Lung carcinoma is the second most prevalent cancer in both men and women, and the
leading cause of cancer-related deaths.[1] According to the American Cancer Society, there will
be an estimated 221,000 new cases of lung cancer diagnosed in the United States this year. For
many patients, radiation oncology plays a key role in the management of lung malignancy.
Treatment planning for lung cancer presents several challenges for the medical dosimetrist.
There are several organs at risk (OR) in the thorax, such as the heart, spinal cord and normal
lung, that must be spared unnecessary radiation dose. It can be difficult to ensure adequate
immobilization for lung cancer patients, given that the target volume is subject to movement
during normal respiration. Finally, the thorax is one of the most heterogenous anatomic areas of
the human body, with large volumes of air adjacent to bone and dense soft tissue. In current
radiation therapy practice, a major source of discussion is whether or not to account for inherent
differences in tissue density when planning photon lung treatments.
Many professionals are skeptical of computer-based treatment planning algorithms, and
believe that planning based on homogeneous tissue density is the best solution, since most
historic treatment data was gathered using this technique.[2] However, modern computer-based
planning has proven the risk of not accounting for tissue heterogeneity in lung planning. One
study noted that nearly 50% of lung plans evaluated had less than 90% coverage of the planning
target volume (PTV) when heterogeneity correction factors were applied after the fact.[3] This
degree of underdose is significant considering even a 5% decrease in dose can limit the
therapeutic efficacy of radiation. In order to illustrate the effects of heterogeneity correction
factors on radiation therapy treatment plans for lung carcinoma, this paper will evaluate
treatment information, including monitor units (MU), isodose curves, and the dose-volume
histogram (DVH) for a lung plan with and without heterogeneity factors applied. To further

!2
demonstrate the range of possible discrepancy, treatment plans for two different PTVs in roughly
the same anatomic location will be compared.
When radiation is incident on a patient, there are two major interactions that occur in
tissue: the beam can be absorbed, resulting in dose to the tissue itself, or it can be scattered,
resulting in dose to adjacent tissues.[4] The amount of absorption and/or scatter depends on the
electron density (electrons/cm3) of the tissue. Homogenous treatment planning assumes all body
tissues are water-equivalent.[5] Heterogenous dose calculations require CT data for planning, and
account for density differences of various body tissues. Water has an electron density of 1.0,
while the density of lung tissue is 0.25 to 0.33 g/cm3, and bone is 1.65-1.8 g/cm3.[4,6] As a result,
lung tissue will absorb less of the radiation beam, and will scatter less to surrounding tissue.
Bone will attenuate more of the beam, and will create increased dose to surrounding tissue as a
result of increased scatter production. The effect of tissue heterogeneity can vary, depending on
beam energy, the size of the heterogeneity, and its location in the patient.
The first treatment plan we shall evaluate is for patient HB, with melanoma metastasis to
the left lung. HBs gross tumor volume (GTV) is quite large, 10cm measured in the anterior to
posterior direction, compared to 15cm of total lung measured in the same plane. This particular
GTV occupies more of the left lung than functional lung tissue does. Therefore, the distance
traveled by the radiation beam is largely homogenous, comprised of soft tissue tumor. This plan
required a 15MV photon beam in order to adequately penetrate the medial aspect of the PTV,
near the hilum. The GTV tapers toward the lateral side of the lung, away from the hilum. As a
result, in this area, there is more lung tissue in the path of the beam than tumor. The amount of
MU and dose needed to adequately cover the dense medial PTV is more than necessary to treat
the lateral edge of the field. This area of the lung attenuates less of the beam, which contributes
to a hot spot in the anterior and posterior chest wall at the lateral edge of the fields. These hot
spots occur because the Dmax depth (3cm) is reached in the chest wall. Consequently, a higher
dose is deposited in tissue and bone. This attenuation creates more scatter, which contributes to
the dose in adjacent tissues. Also, because air is less dense than the GTV, dose from both the AP
and PA beam is traveling through the lung until it is absorbed in the tissue of the chest wall. The
AP/PA plan with heterogeneity correction applied required only a 15 degree AP wedge,

