Brendan Gallagher

Treatment Planning Project

March 13, 2016
Homogeneous vs. Heterogeneous Treatment Planning
Introduction: The objective of this project was to compare AP/PA lung plans that have been
calculated with and without a heterogeneity correction. Treatment planning for pathology in the
lungs can be tricky sometimes if youre not a very experienced dosimetrist. The beams are
passing through so many different densities such as air, muscle, fat, and bone. Structures with a
lower density like the lung attenuate the beam less and cause less scatter than high density
structures like bone. Heterogeneity projects how the beam is attenuated with different structures
that have different densities such as soft tissue, muscle, air, and bone. Homogeneity ignores the
fact that air and bone have different densities when planning a lung and sets all the structures to
the same density as water. Heterogeneity corrections account for differences in electron density
when the irradiated media is other than water. This largely affects the dose that is given to the
target. Prior to CT simulations and 3D treatment planning systems, most people planned with
homogeneity corrections. The reason for using heterogeneity corrections today lies in the visual
display of isodose lines and dose distribution when it is turned on versus off.
Method and Materials: The plan was developed using Acuros in the Eclipse treatment
planning system. The patient would be receiving 30 fractions of 200 cGy for a total dose of
6,000 cGy. At Ellis Fischel we usually use the analytical anisotropic algorithm (AAA), but for
lungs Acuros is used. This is because it is more accurate for lungs with its algorithm by taking
air into better consideration. The lungs, heart, spinal cord, and PTV were contoured. A 1 cm
margin was put around the PTV and a 6 MV beam was used with our Varian TrueBeam. An AP
and PA beam were used and the AP beam had a 15 degree hard wedge. A 1 cm margin was used
with the MLCs. The beams were weighted evenly since any changes caused uneven isodose
lines anteriorly and posteriorly throughout the plan. The dose was calculated at an off-axis
calculation point for a better dose distribution to the PTV since there wasnt enough coverage.
After the plan was complete, the heterogeneity correction was turned off and nothing else was
changed so it could be compared.
Results: There were a few differences between the heterogeneity and homogeneity plans. The
coverage to the PTV was much better with heterogeneity corrections. The isodose lines bowed

in a lot in the homogeneous plan. The DVHs also help illustrate that with heterogeneity
corrections the plan is better. The homogeneous lung plan had a minimum dose of 87.6% (5,256
cGy). The maximum dose was 103.4% (6,204 cGy). With heterogeneity corrections, the
minimum dose was 93.1% (5,585 cGy). The maximum dose was 108.9% (6,534 cGy). By
assessing the dose and isodose lines, the heterogeneity plan provides more adequate coverage to
the PTV. Although it has a higher hot spot, it is providing that extra dose to the PTV. I
accidentally forgot to compute all the beams in RadCalc for the PA beam off-axis calculation
points. The plan MUs for both plans as you can see in the figures were still available though
from Eclipse. In the heterogeneous plan, the MUs calculated for the AP beam were 176 and
129.9 for the PA beam. In the homogeneous plan, the MUs calculated for the AP beam were
188.4 and 130 for the PA beam. The monitor units were pretty high since a 6 MV beam was
used. As you can see, the heterogeneous plan was much better by providing a more adequate
dose to the PTV even though it was a little hotter.
Discussion: The role of heterogeneities in the calculation of radiation dose distributions has
changed in recent years. In many areas in the body, the effects of heterogeneities in dose
distributions are relatively small. However, in the thorax the effects are very significant. The
presence of heterogeneities not only affects the absolute dose delivered to a tumor, but also the
relative dose distribution delivered elsewhere in the patient to the extent that failure to include
heterogeneity corrections in the evaluation of a treatment plan may cause changes in the
acceptance of a treatment plan. 3
When comparing an AP/PA lung plan with heterogeneity corrections turned on and off it
is easy to see the differences. Although the heterogeneous plan was hotter, it provides better
coverage to the tumor. This is easily seen with the isodose lines. With heterogeneity corrections
they are much more evenly distributed throughout the plan. With the homogeneous plan the
100%, 98%, and 95% lines severely bow in. This is because the lung and tissue densities are
seen the same as water by the treatment planning system. Lung tissue has a lower electron
density than water. It was surprising that with this plan that the isodose lines werent very
uniform since the beam sees its path with no differences in tissue. With different densities the
beam is attenuated very differently. The more dense tissue is, the more it attenuates the beam.
This could explain why the homogeneous plan bowed in so much. Since the human body
consists of fat, muscle, bone, and air it is not a homogeneous structure. This is why there is such

