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Stephanie Olson
Dos 523 Treatment Planning
March 2, 2015
Lung cancer plan with and without heterogeneity correction
Introduction: The human body is comprised of tissues which span a range of varying electron
densities. These varying densities create a heterogeneous treatment volume thus having an effect
on the attenuation and absorption of radiation. Tissues with higher electron densities attenuate
and absorb more dose than tissues with lower electron densities.1 Correcting for tissue
heterogeneity is important in treatment planning to more accurately predict the dose received by
a tumor volume and the surrounding critical structures.2 Heterogeneity correction factors have
the largest impact in the thoracic region. The density of lung tissue is approximately 30% of soft
tissue therefore when correcting for the differences in heterogeneity, the greatest impact will be
in treatment areas near the lung.3 The use of computed tomography (CT) in treatment planning
gives the ablility to provide information such as tissue electron densities within the path of a
treatment beam as well as the size, shape and location of those tissues. By obtaining this
information, an effective treatment depth can be calculated for a treatment beam which aids in
correcting for heterogeneity. A calculated effective depth is not the same as the actual depth of
the treatment isocenter.4
Materials and Methods: For this project, a treatment plan was created for a patient with a right
lung mass using a Pinnacle treatment planning system (TPS). Contours drawn included the
planned tumor volume (PTV), right lung, left lung, heart, esophagus, spinal cord, and skin. The
treatment objective for this plan was to obtain 95% of the PTV to receive 95% of the total
prescription dose. The prescription to the right lung was a dose of 50 Gray (Gy) total using 2.5
Gy fractions for 20 fractions. A point of interest was added and automatically placed by the
Pinnacle TPS within the PTV region of interest. This point was used as the treatment isocenter
for this plan. An anterior-posterior (AP) beam was added at the isocenter and a block with a 1.5
cm margin was created around the PTV (Figure 1). After the AP block was created, the AP beam
was copied and opposed to created the posterior-anterior (PA) field for this plan. The initial plan
was computed using 6 megavoltage (6 MV) beams with the heterogeneity corrections turned on.

Physical wedges were needed to produce better coverage of the PTV. A 30 degree wedge was
inserted for the AP beam while a 15 degree wedge was used for the PA beam. Field weighting
was 50.1% and 49.9% respectively. The monitor units (MU) needed to achieve this plan were
282 MU from the AP (Figure 2) and 213 MU from the PA (Figure 3). To achieve the objective of
95% coverage of the PTV by 95% of the prescribed dose, the plan was normalized to the 95%
isodose line (Figure 4). After the heterogeneous plan was finalized, a copy of the plan was made
and the heterogeneity correction factors were turned off while keeping the beam weights, wedges
and normalization the same. The isodose curves for the homogeneous plan were more uniform
throughout the treatment area and conformed better to the PTV when compared to the
heterogeneous plan (Figure 5). The MU computed for this plan were 342 MU from the AP
(Figure 6) and 236 MU from the PA (Figure 7). The coverage of the PTV in this plan increased
to 99.3% of the PTV volume being covered by 100% of the prescribed dose (Figure 8).
Results: The heterogeneous lung plan showed a less conformal dose distribution throughout the
treatment volume when compared to the homogeneous lung plan. Proper dose coverage in the
heterogeneous plan was not achievable with the plan normalized at 100%. Thus, the
normalization was changed to 95% which increased the PTV coverage to 98.1% of the volume
being treated by the 95% isodose line or 47.5 Gy. The isodose lines were less conformal and
bowed in throughout the PTV in all views (Figure 1). When the heterogeneity correction factors
were turned off in the homogeneous lung plan, the PTV coverage increased to 100% of the
volume being covered by the 95% isodose line. The isodose lines were more conformal and
there was little bowing of the isodose lines throughout the PTV volume (Figure 5).
Discussion: Standard isodose and depth dose tables are created assuming homogeneity within a
patient volume.1 To create these tables, measurements are taken within a tissue-equivalent
phantom at a certain depth for a standard field size and distance. With the advancement of CT as
the primary imaging modality for treatment planning, we know treatment beams pass through
many varying tissues which have unique electron densities making the treatment volume
heterogeneous. Heterogeneity within a treatment beam path affects the absorption of the primary
beam and associated scatter with that primary beam as well as the secondary electron fluence.1
The degree to which heterogeneity affects the treatment beam depends on the size, shape and
location of the varying electron densities.4 Soft tissue within the body has an electron density of
approximately 1.0 g/cm3 while lung tissue has an electron density of approximately 30% of soft

