Ian Zoller

DOS 523: Treatment Planning

April 18, 2017
The Effects of Heterogeneities in Lung Treatment Planning
Introduction: When a radiation beam is incident on a patient it interacts with many different
structures that contain a wide range of densities. The change in densities influences the
attenuation and absorption of the radiation beam as it travels through the patient. Before the
existence of planning algorithms that could accurately model the effects of heterogeneities, plans
were created assuming that the patient had a uniform electron density equivalent to water. In
areas of the body with a large amount of soft tissue, corrections for homogeneities potentially are
insignificant. However, in treatments of the chest where a large volume is occupied by lung
tissue, the effects can become quite substantial. The purpose of this project is to evaluate how
heterogeneity correction algorithms can affect the dose distribution in the treatment planning of a
lung tumor.

Methods and materials: All of the plans in this analysis were created using the Varian Eclipse
treatment planning system. For the project, a patient CT scan was chosen that had previously
been planned using a stereotactic body radiation therapy technique (SBRT). At the time of
simulation, a 4 dimension motion management CT was acquired in order to assess movement of
the tumor in creating the planning target volume (PTV). Along with the PTV, delineation of
organs at risk included the left and right lung, heart, and spinal cord. For simplicity, structures
such as the full-body vac bag and indexing table top were excluded from the body contour so
that only attenuation within the patient could be evaluated.

Two plans were created using the CT data set: one utilizing heterogeneity correction
factor (HCF) and one without. The isocenter for both plans was placed close to the geometric
center of the PTV. An anterior (gantry angle 0) and posterior (gantry angle 180) beam
arrangement was used to create each plan. Multileaf collimators (MLCs) were fit to the PTV
using a 0.5 cm margin. Both fields used energies of 6 MV with even tumor dose weighting and
were normalized to 100% at isocenter. A tumor dose of 50 Gy to be delivered in 5 fractions was
entered into the treatment planning system in order to assess dose differences to involved
structures.
Results: Upon calculation of both plans, multiple differences became apparent. The most
noticeable difference occurred when comparing the isodose distribution in all three viewing
planes. With HCF applied, the 5250 through 4500 cGy (105-90%) lines were much more jagged
and irregular in appearance. In the axial plane, these lines constricted inward toward the central
axis of the beam. In addition, there was a collection of 105% dose (5250 cGy) at both the
anterior and posterior aspect of the patient. As for the lower isodose lines, a small outward
bowing towards the medial aspect of the patient could be seen in the 500 cGy isodose line. In
viewing the sagittal plane, the high dose lines were more forward pointed and penetrated deeper
in the superior direction of the patient (see Figures 1-3).

In stark contrast to the corrected lung plan, the uncorrected plan resulted in a very
different dose distribution. In the axial plane, the higher isodose lines were more smoothly
curved in comparison to the corrected plan. These lines took on the classic hour glass
appearance that is associated with opposed beams. The 5250 cGy line was no longer distributed
on both sides of the patient with a larger concentration being deposited in the posterior aspect. In
addition, there was no visible inward restriction of the isodose lines except for that observed with
the 5000 cGy line (see Figure 1). In the sagittal plane, the 5000 cGy line dips in toward the
superior direction just enough to pass through the isocenter (see Figure 2).

Another notable difference occurred when looking at the monitor units (MU) associated
with each plan. Only a small change was observed between the MU delivered from the anterior
fields. For the plan utilizing HCF, 638 MU were delivered in comparison to the 635 delivered
from the uncorrected plan. However, a major difference in MUs was noted when comparing the
posterior beams. Only 700 monitor units were delivered with the corrected plan in comparison
to 837 from the uncorrected plan (see Figures 4 and 5).

Finally, a significant difference was found when evaluating the dose to the PTV and the
right lung using a dose-volume histogram (DVH) that incorporated both plans. In assessing the
coverage of the PTV, 100% of the tumor dose in the corrected plan only covered 35% of the
PTV while 100% of the dose in the uncorrected plan covered 55% of the PTV. As for the right
lung, the volume that received low doses was higher in the corrected plan when compared to the
uncorrected plan. However, the volume of lung that received a high dose was lower in the
corrected plan when compared to the uncorrected plan (see Figure 6).
Discussion: According to Khan,1 inhomogeneities within a patient affect the dose distribution in
two ways: by changing the absorption of the primary beam and by changing the secondary
electron fluence. In the megavoltage energy range, the primary photon interaction with atoms in
the patient is by process of Compton scatter. This interaction is greatly influenced by the
electron density of the material the photon is traversing. In the case of a tumor located in the
lung, the healthy lung itself has an electron density that is approximately 25% that of water.2
Due to this fact, photon beams that travel through lung experience less attenuation resulting in an
increase in dose within and beyond the lung when compared to standard isodose charts.1

Along with this increase in dose, the lesser density of the lung also impacts lateral scatter
equilibrium and the secondary fluence of the electrons set into motion by the photon beam.1 In
the example of a lung tumor, more electrons are scattered outside of the field than are scattered
back within the field so the dose is reduced along the lateral aspects of the beam. Along the
same lines, at the distal portion of the lung when the beam comes back into contact with soft
tissue, the dose may have to again build back up resulting in a reduction in dose at this interface.