!3
positioned with the heel lateral on the patient, to achieve full dose coverage of the PTV and
reduce the hot spots in the anterior and posterior chest wall (Figure 1). The lateral wedge
compensates for less tissue density in the periphery of the lung; the wedge attenuates a portion of
the beam, reducing the hot spots.
With heterogeneity correction factors turned off for HBs lung plan, the PTV is still
adequately covered by the 100% isodose line. However, there is now a hot spot in the medial
portion of the fields. With the correction factors turned off, the planning system assumes the
entire beam path is a density of 1.0, therefore it does not register the decreased density in the
lateral part of the fields, and the wedge merely pushes the dose medially, away from the heel
(Figure 2). In comparing the two plans, with and without heterogeneity corrections applied, the
MU for both plans are very similar (AP 221MU versus 229MU and PA 155MU versus 156MU
respectively), and the DVH is almost identical (Figures 3, 4, 5). In this particular case, due to the
large volume of tumor centrally located in the left lung, the treatment plan would have
successfully treated the PTV whether heterogeneity correction factors were applied or not.
Now, let us consider the second treatment plan. NG is a 90-year-old female with a small,
slow-growing centrally located right lung nodule. Due to her age and the non-agressive nature of
the lesion, NG refused biopsy. NG was ultimately treated with a course of stereotactic body
radiation therapy to the lesion. For the purposes of this comparison, however, we are going to
evaluate an AP/PA treatment plan based on conventional fractionation. The calculation point was
placed in the center of the GTV, blocks were constructed with a 1.0cm margin surrounding the
PTV. At the calculation point, NGs GTV measures 3cm, compared to 16cm of total lung volume
in the same plane. A 6MV beam was used for both the AP and PA fields; the fields were weighted
40% to the AP and 60% to the PA, due to the tumor lying slightly closer to the posterior chest
wall. A 15 degree superior wedge was used with the PA beam, to shift the dose inferiorly and
match the isodose lines to the tumor location, angled slightly inferior in the lung. Due to the
increased weighting of the PA field, and Dmax of the 6MV beam lying in the posterior chest
wall, the hot spot is predominantly posterior. With the heterogeneity correction factor turned on,
it is very difficult to achieve 100% isodose coverage of the entire GTV and PTV (Figure 6). This
can be attributed to the two primary photon interactions in tissue: attenuation and scatter. The

!4
anatomy traversed by the AP beam is largely air, prior to meeting the PTV. As a result, less of the
primary beam is attenuated, which results in decreased dose to the anterior lung tissue and
decreased scatter dose created which would contribute dose to tissue beyond it.[6] This accounts
for the lower dose at the anterior surface of the PTV. Also, increasing the weighting of the PA
beam increases the dose attenuated in the posterior chest wall, which in turn increases scatter
production in the forward direction, pushing more dose out toward the tumor. In order to achieve
an acceptable plan with heterogeneity corrections accounted for, we would need a right lateral
beam, or perhaps two oblique beams, incident on the PTV, at an angle that puts less lung tissue
between the patient surface and the tumor.
When the heterogeneity correction factor is turned off for NGs lung plan, the distribution
of the isodose lines changes considerably (Figure 7). Assuming a homogenous tissue density, the
beam is evenly attenuated throughout the treated volume, which creates a near perfect rectangle
of dose between the AP and PA beams. The homogeneity plan MUs show an increase of 25% for
the AP and 12.5% for the PA over the heterogenous plan (Figures 8 and 9). This increase is
necessary, but not exactly proportional, because we are trying to achieve the same dose in a
volume that is now on average four times as dense, which attenuates more of the beam but also
contributes more scatter dose in the lung. According to the DVH comparing both plans, the
homogenous plan overestimates the dose to the GTV by 4.5%, the PTV by 5%, and the right
lung by 2.4% (Figure 10). The homogenous plan misrepresents the actual dose to the tumor
volume, and would result in an underdose and possible treatment failure.
The question of whether or not to apply heterogeneity correction factors to lung treatment
plans is complex, and not easily agreed upon. As we have just seen in our comparison of two
lung plans, the effects of heterogeneity on radiation treatment plans can vary significantly,
depending on the size and location of the target volume. Also complicating matters is the fact
that various treatment planning systems calculate and account for tissue density differently,
which makes comparison between plans difficult. Prior to the widespread use of computed
tomography (CT) and software-based therapy planning, common practice was to assume a
homogenous density for all body tissues. However, as the availability and accuracy of anatomical
information has developed, so has modern dosimetry. The effects of tissue heterogeneity on

