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Shelby Hall

DOS 523

April 19, 2019

Heterogeneity Corrections

Introduction: In order to create the most accurate treatment plans possible, we must take into
account the many different tissues, organs, and cavities that are present inside each patient and
how this can affect the desired dose. Dose distributions inside a patient can vary greatly when
comparing them to standard isodose charts and depth dose tables. These standard charts and
tables are measured using a solid water phantom, which has a uniform density of 1g/cm3,
meaning that they don’t account for the heterogeneous conditions inside a patient. When a
radiation beam traverses through a patient, it can encounter muscle, fat, air, bone, lung tissue,
metal protheses, etc.1 All of these have different densities that can create different interactions
inside the patient. These interactions effect the beam is three different ways. The first is a shift in
the absorption of the primary radiation, the second is changes in dose due to scatter radiation,
and the third is changes in the secondary electron fluence.2

In the past, we didn’t have three-dimensional (3D) data, or CT-based planning, therefore,
treatment plans did not account for the different densities inside a patient. Today, by utilizing
CT-based planning and using more advanced treatment planning systems, we now have dose
calculation algorithms that can apply heterogeneity corrections to give us more accurate dose
distributions. A perfect example of an area of the body where heterogeneity largely affects the
beam is in lung treatments. To demonstrate the effect of these heterogeneity corrections, I will
compare two lung treatment plans created on the same patient.

Materials and Methods: Two treatment plans were generated using Eclipse treatment planning
system. The patient I chose had a diagnosis of stage IV non-small cell lung cancer and the plan
was to treat a left lung lesion. The patient underwent CT simulation in the treatment position,
which included having his arms up over his head. Using this CT scan, I was able to create two
sample treatment plans to demonstrate the effect of heterogeneity corrections. The default of the
planning system is to utilize heterogeneity corrections in all calculations. One treatment plan was
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created with the default heterogeneity corrections, and the other was planned with the
heterogeneity corrections turned off.

The dose prescription given by the physician was 3Gy x 10 fractions, for a total of 30Gy.
In order to evaluate dose to critical structures near the tumor volume, contours of the patient’s
body surface, left lung, right lung, heart, and spinal cord were performed by the dosimetrist. The
gross tumor volume (GTV) was contoured by the physician, and then a planning target volume
(PTV) was created by the dosimetrist by creating a 1cm margin around the GTV. To create the
treatment plans the isocenter was placed in the center of the PTV, 6MV beam energy was
chosen, and an anteroposterior (AP)/posteroanterior (PA) beam arrangement was placed. Both
fields were given equal weighting and normalized to the isocenter. Multileaf collimator (MLC)
blocking was then applied to each field and gave an additional 0.8cm margin around the PTV.
Once each plan was calculated, the dose distributions were evaluated and compared.

Results: In comparing each plan, it was immediately apparent that there were significant
differences between the two plans. First in the plan with heterogeneity corrections, when looking
at the isodose lines in Figures 1 and 2, we can see that the lines are not uniform across the
patient. The 100-110% isodose lines are primarily located in the patient’s soft tissues where each
beam enters the patient anteriorly and posteriorly, and do not penetrate deeper into the patient.
The lower isodose lines bow in towards the lung tissue, and then the 10% isodose line bows out
laterally. The result is a very minimally covered PTV, and a maximum dose of 113.6%. When
evaluating PTV coverage and dose to critical structures, we can see that overall the plan with
heterogeneity corrections has less dose. Utilizing the dose volume histogram (DVH), as shown in
Figure 3, only about 16.5% of the PTV is receiving 100% of the dose. The maximum dose to the
left lung is about 31.6Gy, and the mean dose to the heart is about 3.3Gy. Another difference to
note is the amount of monitor units between the plans. This plan has 175.8 for the AP, and 181.2
for the PA (Figure 4), for a total of 357 monitor units.

In comparison, looking at the plan without heterogeneity corrections, the isodose lines
appear more uniform across the patient. In Figures 5 and 6, you can see that the isodose lines
penetrate deeper into patient, and the 100% isodose line bows in near the isocenter to create an
hourglass shape. This plan is significantly “hotter” than the previous plan, with the maximum
dose increasing up to 126%. While the PTV still isn’t adequately covered, the coverage has gone
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up significantly, with about 47.2% of the PTV receiving 100% of the dose. As you can see in
Figure 7, the DVH demonstrates that the maximum dose for each structure has also gone up.
Specifically, the maximum dose to the left lung is now about 36.6Gy. Also, the mean heart dose
is now at 4Gy. The monitor units have increased as well, the AP field has 227.3 and the PA has
193.3 (Figure 8), for a total of 420.6 monitor units.

