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Brittany Butler
Treatment Planning
4/23/2018

The human body is made up of various tissues, structures and densities throughout.
When cancerous disease invades these cells, the use of ionizing radiation in radiation therapy can
be beneficial in curing disease and/or prolonging one’s quality of life. Modern treatment
planning systems aide in accurately displaying, calculating and organizing the dose that is
delivered to the patient. There are many components in this process that work together in
achieving accurately delivered treatment plans. Inhomogeneities in the human body have
various interactions with ionizing radiation and therefore need to be accounted and corrected for
according to the medium they are passing through. The focus of this paper will involve
analyzing how heterogeneity factors are obtained and how these corrections can affect treatment
planning, specifically in the lung region.
To initially obtain patient data, a CT simulation scan needs to be acquired. This data is
reconstructed into a matrix of 3 dimensional voxels from which CT numbers are generated. The
division of these pixel voxels can be directly related to calculated attenuation coefficients, or
how the energy beam passes through.1 From the CT number and linear attenuation coefficients,
Hounsfield units(HU) are derived. Various tissue types correlate to the HU range with water
being the baseline at zero. Due to change in atomic numbers, Compton and photoelectric
interactions attenuating portions of the beam differently, some of this scale is nonlinear. To
obtain this data, the CT machine is calibrated with phantoms of known tissue density, such as
equivalents to fat, bone, and muscle, and electron density ranges can be established. Khan1
states, “atomic number information can also be obtained if attenuation coefficients are measured
at two different x-ray energies.” These diagnostic energies attenuation coefficients can then be
converted to therapeutic energies. From these calculations, the planning system is able to
accurately account for heterogeneity in the human body and can visually represent the dose
distribution. This correction is especially noticeable in the chest region where heterogeneity is
more prevalent as the density and HU changes are more drastic as the beams passes through soft
tissue, bone, air, and tumor. This brings me to demonstrating this effect in the treatment planning
system with and without heterogeneity corrections.
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Using Eclipse version 11 software, 6MV AP/PA beams were placed with isocenter mid
planning target volume (PTV) and 50/50 beam weighting. To demonstrate the heterogeneity
corrections concept in lung tissue, I contoured a spherical PTV mid right lung with the density
overridden to a soft tissue/water equivalent of zero. This density override simulates HU close to
what a tumor density in the lung may be. The PTV was given a 2mm margin, which is a
common margin that the physicians would use at my clinic. The patient’s right lung, left lung,
spinal cord, and heart volumes were also contoured.
Plans were created using the Anisotropic Analytical Algorithm (AAA). This algorithm
was chosen, versus Acuros algorithm, for ease of demonstrating heterogeneity correction
concepts. In the AAA algorithm, Eclipse calculates heterogeneity by using photon scatter
kernels in multiple directions within the entire 3-dimensional interaction site.2 The dose
calculation is finalized with superimposition of photon and electron data convolution
calculations. There are some known limitations of both algorithms but using 6MV, AAA tends to
overestimate dose to water and underestimate dose to lung.2
Two plans were created for comparison. The first one was calculated to a point at
isocenter and normalized to the 94.2% isodose line to obtain 95% coverage of the PTV. The
second plan, plan 2, was calculated using the same parameters and monitor units as plan 1. For
plan 2, the only change was that heterogeneity correction was turned off. This allowed me to
visually compare isodose distributions between both plans with other variables remaining
constant. With heterogeneity turned off, the treatment planning system recognizes the entire
body volume as water. At first glance it was easy to see my PTV coverage decreased
significantly as compared to the first plan with heterogeneity on (Figure 1 &2). The 100%
isodose line has shifted toward the patient surface in plan 2, only encompassing a small portion
of the patient’s posterior aspect. In plan 1, the 95% isodose line was continuous throughout the
fields but with plan 2, only the 80% isodose line is continuous (Figure 3 &4). This makes sense
when you compare the densities of water and lung tissue. According to DeMaio3, lungs range in
HU from approximately -550 to -950 and linear attenuation coefficients of 0.093. Based upon
these numbers, you can correlate that the beam is able to pass through relatively easily as there is
not much matter to interact with in aerated lungs. In fact, there is an increase in dose to tissue
past healthy lung. There are two parts to how heterogeneities are included. One is the change in
the primary photon fluence and the second part to that is adjusting the dose kernels to the density
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it is passing through. For example, when you have bone next to lung tissue, the bone will
attenuate some of the beam and if lung happens to be adjacent, some of those secondary
interactions will travel farther in lung tissue. This would cause the original tear dropped shaped
kernel to bulge over the area of lung interactions, as they scatter farther. These factors are
dependent on beam energy and field size. According to Kahn1, with a 10x10cm field, the
correction factor for lung using 4MV x-rays is an additional 3% per cm of lung. As energy
increases, this percentage gets smaller. With 20MV beams it is 1% per cm of lung. When
comparing to bone, there is a reduction of dose beyond it. Per Kahn1, beyond 1cm of bone in 10
MV, the correction factor is -2%. In plan 2, with the heterogeneity correction turned off, the
PTV coverage went from 100% covering 95% of the volume to approximately 87% covering
95% of the volume (Figure 5 & 6). This is a huge difference when you consider it from a patient
treatment perspective as the patient volume could be significantly overdosed if the MU were to
be calculated and treated as water, without heterogeneity correction inside the body.
To demonstrate the change in MU, two more plans were created, plans 3 and 4, with
normalization set to 95% coverage of the PTV volume. In plan 3, the heterogeneity correction
factor was turned off and for plan 4 it was turned on (Figure 6 &7). Plan 4’s overall maximum
dose and PTV maximum dose was slightly higher than plan 3’s. The 105% isodose line was also
continuous throughout in some areas of the patient volume compared to plan 3 which was only
encircling the anterior and posterior aspects of the patient (Figures 8 & 9). The minimum dose
for the PTV was lower in plan 4, with the heterogeneity turned on. The fact that plan 3 has a
lower minimum dose to the PTV than plan 4 could be due to the loss of lateral electronic
equilibrium as photon beams travel through the lung. This effect increases significantly with
smaller field sizes and higher energy beams that are greater than 6MV.1 A study performed by
Wang et al4, compared 6MV and 15MV beams using Monte Carlo calculation. They
demonstrated that the increased penumbra width with increasing energy had resulted in
decreased homogeneity in dose to the lateral aspect of the PTV.
In comparing monitor units (MU), plan 3 required more MU than plan 4 for both beams
to achieve the same coverage of 95% of the PTV (Figure 10 & 11). As plan 4 is accounting for
the patient’s true anatomic makeup, with the heterogeneity correction on, it would need less MU
to deliver the same dose as the beam traverses lung tissue with ease. The AP beams from plans 3
and 4 were 203 MU versus 183 MU (Figure 12). The PA beams for plans 3 and 4 were 223 MU
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versus 187 MU (Figure 13). The plan with heterogeneity turned off, plan 3, required more MU’s
to achieve the set coverage in the planning system than when the patient density was accounted
for. Another way we can analyze this is in the difference in coefficients from the TPS. The AP
beam in plan 3 required 131 MU per Gray whereas plan 4 required only 117 MU per Gray (Table
1 & 3). The TPS also calculates the true depth of your point along with what the equivalent path
length of that distance. For example, traversing through air, the beam is able to go farther than
compared to traversing through bone. Accounting for this in planning is significant, as you could
either under or overdose your target volume without heterogeneity corrections. To put this in
perspective, my PA beams isocenter depth is 11cm and my equivalent path length is 6.1cm. This
calculation accounts for the electron density in the longitudinal direction of the primary photon
beam.5
For these plans, the organs at risk (OAR), such as the heart and spinal cord, were well
within dose tolerances as they were not included in the field. As this was a drawn in PTV, this
may not be the case with differing PTV volumes and locations. In both instances, from keeping
the MU constant comparison to same volume coverage, the dose volume histogram (DVH) dose
was lower for heart and cord (Figure 6 & 11). With heterogeneity turned off, water is denser
than lung tissue and therefore more scatter occurs. This contributing to the increased dose shown
for these organs.
As one can see, heterogeneity corrections have a large impact on the treatment planning
process. Dose distributions can vary significantly with the material they are interacting with
from primary photon fluence to multiple scattering interactions. These density interfaces within
the human body need to be accounted for and accurately demonstrated in visually appropriate
ways. This correction directly affects the monitor unit calculation and therefore the amount of
dose the patient will receive. Inherently, there are variables within the human body that are
difficult to account for on a day to day basis but it is important to have data as true to patient
anatomy as possible.
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References

