When talking to my clinical preceptor, who is our chief medical physicist, I was told that

we always use heterogeneity correction factors at our clinic. This is because every patient we
treat will have a heterogeneous composition, and we need to account for all densities in order for
our plans to be accurate. Our facility currently uses the anisotropic analytical algorithm (AAA)
for dose calculations. Our physicist explained that this algorithm assigns a density to tissue and
factors in the total area. For example if a lung were given a density of.25, for every 4 cm of lung
tissue it would have a density of 1. The AAA is widely used today and is a modification of the
earlier, more basic pencil beam algorithm that did not account for scatter.
According to a study by Ding and Duggan et al,1 the use of a pencil beam algorithm with
no heterogeneity corrections cannot guarantee the real minimum PTV dose coverage in SBRT
lung plans. For this study plans were done using no heterogeneity correction and then
recalculated with both the modified Batho heterogeneity correction and then again with the more
accurate AAA. The AAA was used as the reference in this study and found that maximum doses
were underestimated by up to 27% when no heterogeneity correction was used and
overestimated by 19% using heterogeneity correction.1
Our physicist explained that the Monte Carlo algorithm is the “gold standard” of today;
however, if we were to use it we would have to go home for a week and wait for it to
calculate. Obviously this is an exaggeration, but it is why Monte Carlo is not widely used in the
clinic. A study done by Sterpin et al2 compared the accuracy of AAA against Monte Carlo in
inhomogeneous media and found that deviations were generally below 3% in lung
inhomogeneities and below 5% at interfaces. However, the effects of attenuation and scattering
close to the ribs were not completely taken into account by AAA.

In most commercial treatment planning systems, it is possible to override the density of a

patient's CT scan. Please explain what this means and how it is used.

For some patients it may be necessary to override certain structures before beginning the
treatment planning process. For example, when contouring a breast patient there will be
fiducials on the patient’s skin in the treatment planning CT that will not be there everyday for
treatment. These fiducials are a higher density than the patients skin and can have an effect on
the dose distribution if not corrected for. Dosimetrists at my facility contour all fiducials and
then use a density override feature to change the value to 0 (hu for water) in order to obtain more
accurate isodose lines. Another instance would be if contrast were used to visualize internal
anatomy for the CT scan that would not be present daily for treatment. By taking the time to
correct for density differences, the resulting isodose lines will more closely represent what will
be achieved daily during treatment.

1. Ding GX, Duggan DM, Lu B, et al. Impact of inhomogeneity corrections on dose coverage in
the treatment of lung cancer using stereotactic body radiation therapy. Medical Physics. 2007;
34(7): 2985-2994. http://dx.doi.org/10.1118/1.2745923

2. Sterpin E, Tomsej M, De Smedt B, Reynaert N, Vynckier S. Monte carlo evaluation of the

AAA treatment planning algorithm in a heterogenous multilayer phantom and IMRT clinical
treatments for an Elekta SL25 linear accelerator. Med Physics. 2007; 34(5):1665-1677.
http://dx.doi.org/10.1118/1.2727314