!5
isodose distribution and target dose cannot be ignored. Now is the time to begin amassing new
clinical data, based on the technologically superior treatment planning techniques available
today.

RT

Patient Name:
Patient ID:
Plan Name:
Lock Status:

TESTBRAHMAN, HERBERT,
L2592
L LUNG
Not Locked

Date/Time:
20150306 19:28:59
Comment:
heterogeneity on
Physician/Physicist:
DK/

Figure 1: HB isocenter, heterogeneity correction ON

Revision:
Planner:
Institution:

R02.P02.D04
SMB
MANDY

Page:
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Patient Name:
Patient ID:
Plan Name:
Lock Status:

TESTBRAHMAN, HERBERT,
L2592
L LUNG
Not Locked

Date/Time:
20150306 19:39:52
Comment:
heterogeneity off
Physician/Physicist:
DK/

Figure 2: HB isocenter, heterogeneity correction OFF

Revision:
Planner:
Institution:

R02.P02.D04
SMB
MANDY

!6

RTP

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!7

RTP System 9.6

TESTBRAHMAN, HERBERT,Date/Time:
20150303 11:40:38
L2592
Comment:
heterogeneity on
L LUNG
Institution:
MANDY
TXPLAN1
Physician/Physicist: DK/
R02.P02.D03
Planner:
SMB
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Plan Summary Sheet

Beam Setup
Beam
0AP
180PA

Beam
0AP
180PA

Machine
LMH IX
LMH IX

Energy
Modality Prescription
15XLCCO Photons L LUNG
15XLCCO Photons L LUNG

Collimators (cm) (Control Pt 1)

X1
X2
Y2
Y1
6.00
7.00
7.00
7.00
7.00
6.00
7.00
7.00

Gantry
Start / Stop
0 / 0
180 / 180

Couch
0
0

Isocenter
isocen...
isocen...

SSD (cm)
Start / Avg
89.43 / 89.43
89.00 / 89.00

Coll Block
0.0 Yes
0.0 Yes

MU Per Fraction
221
155

Wedge
Bolus
15_MLC... No
None
No

Comp
No
No

Prescriptions
L LUNG
Prescribe 300 cGy per fraction to 98 % of point dose at "isocenter" for 18 fractions.
Beam weights are proportional to point dose.
Actual point dose at "isocenter" from all prescriptions/beams is 5518.67 cGy.
2 beams are assigned to this prescription.

Isocenter
isocenter
Position patient such that lasers line up with patient marks.
Move the table LEFT 4.50 cm (looking from foot of table.)
Move the table DOWN 1.00 cm.
Move the table OUT (away from the gantry) 1.00 cm.

Plan Authorization:

Figure 3: HB MU sheet, heterogeneity ON

Pinnacle v9.6
Pg 1 of 1 PLN

!8

RTP System 9.6

TESTBRAHMAN, HERBERT,Date/Time:
20150303 11:40:03
L2592
Comment:
heterogeneity off
L LUNG
Institution:
MANDY
TXPLAN2
Physician/Physicist: DK/
R02.P02.D03
Planner:
SMB
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Plan Summary Sheet

Beam Setup
Beam
0AP
180PA

Beam
0AP
180PA

Machine
LMH IX
LMH IX

Energy
Modality Prescription
15XLCCO Photons L LUNG
15XLCCO Photons L LUNG

Collimators (cm) (Control Pt 1)

X1
X2
Y2
Y1
6.00
7.00
7.00
7.00
7.00
6.00
7.00
7.00

Gantry
Start / Stop
0 / 0
180 / 180

Couch
0
0

Isocenter
isocen...
isocen...