1. Khan FM, Gibbons JP. Khans the physics of radiation therapy. 5th ed. Philadelphia:
Wolters Kluwer Health; 2014.

2. Varian Medical Systems. Anisotropic analytical algorithm (AAA) for photons. In: Eclipse
Algorithm Reference Guide. 2013; 113-123.

3. DeMaio D. Review of physics and instrumentation in computed tomography. In: Mosby’s

Exam Review for Computed Tomography. St. Louis, MO: Mosby Elsevier;2011:88-92.

4. Wang L, Yorke E, Desobry G, Chui C-S. Dosimetric advantage of using 6 MV over 15

MV photons in conformal therapy of lung cancer: Monte Carlo studies in patient
geometries. J Appl Clin Med Phys 2002; 3(1): 51-59.
http://dx.doi.org/10.1120/1.1432862

5. Chen WZ, Xiao Y, Li J. Impact of dose calculation algorithm on radiation therapy. World
J Radiol. 2014; 6(11): 874-880. http://dx.doi.org/10.4329/wjr.v6.i11.874
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Figures

Figure 1. Axial image of plan 1 with heterogeneity correction on. The red isodose line is in red
for this image and all images to follow.

Figure 2. Axial image of plan 2 with heterogeneity correction off. Calculated using same MU’s
as plan 1.
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Figure 3. Coronal and sagittal view of plan 1. Hot spots of 105% marked with green isodose
line.

Figure 4. Coronal and sagittal view of plan 2. Yellow isodose line is 90%. Cyan blue isodose
line is 95%.
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Figure 5. DVH of plan 1 and plan 2.

Figure 6. Zoomed in region on DVH of plan 1 and plan 2.

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Figure 6. Axial view of plan 3 with heterogeneity correction off. Planned using 100% isodose
line covering 95% PTV.

Figure 7. Axial view of plan 4 with heterogeneity correction on. Planned using 100% isodose
line covering 95% PTV.
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Figure 8. Coronal and sagittal view of plan 3.

Figure 9. Coronal and sagittal view of plan 4.

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Figure 10. DVH plan 3 and 4.

Figure 11. Zoomed in region on DVH of plan 3 and 4.

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Tables

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Table 1. Plan 3 MU AP beam.

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Table 2. Plan 3 MU PA beam.

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Table 3. Plan 4 MU AP beam.

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Table 4. Plan 4 MU PA beam.