a big difference when the heterogeneity corrections are turned off. Also, since a low energy
beam was used the buildup region is decreased and better tumor coverage is provided. With lung
tumors, it is usually where the beam enters the tumor in the lung since lungs have a low density.
If the homogeneous plan was used the tumor would be underdosed.
The monitor units were slightly lower in the heterogeneous plan. This could be due to the
effective depth being used for the calculations. When heterogeneity corrections are turned off,
only the physical depth is taken into account. Effective depth takes the density of tissues into
account by assigning the depth based off of the depth of water that would cause the same
attenuation5. The density of water is 1.0 g/cm3 while the density of lung tissue is near 0.2-0.33
g/cm3.5 The effective depth used in the heterogeneous calculation will be lower than the depth
used for the homogeneous calculation. If the effective depth is lower, fewer monitor units are
needed to deliver the same amount of dose.
Conclusion: The lung is a very radiosensitive structure and it is critical to limit over or
underdosing the structures in or near the thorax when planning treatments in that area. This was
just a study of one patient where heterogeneity corrections were more beneficial than not using
them. Other plans that do this exact process maybe get varying results. There are many
variables in dosimetry. Every dosimetrist plans differently and every patient is different. The
location of the tumor or the type of treatment planning system and algorithm may affect your
results. Also, since there are so many structures with different densities in the thorax there is a
large difference in heterogeneity and homogeneity. There are many principles to consider when
treating a tumor in the lung. The dose and isodose lines can fluctuate very easily depending on
the energy of the beam, the effective depth, the density of the structures, weighting the beam, or
if you use a wedge. These are just some of the many factors that effect a lung plan. The main
difference in this project was the difference in densities. This caused different isodose lines,
doses, PTV coverage, and the amount monitor units. In my opinion, heterogeneity corrections
must be used to accurately predict how the radiation beam will interact in the patient. Lung
tissue is less dense than water and a homogeneous plan may overdose the target. It is very
important to understand all of this information when creating a lung plan and whether to use
heterogeneity or homogeneity which has been debated in the past.

References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
2. Khan FM. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2014.
3. Washington CM, Leaver D. Principles and Practice of Radiation Therapy.3rd
ed.St. Louis,Mo:2010
4. Discussion with Karen Kleiner, Medical Dosimetrist at Ellis Fischel Cancer Center. March
9, 2016.
5. 5. Orton CG, Chungbin S, Klein EE, et al. Study of lung density corrections in clinical trial
(RTOG 88-08). Int J Radiat Oncol Biol Phys. 1998;41(4):788-792.

Figures

Figure 1: Axial view of AP/PA lung treatment calculated with heterogeneity corrections.

Figure 2: Axial view of AP/PA lung treatment calculated without heterogeneity corrections.

Figure 3: Coronal view of AP/PA lung treatment calculated with heterogeneity corrections.

Figure 4: Coronal view of AP/PA lung treatment calculated without heterogeneity corrections.

Figure 5: Sagittal view of AP/PA lung treatment calculated with heterogeneity corrections.

Figure 6: Sagittal view of AP/PA lung treatment calculated without heterogeneity corrections.

Figure 7: DVH of AP/PA lung plan calculated with heterogeneity corrections.

Figure 8: DVH of AP/PA lung plan calculated without heterogeneity corrections.

Figure 9: RadCalc report displaying MU for AP/PA lung treatment plan calculated
with heterogeneity correction factors.

Figure 10: RadCalc report for AP/PA lung treatment plan calculated with heterogeneity
correction factors.

Figure 11: RadCalc report displaying MU for AP/PA lung treatment plan calculated
without heterogeneity correction factors.

Figure 12: RadCalc report for AP/PA lung treatment plan calculated without heterogeneity
correction factors.