All of the effects described above are demonstrated when comparing the heterogeneity
corrected plan with the uncorrected plan. When looking at the isodose distribution in the
corrected plan, pockets of 5250 cGy collected at the anterior and posterior portion of the patient
(see Figure 1). The increase in dose beyond the lung combined with the entrance dose from each
beam caused these pockets to be more exaggerated in comparison to the uncorrected plan. Next,
it was observed that the higher isodose lines in the corrected plan constricted within the lung
toward the central axis of the beam. The loss of electrons scattered out of the beam path resulted
in a reduction in dose along the lateral aspects of the field. These outward electrons then
contributed in depositing low dose to healthy lung outside of the field which was observed with
the slight bowing of the 500 cGy line (Figure 1).

The changes that the lower density lung caused on the attenuation of the beam can further
be seen when analyzing the monitor units delivered among the plans. Only a small change was
observed between the monitor units delivered from the anterior beams of both plans. The small
change in the monitor units between these fields may be attributable to the location of the tumor
and the placement of the isocenter. With the tumor being located within the anterior portion of
the chest, only a small amount of lung was encountered before reaching isocenter. Therefore,
both beams travelled through materials that were very similar in electron densities. In contrast, a
large difference in monitor units was recorded among the posterior beams. In these fields, the
uncorrected plan assumed much more attenuation than that occurring in lungcausing a much
higher number of monitor units to be calculated.

The effects of heterogeneities also have a significant impact on dose recorded to targets
and surrounding organs at risk. A research study completed by Chang et al3 planned lung
patients utilizing corrected and uncorrected treatment plans to evaluate the effects of
heterogeneities on gross tumor volume (GTV) coverage and dose to the healthy lung. The
authors showed that plans with heterogeneity corrections using monitor units calculated from
homogenous plans increased the mean dose to the GTV by 4.7% while increasing lung dose by
approximately 1%. A similar study completed by Herman et al4 compared SBRT lung planning
utilizing heterogeneity corrections to verification plans using monitor units derived from
homogenous plans. The mean dose to the PTV in the verification plans was increased by 8%,
prompting the authors to conclude that plans not taking into account heterogeneities cause a
significant overdose to the PTV and adjacent organs at risk.

Conclusion: Before treatment planning algorithms that could accurately predict alterations in
dose due to heterogeneities, treatment plans were created assuming a uniform electron density.
This assumption created an incorrect model of what was actually occurring within the patient
especially in the treatment of lung tumors. Multiple studies have shown that creating treatment
plans ignoring inhomogeneity corrections results in an overdosing of targets and adjacent organs
at risk. These corrections need to be taken into account not only to deliver a tumor dose
accurately, but also to keep the safety of the patient a major priority.
 Figures

Corrected Uncorrected

Figure 1: Axial view of the isodose distribution of both plans at isocenter.

Corrected Uncorrected

Figure 2. Sagittal view of the isodose distribution of both plans at isocenter.

 Corrected Uncorrected

Figure 3. Coronal view showing the isodose distribution of both plans at isocenter.

Figure 4. Treatment plan summary of the heterogeneity corrected plan showing the monitor
units for each beam.
Figure 5. Treatment plan summary of the uncorrected plan indicating the monitor units calculated
for each beam.

Figure 6. DVH for both the heterogeneity corrected and uncorrected plans. The squares indicate
structures of the corrected plan and triangles indicate structures for the uncorrected plan.
 References
1. Khan FM. The Physics of Radiation Therapy. 4th ed. Philadelphia, PA: Lippencott Williams &
Wilkins; 2010.
2. McDermott PN, Orton CG. The Physics and Technology of Radiation Therapy. Madison, WI:
Medical Physics Publishing; 2010.
3. Chang D, Liu C, Dempsey JF, et al. Predicting changes in dose distribution to tumor and
normal tissue when correcting for heterogeneity in radiotherapy for lung cancer. Am J Clin
Oncol. 2007;30(1):57-62.
4. Herman Tde L, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of tissue heterogeneity
corrections in stereotactic body radiation therapy treatment plans for lung cancer. J Med Phys.
2010;35(3):170-173.