SSD (cm)
Start / Avg
89.43 / 89.43
89.00 / 89.00

Coll Block
0.0 Yes
0.0 Yes

MU Per Fraction
229
156

Wedge
Bolus
15_MLC... No
None
No

Comp
No
No

Prescriptions
L LUNG
Prescribe 300 cGy per fraction to 98 % of point dose at "isocenter" for 18 fractions.
Beam weights are proportional to point dose.
Actual point dose at "isocenter" from all prescriptions/beams is 5506.81 cGy.
2 beams are assigned to this prescription.

Isocenter
isocenter
Position patient such that lasers line up with patient marks.
Move the table LEFT 4.50 cm (looking from foot of table.)
Move the table DOWN 1.00 cm.
Move the table OUT (away from the gantry) 1.00 cm.

Plan Authorization:

Figure 4: HB MU sheet, heterogeneity OFF

Pinnacle v9.6
Pg 1 of 1 PLN

!9

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

TESTBRAHMAN, HERBERT,
L2592
L LUNG
Not Locked

Date/Time:
20150306 19:33:02
Comment:
heterogeneity dvh
Physician/Physicist:
DK/

Revision:
Planner:
Institution:

R02.P02.D04
SMB
MANDY

Page:
Scaling:

1 of 1
Fill Page

Pink=PTV
Red=GTV

Blue=Left Lung

Figure 5: HB DVH comparison. Solid line-heterogeneity ON, dash-heterogeneity OFF

!10
Patient Name:
Patient ID:
Plan Name:
Lock Status:

GEISS restored, NORMA,

L2756
R LUNGSBRT
Not Locked

Date/Time:
20150303 12:01:39
Comment:
hetero on
Physician/Physicist:
DK/

Figure 6: NG isocenter, heterogeneity correction ON

Revision:
Planner:
Institution:

R01.P01.D02
SMB
MANDY

Page:
Scaling:

1o
Fil

Patient Name:
Patient ID:
Plan Name:
Lock Status:

GEISS restored, NORMA,

L2756
R LUNGSBRT
Not Locked

Date/Time:
20150307 19:15:49
Comment:
ng hetero off
Physician/Physicist:
DK/

Figure 7: NG isocenter, heterogeneity correction OFF

Revision:
Planner:
Institution:

R01.P01.D03
SMB
MANDY

Page:
Scaling:

!11

RTP System 9.6

1 of 1
Fill Page

!12

RTP System 9.6

GEISS restored, NORMA,

L2756
R LUNGSBRT
MANDY
R01.P01.D02
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Date/Time:
20150303 12:00:44
Comment:
hetero on
Institution:
MANDY
Physician/Physicist: DK/
Planner:
SMB

Plan Summary Sheet

Beam Setup
Beam
AP
PA

Beam
AP
PA

Machine
LMH IX
LMH IX

Energy
6XLCCO
6XLCCO

Modality Prescription
Photons MANDY
Photons MANDY

Collimators (cm) (Control Pt 1)

X1
X2
Y2
Y1
5.00
4.50
4.50
4.00
4.50
5.00
4.50
4.00

Gantry
Start / Stop
0 / 0
180 / 180

Couch
0
0

Isocenter
isocen...
isocen...

SSD (cm)
Start / Avg
88.53 / 88.53
91.86 / 91.86

Coll Block
0.0 MLC
0.0 MLC

Wedge
None
EDW

MU Per Fraction
92
144

Bolus
No
No

Comp
No
No

Prescriptions
MANDY
Prescribe 200 cGy per fraction to 95 % of point dose at "isocenter" for 33 fractions.
Beam weights are proportional to point dose.
Actual point dose at "isocenter" from all prescriptions/beams is 6951.94 cGy.
2 beams are assigned to this prescription.

