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Renee Jackson

Treatment Planning Project

April 27, 2019

Lung tumor case with heterogeneity correction and without heterogeneity correction.

Introduction: There are more than 200,000 lung cancer patients diagnosed each year in the
United States.1 Smoking is the primary cause of lung cancer, while other risks include asbestos
exposure and industrial irritants.2 The two main types of lung cancers are small cell and non-
small cell cancers. The thorax consists of several organs at risk that are highly sensitive to
radiation. These structures have different densities and tissues throughout. When performing
treatment planning for lung tumors, these organs at risk and changes in densities must be
considered.

For treatment planning, computed tomography (CT) is used for radiation treatment
planning. Different attenuation coefficients are assigned to various structures with different
densities and a CT image is created. The Hounsfield unit ranges from -1000 (air), 0 (water), and
+1000 (bone).4

CT images can be distorted by metal artifacts such as hip replacements, dental work,
pacemakers, and rods inside of bones. The streaking will cause the HU value to be inaccurate
and will affect the dose calculation by assuming the streaks are actually inside of the patient.
The streaking and metal object should be contoured and reassigned another HU value. My clinic
uses the value of water since that is what the majority of the body is made of.

When treating through air cavities such as breast, lung, and sinuses, heterogeneity
corrections should also be used. The drop in densities in these areas can cause underdosing in
the interfaces due to the ionization build up and electronic equilibrium. This will affect the
accuracy of dose calculation near the air cavites.1

Methods and Materials: In this study, a 70-year-old female patient with non-small cell cancer
of the left lung was used. Two treatment plans were created in Eclipse version 13.6 treatment
planning system using heterogeneity corrections and without heterogeneity corrections. A 1.5cm
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circular margin was placed around the GTV to create the PTV. The isocenter was placed in the
center of the PTV.

For the first plan, two parallel opposed fields, AP/PA, were planned with 6MV to a dose
of 6660cGy for 37 treatments at 180cGy per day. The organs at risk that were contoured
included: body, heart, right lung, left lung, spinal cord, and total lung. The heterogeneity factor
was used for this plan. Applying this feature will allow the treatment planning to take into
account for the different densities inside of the lung treatment field.

For the second plan, the initial plan was copied, and the heterogeneity factor was
removed. The plan was then calculated. Removing this feature, the treatment planning system
will not take into consideration of the different densities of tissues inside of the lung.

Results: For the heterogenous plan, the traditional hourglass shape is shown by the isodose line.
The plan shows that 71.8% of the PTV is covered by 100% of the dose. The global max dose is
117.6% and is located in the tissue that is anterior of the patient. The hotter regions are located
anteriorly and posteriorly at the beam entries near the surface of the patient. The monitor units
calculated for the AP field is 108MU and the PA is 115MU.

For the homogenous plan, an even distribution of the dose was seen throughout the lung
field. The plan shows that 100% of the PTV is covered by 100% of the dose. The global max
dose is 127.6% and located in the tissue that is anterior of the patient. The hotter region is now
pushing into the air of the lungs from the anterior surface. The monitor units calculated for the
AP field is 141MU and the PA is 122MU. The monitor units are higher in this plan because it
does not take into consideration the different densities, especially the air in the lungs. You will
need less since the beam is going through air.

Discussion: Tissue inhomogeneities involve secondary electrons and beam attenuation. Lung
tissues have lower densities and reduces the dose along the central axis.1 In the initial plan that
included the heterogeneity correction factor, the loss of dose can be seen by the isodose lines
giving the hourglass shape possibly losing coverage of the PTV from the electrons scattering
laterally.

The homogenous plan overestimates the attenuation of the beam and an underestimation
of dose to the tumor. 1 Not using the heterogeneity correction factor does not take into
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consideration of the lateral electron scatter. According to Herman et al5, lung tissue plans that
are created without tissue heterogeneity corrections, will have a much lower equivalent uniform
dose.

Conclusion: Planning without the heterogeneity correction factor will make the plan look nice
and evenly distributed. However, we are not taking into consideration the different densities that
are located inside the patient which will not give us an accurate measure of dose. When the
heterogeneity factor is not applied for treatment planning, the PTV could easily be mistreated.
The treatment planning system assumes there is more attenuation happening than it is actually
occurring and will cause an overdose to the target.5 It is the responsibility of the treatment
planning team to make sure they are creating the best plan for the patient, maximizing the dose to
the tumor and limiting the dose to the organs at risk.

Figure 1. Anterior field with 1.5cm circular margin around the PTV.
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Figure 2. Posterior field with 1.5 circular margin around the PTV.

Figure 3. Isodose distribution for heterogenous plan. Transversal View (Note the hourglass
shape of the isodose lines)
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Figure 4. Isodose distribution for heterogenous plan. Frontal View

Figure 5. Isodose distribution for heterogenous plan. Sagittal View

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Figure 6. Monitor units for heterogenous plan.

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Figure 7 . Dose Volume Histogram for heterogenous plan.

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Figure 8. Isodose distribution for homogenous plan. Transversal View

Figure 9. Isodose distribution for homogenous plan. Frontal View

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Figure 10. Isodose distribution for homogenous plan. Sagittal View

Figure 11. Monitor units for homogenous plan. (Increased number of monitor units)
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Figure 12. Dose Volume Histogram for homogenous plan.

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References

1. Khan F. Treatment Planning in Radiation Oncology. 4th Ed. Philadelphia, PA:

Lippincott Williams & Wilkins; 2016.
2. Lung Cancer. National Cancer Institute Website. https://www.cancer.gov/types/lung.
Accessed April 15, 2019.

3. Ziemann C, Stille M, Cremers F, et al. American Association of Physicist in Medicine.

The effects of metal artifact reduction on the retrieval of attenuation values. J Appl Clin
Med Phys. 2017;18(1):243-250. https://doi.org/10.1002/acm2.12002.
4. Khan F. The Physics of Radiation Therapy. 5th Ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2014.
5. Herman T, Gabrish H, Herman T, et al.US National Library of Medicine. Impact of
tissue heterogeneity corrections in stereotactic body radiation therapy treatment plans for
lung cancer. J Med Phys. 2010;35(3):170-173.doi:10.4103/0971-6203.62133.