Discussion: These two plans demonstrate the significance of utilizing heterogeneity corrections
in our treatment plans. The isodose distributions can be altered significantly in the presence of
varying tissue densities, especially in lung tissue as shown above. Due to the decrease in density
in the lungs, more electrons are being scattered laterally outside the intended beam. More
electrons being scattered results in an increase in penumbra (especially with higher energies) and
a decrease in dose on the central axis.1 This explains why the isodose lines bow in, and why there
is a significant loss of coverage on the PTV. Herman et al studied the impact of tissue
heterogeneity corrections in stereotactic body radiation therapy (SBRT) for lung treatments.
They created plans optimized with tissue heterogeneity corrections, and then regenerated new
plans without heterogeneity corrections utilizing the same beam arrangements and monitor units.
They concluded that while the plan without heterogeneous corrections might look better on the
computer screen, the reality is that the actual dose coverage of the PTV could be poor enough to
decrease tumor control probability.3 Similarly, in a study by Chaikh et al,4 plans were compared
by using a pencil beam convolution (PBC) algorithm without heterogeneity corrections, and then
using the Modified Batho method (PBC-MB) with heterogeneity corrections. Their conclusions
also agreed with the demonstration above, in that the tissue heterogeneity corrections have a
significant impact on the dose throughout a plan, specifically for the PTV and organs at risk.
They even recommended improving our treatment regimens, when it comes to lung cancer, to
take advantage of these corrections for the protection of the organs at risk. They discuss
potentially adjusting the target dose prescription, dose constraints, and further evaluation of
tumor control and normal tissue complications.

While evaluating the dose distributions involving the lung can be a great example of the
impact of heterogeneity corrections, there are other areas of the body that can be affected by this
as well. Areas such as bone, different air cavities/sinuses, and the breast/lung interfaces can also
affect dose. The disturbance of dose distributions at air cavity-tissue interfaces can be difficult to
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calculate because of the lack of electronic equilibrium at the cavity surface. This can lead to
underdosing at the distal and proximal air cavity interfaces. The amount of underdose can be
dependent on the cavity size, location, and beam energy. Regarding breast treatments, the
inclusion of low-density lung tissue in standard breast tangential fields can result in higher doses
to some parts of the breast.5

Lastly, there can also be foreign materials in the body that can affect dose accuracy, such
as metal hip protheses, metal dental work, or contrast material. When planning cases in the lung,
we wouldn’t manually change the density in the lung (at my facility) because that wouldn’t be an
accurate representation of the patient’s anatomy. In contrast, for foreign materials, it may be
necessary to manually change the density so that the heterogeneity correction in the calculation
doesn’t account for a change in density that is inaccurate. An example of this would be the metal
streaking that is produced on a CT scan when a patient has metal dental work. The metal
streaking produces the appearance of air all around the patient’s mouth. We know that this is not
an accurate representation. To correct the potential dose inaccuracy here, the dosimetrist could
contour the “air” and change the density to be more like water or soft tissue. For contrast
material that was only meant be there during the simulation, the dosimetrist can also make that
same adjustment in density. Aside from correcting the artifacts, we must also be aware of the
effects of the metal and its ability to create dose inaccuracies. For example, in head and neck
treatments the metal dental work can create an increase in dose near that area, due to scatter
radiation, that may not be accurately displayed in the treatment planning system. Metal hip
prostheses can also create this problem and attempting to treat through that metal to a target can
lead to underdosing of the target. Therefore, we typically avoid treating through metal
prostheses.

Conclusion: The ultimate goal in any treatment plan is to maximize tumor coverage and
minimize any dose to critical structures. There are many different aspects involved in creating
the best possible treatment plan and being aware of how different densities can affect dose
distributions is crucial. While heterogeneity corrections clearly have a significant impact in
calculating accurate dose distributions, we must also recognize that dose inaccuracies can still be
present. As a dosimetrist, having a clear understanding of the interactions occurring inside a
patient guides us in creating optimal treatment plans.
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References

1. Khan FM, Gibbons JP. Treatment Planning II: Patient Data Acquisition. In: Pine JW, Moyer
E, eds. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2014:214-223.
2. McDermott PN, Orton CG. The Physics & Technology of Radiation Therapy. Madison, WI:
Medical Physics Publishing; 2010.
3. Herman T, 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. https://doi.org/10.4103/0971-6203.62133
4. Chaikh A, Giraud JY, Balosso J. A method to quantify and assess the dosimetric and clinical
impact resulting from the heterogeneity correction in radiotherapy for lung cancer. Int J
Cancer Oncol. 2014;2(1):1-7. http://dx.doi.org/10.14319/ijcto.0201.10
5. Papanikolaou N, Battista JJ, Boyer AL, Kappas C, et al. Tissue inhomogeneity corrections
for megavoltage photon beams. American Association of Physicists in Medicine.
https://www.aapm.org/pubs/reports/RPT_85.pdf. Published August 2004. Accessed April 25,
2019.
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Figure 1. Axial view of isodose distribution in plan with heterogeneity correction.

Figure 2. Isodose distributions with heterogeneity corrections. A) Coronal view B) Sagittal View

A)

B)
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Figure 3. DVH for plan with heterogeneity corrections.

Figure 4. Monitor units given in plan with heterogeneity corrections.

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Figure 5. Axial view of isodose distribution in plan without heterogeneity correction.

Figure 6. Isodose distributions without heterogeneity correction A) Coronal view. B) Sagittal

View

A)

B)
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Figure 7. DVH for plan without heterogeneity correction.

Figure 8. Monitor units given in plan without heterogeneity correction.