Isocenter
isocenter
Position patient such that lasers line up with patient marks.
Move the laser LEFT 7.30 cm (looking from foot of table.)
Move the table UP 5.30 cm.
Move the table OUT (away from the gantry) 11.00 cm.

Plan Authorization:

Figure 8: NG MU, heterogeneity correction ON

Pinnacle v9.6
Pg 1 of 1 PLN

!13

RTP System 9.6

GEISS restored, NORMA,

L2756
R LUNGSBRT
MANDY2
R01.P01.D03
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Date/Time:
20150307 19:14:45
Comment:
ng hetero off
Institution:
MANDY
Physician/Physicist: DK/
Planner:
SMB

Plan Summary Sheet

Beam Setup
Beam
AP
PA

Beam
AP
PA

Machine
LMH IX
LMH IX

Energy
6XLCCO
6XLCCO

Modality Prescription
Photons MANDY
Photons MANDY

Collimators (cm) (Control Pt 1)

X1
X2
Y2
Y1
5.00
4.50
4.50
4.00
4.50
5.00
4.50
4.00

Gantry
Start / Stop
0 / 0
180 / 180

Couch
0
0

Isocenter
isocen...
isocen...

SSD (cm)
Start / Avg
88.53 / 88.53
91.86 / 91.86

Coll Block
0.0 MLC
0.0 MLC

Wedge
None
EDW

MU Per Fraction
116
162

Bolus
No
No

Comp
No
No

Prescriptions
MANDY
Prescribe 200 cGy per fraction to 95 % of point dose at "isocenter" for 33 fractions.
Beam weights are proportional to point dose.
Actual point dose at "isocenter" from all prescriptions/beams is 6943.5 cGy.
2 beams are assigned to this prescription.

Isocenter
isocenter
Position patient such that lasers line up with patient marks.
Move the laser LEFT 7.30 cm (looking from foot of table.)
Move the table UP 5.30 cm.
Move the table OUT (away from the gantry) 11.00 cm.

Plan Authorization:

Figure 9: NG MU, heterogeneity correction OFF

Pinnacle v9.6
Pg 1 of 1 PLN

!14
Patient Name:
Patient ID:
Plan Name:
Lock Status:

GEISS restored, NORMA,

L2756
R LUNGSBRT
Not Locked

Date/Time:
20150307 19:18:11
Comment:
ng hetero dvh
Physician/Physicist:
DK/

Revision:
Planner:
Institution:

R01.P01.D03
SMB
MANDY

1JOL157
3FE(57

"RVB3JHIU
-VOH

Figure 10: NG DVH comparison. Solid line-heterogeneity ON, dash-heterogeneity OFF

RTP Sys

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!15
Works Cited
1. American Cancer Society. What are the key statistics about lung cancer? American Cancer
Society Web site. http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/nonsmall-cell-lung-cancer-key-statistics. Revised March 4, 2015. Accessed March 5, 2015.
2. Papanikolaou N, Klein E. Heterogeneity corrections in clinical trials. Talk presented at
AAPM meeting. http://www.aapm.org/meetings/amos2/pdf/35-9943-67765-330.pdf.
Accessed March 3, 2015.
3. Kong F-M, Jin J-Y, Bradley JD, Martel MK. Cancers of the thorax. In: Khan FM, Gerbi BJ,
eds. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2012: 677-732.
4. Bentel GC. Dose determination for external beams. In: Bentel GC, ed. Radiation Therapy
Planning. 2nd ed. New York, NY: McGraw-Hill; 1996: 32-58.
5. Hendee WR, Ibbott GS, Hendee EG. Computer-based treatment planning. In: Hendee WR,
Ibbott GS, Hendee EG, eds. Radiation Therapy Physics. 3rd ed. Hoboken, NJ: John Wiley &
Sons, Inc.; 2005: 246-283.
6. Khan FM. Interactions of ionizing radiation. In: Khan FM, ed. The Physics of Radiation
Therapy. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010: 54-69.