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Dana Morgan
Treatment Planning Project
March 13, 2016
Heterogeneity vs. Homogeneous Project

Objective:

This project serves to compare a heterogeneous lung plan vs. a homogenous lung

plan and the effects such planning techniques have on dose distributions. Further implicating
the advantages and disadvantages one technique would have in a given situation.
Methods and Techniques: Methods include analyzing two 18MV lung plans comprised of an
anterior to posterior (AP) and posterior to anterior (PA) fields. The right upper lobe lung plans
were formed with a 2 cm margin around the PTV and a 15 degree wedge was utilized on the
anterior field. A total dose of 4500 Gy was achieved with 180 per fraction. The lung plan was
first examined with heterogeneity on and further evaluation of the same plan was done with the
heterogeneity factor off. Both plans were normalized 100% of the PTV to receive 95% of the
dose.
Comparison: Evaluation of the inhomogeneous nature of the body tissue, organs, and bones
validates that planning without a heterogeneity factor will produce changes in the dose
distribution. Specifically, the lungs are heterogeneous organs composed of air and soft tissue
thus, heterogeneity corrections have a prominent impact on dose distribution to the target.
When comparing the two plans with and without heterogeneity correction factor, there are
several notable differences. When utilizing the heterogeneity correction for the lung plan, the
isodose curves follow more hourglass figure or bowed toward the middle, as tissue delineations
account for electron density variances of the lung. Overall, tumor coverage has a remarkable
variation between the heterogeneous and homogeneous plan, with the heterogeneous plan

displaying less coverage to the lung mass. This is due in part because of electronic equilibrium
occurring at the boundaries of low density material or air cavities.1
In figures 1 and 2 below, the plans showcase the differences in the tumor coverage. Tumor
coverage is adequate for plan heterogeneity plan however, as compared to the homogeneous
plan, dose is not as uniformly distributed. The homogeneous plan displays isodose curves with
complete coverage and without the bowed in effect. The tumor dose for the homogenous plan is
noted to be less than the heterogenic plan as there is no accounting of the different tissue
densities or interfaces affecting dose. Further comparison notes a difference in monitor units as
the homogenous plan displays less monitor units, noting 130 for the AP field vs 138 on
heterogeneous AP plan. Also, the comparative DVH is better on the homogeneous plan.
Discussion: Attenuation of the beam is determined by electron density or number of electrons
per cm.2 For megavoltage beams, points of interest in non-tissue equivalent medium can be
accounted for with effective depth calculations.1 Compared to water, lung tissue has lower
electron density and thus fewer interactions occur, therefore, less dose is attenuated by the lung
tissue. Correcting for inhomogeneitys requires knowledge of the electron density of the tissue
such as air or bone or and the dimensional characteristics of the inhomogeneity. The effect noted
is a change in absorption of primary beam and associated scattered photons and second a change
in secondary electron fluence.4 Dose perturbations in the lung occur at the point of the
inhomogeneity as well as points lying beyond where primary beam is attenuated. Scatter
distribution changes dose near the inhomogeneous area. Furthermore, secondary electron fluency
affects dose to the tissues within the inhomogeneous boundaries. Heterogeneity corrections are
influenced by electron fluency and are dependent upon energy, field size, tissue density, travel
length the of beam. 3

In lung tissue, failure to account for the variation of interfaces can potentially increase overall
dose to lung and tissues and beyond. This can be accounted for manually by an attenuation
coefficients ascertained from comparative water studies to adjust for the attenuation variances.
For instance, compact bone attenuation factor is 1.5 g/cm3, spongy bone is 1.1g/cm3, and an
average of 0.5 cm can be utilized for lung interfaces.3 Lung tissue is one fourth to one third the
density of tissue therefore, high energy electrons travel three to four times farther in this material
than in tissue. Today, the modern treatment planning system of analytic anisotropic algorithm
(AAA), a superposition-convolution algorithm, accurately accounts for the presence of
inhomogeneity through complex algorithms. The goal of 2% accuracy, as set by the American
Association of Physicists in Medicine (AAPM) Task Group 65, functions as a useful guideline to
evaluate the inhomogeneity correction capabilities of this algorithm.4 While the systems is not
perfect and cannot account for patient density variations it does provide some means to account
for inhomogeneity. The AAPM reports that the AAA typically over predicts dose beyond low
density regions while under predicts dose beyond high density.
Conclusion: Considerations must be made when treatment planning to account for electron
interaction occurring at different tissue densities. The presence of bone, lung, teeth and hardware
materials influence the scattering components and affect the dose distribution. Multiple density
interfaces changes the dose distribution and can alter the intended dose. Historically, in the
clinical setting inhomogeneity was not accounted for and often disregarded because of the
inability to account for exact location of those interfaces. As technology has progressed,
treatment planning systems are better equipped to calculate different tissue densities and most
institutions now factor in tissue densities and use the AAA heterogonous algorithm. Ultimately,
we can more accurately represent absorbed dose within the patient. As stated, it is the goal of the

AAPM to attain accuracy of 2%, although applying heterogonous technique is not perfect, it is a
favorable technique on the constant quest for improved accuracy of treatment delivery.4 Failure
to utilize a heterogeneity correction creates a plan with different absorption of the primary beam,
which could potentially represent suboptimal dose distributions and an under dose to the target,
thus decreased tumor control.5 Therefore, planning with or without heterogeneity correction
factor greatly influences planning and must be used appropriately.

Figure 1. - Heterogeneity correction turned on

Figure 2. - Homogenous plan with heterogeneity turned off

References
1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2014.
2. Khan FM, Gerbie B. Treatment Planning in Radiation Oncology. 3Rd. Philadelphia, PA:
Lippincott Williams & Wilkins; 2012.
3. Robinson D. Inhomogeneity correction and analytic anisotropic algorithm. J Appl Clin Med
Phys. vol 9, No 2. 2008.
4. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill.1996:100-101.
5. Discussion with Judy Turner, Senior Dosimetrist Brown Cancer Center. March 10.2016