tissue.3 This means that as a radiation beam travels through the lung, only approximately onethird of the dose that would normally be absorbed by soft tissue will be absorbed by the lung
tissue. Therefore, more radiation is passing through the lung tissue, giving rise to higher doses
beyond the lung. To account for the difference in heterogeneity within a treatment beam path, an
effective depth can be calculated.3 In a homogeneous lung plan, the assumed electron density of
all tissues is equal to 1.0 g/cm3 making the effective depth equal to the depth of the isocenter.
For that reason, it is assumed that the radiation beam interacts with all tissues alike which creates
a more conformal and uniform dose distribution. The dose distribution follows closely to the
field dimensions and field shape and there is little bowing of the isodose lines. However, when
creating a lung plan using heterogeneity correction factors, there is less scatter and dose buildup
within the treatment volume due to the greater area of less dense tissue or lung.4 This creates a
plan which is less conformal and causes the isodose lines to bow inward near the tumor volume.
The actual depth of the isocenter is quite different than the effective depth due to the variance in
tissue densities between lung and soft tissue within the path of the beam. Factors which are
influenced by varying tissue densities include the effects of Compton interactions, the rebuild up
of dose in a tumor volume and penumbra. First, the effect of Compton interactions within a
treatment region is reduced due to less dense lung tissue causing fewer electrons to interact
which also reduces the dose absorbed in that tissue. Second, as the beam re-enters soft tissue or
an area of higher density than lung tissue, a buildup region of electronic equilibrium restarts
causing an underdose in the interface between the lung and soft tissue. There is also a build
down region at the distal region of the soft tissue again due to the lung-soft tissue interface.
Lack of scatter and lateral electronic equilibrium are contributing factors to the underdosed areas.
Third, penumbra is increased due to the reduced Compton interactions and reduced scatter which
causes a bowing in of the isodose lines.5 When using the effective depth to calculate the number
of monitor units needed for a plan which corrects for heterogeneity to a plan which does not, it
will typically be seen that more monitor units are needed for the plan which does not correct for
heterogeneity. This means that tumor volumes and critical structures may not be receiving the
doses prescribed when heterogeneity corrections are used. In a study by Chang et al,3 it was
found that when heterogeneity corrections were applied in a treatment plan of the lung, the dose
to the tumor was approximately 5% less than desired on average.

Conclusion: The use of heterogeneity correction factors in radiation treatment planning can
have a significant effect on the dose distribution of a treatment plan. Historically, treatment
planning was computed based on homogeneous target volumes. However, with the increased use
of CT in treatment planning, we know the body is comprised of varying tissues which span a
wide range of electron densities. With the advent of more conformal treatment planning and
delivery, the desired objectives and constraints can be more easily achievable and understood
with the use of heterogeneity correction factors. Without these factors, the dose being prescribed
can vary greatly from the dose which is actually being delivered.


Figure 1: Axial, sagittal, coronal and beams-eye views of heterogeneous lung plan.

Figure 2: Monitor unit page for the AP heterogeneous lung field.

Figure 3: Monitor unit page for the PA heterogeneous lung field.

Figure 4: DVH for the heterogeneous lung plan.

Figure 5: Axial, sagittal, coronal and beams-eye views of homogeneous lung plan.

Figure 6: Monitor unit page for the AP homogeneous lung field.

Figure 7: Monitor unit page for the PA homogeneous lung field.


Figure 8: DVH for the homogeneous lung plan.


1 Khan F. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott, Williams, and
Wilkins; 2010.
2 Papanikolaou N, Klein EE, Hendee WR. Heterogeneity corrections should be used in
treatment planning for lung cancer. Med Phys. 2000;27(8):1702-1704.
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;30:50-62.
4 Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
5 American Association of Physicists in Medicine. Tissue inhomogeneity corrections for
megavoltage photon beams. Report No. 85. Wisconsin: Medical Physics Publishing; 2004.
https://www.aapm.org/pubs/reports/rpt_85.pdf. Accessed February 20, 2015.