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Teri Burrier
Heterogeneity Corrections
April 20, 2018
Heterogeneity Corrections
Introduction: All structures within the body have a unique density that will affect how dose is
distributed throughout it. When a patient has a computed tomography (CT) scan for treatment
planning, the patient’s scan is broken down into tiny volumes called voxels. These voxels are
assigned a CT number related to its attenuation coefficient and normalized so that water is given
a value of 0.1 Dense objects, such as bone, will have a high number (+1000), while low density
objects, such as the lung, will be assigned a negative unit (-1000). CT numbers normalized in
this way are referred to as Hounsfield units, and represent a change of 0.1% in the attenuation
coefficient of water.1 Hounsfield units play an important role in calculating dose for treatment
plans because, without this information, the body would be viewed as one homogeneous density.
Current treatment planning systems are able to use this density information and apply a
heterogeneity correction factor per voxel to beam calculations in order to obtain a more accurate
display of dose throughout the body.
Process: To test the effects of heterogeneity on dose distribution, two plans with parallel
opposed anterior posterior (AP) and posterior anterior (PA) fields were created. Normal
structures were contoured including the right and left lung, spinal cord, tumor volume, and heart.
A 2-centimeter margin was placed around the tumor to create a PTV. Each plan used 6
megavoltage (MV) beams and was normalized to the isocenter; the only difference between the
two plans being that heterogeneity correction factors were applied in one and not the other.
Findings: The dose distributions were quite different in the two plans and can be seen in Figure
1. The reason for such a drastic change in the isodose lines between the two plans is due to the
amount of low-density lung and high-density rib that the beam is traveling through. The first
image in figure 1 represents the body as one uniform density, and thus there is no change in the
beam as it encounters the lung tissue since it is seen as the same density as the soft tissue around
it. In the second image there is a noticeable difference in dose at the lung tissue interfaces
throughout the plan, which is caused by the partial loss of lateral electronic equilibrium due to
the density changes. According to Kahn and Gibbons,1 in areas with lower density, such as the
lung, an increasing number of electrons travel outside the geometric limits of the beam which
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will cause the dose profile to be less sharp, a greater loss of laterally scattered electrons, and a
reduction in dose at the beam axis. This is represented in the heterogeneous plan in the hourglass
appearance that results from the isodose curves pulling in and the lack of 98% and 100% isodose
lines present in the lung tissue.
Figures 2-7 show isodose line, monitor unit (MU), and dose volume histogram (DVH)
variances between the two plans. In Figures 3 and 6 the differences in monitor units can be seen,
showing the plan with heterogeneity correction factors applied requires fewer monitor units to
deliver the desired dose to the isocenter. Fewer monitor units are required because lung tissue is
less dense, resulting in less attenuation, making it easier to pass through. The DVH information
shown in Figures 4 and 7 show the much preferable dose coverage that is achieved for the PTV
without the heterogeneity factors applied. Due to uniform tissue density in this plan, the mean
PTV coverage is 100.2% compared to 97.2% in the corrected plan. Minimum PTV dose is
98.4% in the uncorrected and only 91.8% in the heterogeneity corrected plan. The hotspot is also
preferable in the plan without heterogeneity factors applied and is 110.5% compared to 115%. A
study by Ding and Duggan et al,2 reported that maximum doses were underestimated by as much
as 27% when heterogeneity corrections were not applied during planning. The maximum dose is
higher in the plan with heterogeneity corrections applied, even though that plan has few monitor
units. This increase in dose is due to the fact that exit dose will be increased after traveling
through an area of decreased density. In contrast, the increase in coverage to the PTV in the
homogeneous plan, also leads to an increase in dose to the critical structures within the treated
area. The dose to the heart, lungs and spinal cord are less in the plan that takes heterogeneity
correction into account.
The differences seen between the plan with heterogeneity corrections and without can be
quite concerning from a planning perspective due to the variations in dose delivered to the PTV
as well as critical structures. If heterogeneity corrections are not used in planning, there may not
be an accurate representation of dose to the PTV, which can negatively affect patient outcome.
According to De La Fuente Herman and Gabrish et al,3 homogeneous plans look good on a
computer screen, but in reality, the dose being delivered to the PTV will often be poor enough to
significantly decrease the probability of tumor control. Furthermore, a study by Xiao and Papiez
et al4 found that the PTV coverage for stereotactic body radiotherapy (SBRT) lung plans
decreased on average 10.1% when heterogeneity corrections were applied. Figure 8 shows an
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example of the variation in PTV coverage from their study, while Figure 9 represents the change
that was seen in PTV coverage from this study.
Summary: Heterogeneity corrections are always used at the facility where I am doing my
training and tissue densities are never overridden. This is done to ensure the dose distribution is
as accurate as possible. In this study it was shown that the plan without corrections
overestimated the coverage to the PTV, while the maximum dose was underestimated.
Therefore, not applying heterogeneity corrections will produce a more uniform plan that is
visually acceptable; however, it is not an accurate depiction of what is truly taking place within
the patient. Performing this study has shown me how significantly heterogeneity corrections can
affect isodose distributions. I now have a better understanding of why it is so importance to
include these correction factors in calculations. As dosimetrists it is our responsibility to create
the best plan possible for our patients by maximizing dose to the tumor and limiting dose to
surrounding normal structures. In order to accurately do this, we must use all information
available to us, which includes applying heterogeneity correction factors to our plans.
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Figures

Figure 1: Side by side comparison of how heterogeneity corrections affect isodose coverage
when traveling through lung tissue. The first image has no heterogeneity correction factors
applied, while the second image does.

Figure 2: Axial, coronal, and sagittal view of the isodose lines with heterogeneity corrections
on.
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Figure 3: Beam data showing beam energy, weighting, and mu for each field using
heterogeneity corrections.

Figure 4: DVH and dose statistics for PTV and critical structures in plan with heterogeneity
corrections used.
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Figure 5: Axial, coronal, and sagittal view of the isodose lines with heterogeneity corrections
turned off.

Figure 6: Beam data showing beam energy, weighting, and mu for each field without
heterogeneity corrections.
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Figure 7: DVH and dose statistics for PTV and critical structures in plan without heterogeneity
corrections.
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Figure 8: Graph showing comparison of PTV coverage for a plan calculated with heterogeneity
corrections and without.4

Figure 9: Variation in PTV coverage for the two plans. Line with the square represents the plan
with heterogeneous correction factors applied and the line with the triangle represents the
homogeneous plan.
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References

1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.
2. Ding GX, Duggan DM, Dennis BL, et al. Impact of inhomogeneity corrections on
dose coverage in the treatment of lung cancer using stereotactic body radiation
therapy. Med Phys. 2007;34(7):2985-2994. http://dx.doi.org/10.1118/1.2745923
3. De La Fuente Herman T, Gabrish H, Herman TS, et al. Impact of tissue heterogeneity
corrections in stereotactic body radiation therapy treatment plans for lung cancer. J
Med Phys. 2010;35(3):170-173. http://dx.doi.org/10.4103/0971-6203.62133
4. Xiao Y, Papiez L, Paulus R, et al. Dosimetric evaluation of heterogeneity corrections
for RTOG 0236: stereotactic body radiation therapy of inoperable stage I/II non-
small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2009;73(4):1235-1242.
http://dx.doi.org/10.1016/j.ijrobp.2008.11.019