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Brandon Williamson
Treatment Planning Project
05/06/20
Treatment Planning Lung Cases With and Without Heterogeneity Correction
Over the past fifty years, there have been a number of innovations that have increased the
accuracy of dose calculation for radiotherapy treatment planning. The field began without CT
machines that would eventually give the ability to gather in vivo electron density information on
patients that could be used for more accurate dose calculations. 1 It is understandable then that,
prior to this data, patients were treated affectively as homogenous bags of water with no electron
density differences between tissues that could alter radiation dose distributions. 1 Thankfully now,
however, with this CT technology and more accurate algorithms to correct and account for
individual differences between tissues and people, patients can receive more accurate
treatments.1 These correction algorithms are called heterogeneity correction (or inhomogeneity
correction) algorithms. They use the electron density information gathered by these CT machines
to account for changes in the absorption of primary and scattered photons, and changes in the
fluence of the electrons that followed.2 The power of these factors have on the absorbed dose
differ depending on a number of variables such as the location of calculation relative to the
location of inhomogeneity, and the electron density of the tissues involved. 2 There are a number
of algorithms used to correct for tissue inhomogeneities, with convolution/superposition
algorithms being the most commonly used. 3 The Equivalent Tissue-Air Ratio method (ETAR) is
an algorithm suggested for energies less than or equal to 6 MV; which is also one of the
preferred energies for lung radiotherapy treatments where the use of heterogeneity corrections
are very important.2 In one research study, in fact, if inhomogeneity corrections were not used in
calculating the absorbed dose in lung treatments then there was an increased risk of radiation
pneumonitis up to 19%, with an average of 7%.4
In order to see the effects of heterogeneity correction myself, I created two identical lung
radiotherapy plans with and without this correction for comparison; labeled as “BW_LP_HC”
and “BW_LP_noHC,” respectively. Both of these plans were a 3-D conformal plan utilizing
6MV anterior and posterior parallel opposed beams so that the dose distribution should be evenly
spread throughout the tumor and irradiated volume, while also minimizing the chance of under-
dosing the periphery of the lung tumor.2 Each of these beams were centered on the lung tumor,
blocked to encompass the planning tumor volume (PTV) with a 2 cm margin, weighted 53.6 AP :
46.4 PA to evenly distribute the dose based on patient anatomy and tumor location, and the plan
was normalized to the 100% isodose line. The patient (labeled as “BODY2”), right lung, left
lung, spinal cord, tumor (labeled as “PTV_Lung”), and heart were also all contoured to evaluate
dose metrics on a dose-volume histogram (DVH). Most often contouring heterogeneities is not
needed, but when one is present that will not be there for treatment or that produces imaging
artifacts, then CT numbers can be changed to nearby tissue or air to match the everyday
treatment scenario.3 Some examples of these heterogeneities that produce calculated dose
inaccuracies by altering the calculation of radiographic path length include streaking from
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motion, metal and other contrast media, as well as beam hardening from opaque bone or dental
fillings.3 For the patient dataset used for this comparison, there were no heterogeneities of these
types present and therefore did not require additional contouring and CT number modification.
During the evaluation of both plans, the effects of heterogeneity correction become very
apparent. It can be seen that there is greater coverage to the PTV when heterogeneity correction
is turned off (about 63% vs 22% in this example) and decreased dose in the PTV’s periphery
when turned on. There is less dose on the surface of the PTV due to the increased range of
secondary electrons when heterogeneity correction is turned on. 3 The hour-glass shaped dose
distribution characteristic of this beam arrangement is also very apparent when the correction is
turned on versus a more homogenous distribution when turned off. This is due to the correction
accounting for the different attenuation properties of the different tissues present. This also
accounts for the increased monitor units required for non corrected plans as all tissues are treated
as denser soft tissue versus lung. Unlike other areas of the body, the lungs exhibit very low
attenuation to radiotherapy beams because of the very low electron density of the lungs. 3
Radiation will move much faster through lung tissue (which is comprised mostly of air that is
less dense) compared to denser structures for example bone or soft tissue (which is mostly water)
where radiation moves slower (or rather exhibits increased energy absorption). 2 There is an
increase in dose beyond air cavities such as sinus cavities and lung tissues and a reduction in
dose beyond bone tissues such as the ribs.2 For bone, this is due to the shielding effect of the
bone caused by the electron density of the bone minerals being higher than the tissue that follows
thereby attenuating the beam.2 For air cavities, there is nothing to attenuate the beam (less
density than bone) and therefore lines shifts beyond the interface of the beam and the air cavity. 2
The accuracy of which these isodose lines are displayed on treatment planning computers
depends on the algorithm chosen for the particular clinical situation. 2 These variances in dose
rate can be visually seen on AP-PA lung patients, such as the ones performed in this comparison,
pretty dramatically where when heterogeneity correction is turned off larger and hotter hot spots
can be seen closer to the chest wall or the back of the patient with lower doses in the center of
the lung.2
When heterogeneity correction is turned off, all tissues are affectively given the electron
density of water which is equal to 1.2 The actual electron densities of air and tissues within the
path of lung treatment beams include 0.001 for air, 1.04 for muscle, 0.916 for fat, and 1.65 for
bone.2 When these values are not accurately accounted for, inaccurate radiation dose calculations
and distributions can be displayed giving a false sense of tumor coverage and sparing of at risk
organs. This can be seen on comparative DVHs and dose distributions displayed on CT datasets
such as in the images seen from this comparison. The various densities of lung and nearby tissue
play a dominant role in the distribution of absorbed dose. 2 This is why using heterogeneity
corrections is very important, and is why the AAPM TG No. 65 Report No.85 highly
recommends it.1
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Figure 1: Comparison with (left) and without (right) heterogeneity correction (HC)

Figure 2: DVH Comparison of both plans with key in image below; no HC (square) and with HC
(triangle)
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Figure 3: HC Plan displayed in 3 Planes with MUs

Figure 4: No HC Plan displayed in 3 Planes with MUs

Figure 5: HC Plan DVH with Key

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Figure 6: No HC Plan DVH with Key

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Figure 7: HC Plan displaying value and location of Max Hot Spot

Figure 8: No HC Plan displaying value and location of Max Hot Spot

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Figure 9: HC Plan DVH displaying coverage of PTV at 100% of prescription dose in both
percentage and cubic centimeters
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Figure 10: No HC Plan DVH displaying coverage of PTV at 100% of prescription dose in both
percentage and cubic centimeters
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References

1. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue Inhomogeneity Corrections for
Megavoltage Photon Beams. Madison, WI: American Association of Physicists in
Medicine; 2004:142. https://www.aapm.org/pubs/reports/rpt_85.pdf.
2. Khan, FM. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2014.
3. Khan F, Gibbons J, Sperduto P. Treatment Planning in Radiation Oncology. 4th ed.
Wolters Kluwer; 2016.
4. Mah K, Van Dyk J. On the impact of tissue inhomogeneity corrections in clinical thoracic
radiation therapy. Int J Radiat Oncol Biol Phys. 1991;21(5):1257-1267.
doi:10.1016/0360-3016(91)90284-b