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Heather Maurer Treatment Planning Project March 2014 Lung Treatments AP/PA with and without Heterogeneity Correction Treating a tumor located in the lung can create its own set of obstacles. The one addressed here will be the effects of using heterogeneity correction or not, while planning radiation treatment for a lung tumor. Heterogeneity correction is the correction of the calculation to account for the inhomogeneity of the treatment area, since standard charts and tables are designed using a density of water and assuming all areas are homogeneous.1 When treating through inhomogeneous areas, or areas composed of different densities, the scatter and absorption of the beam will be affected.2 These effects will change the dose to the area. How much the does changes will depend on what densities the beam will pass through, the amount of the density, and the energy of the beam.3 The most common way to acquire the information needed for these calculations is by planning off of a CT (computed tomography) scan loaded into a TPS (treatment planning system). It is best if the patient is scanned in the treatment position for precise localization of internal structures. With the reconstruction of the CT scan a CT number is also generated related to the density of each area, ranging from -1,000 for air to +1,000 for bone, with water being represented as 0.2 Once this information is acknowledged by having the heterogeneity correction turned on in the TPS, an algorithm will take these factors into account while calculating. While planning in Varians Eclipse TPS the Anisotropic Analytical Algorithm (AAA) is used. According to the Varian Medical Systems Eclipse Algorithms Reference Guide The AAA is a 3D pencil beam convolution/superposition algorithm that uses separate Monte Carlo derived modeling for primary photons, scattered extra-focal photons, and electrons scattered from the beam limiting devices.4 AAA is a common algorithm used by many facilities due to its balance between speed and accuracy though it does have limitations. Studies have shown that the AAA algorithm is superior to the PBC (Pencil Beam Convolution) algorithm when calculating treatments through mixed densities.5 Though some also show AAAs inaccuracies. According to Robinson6, the AAA algorithm over calculates dose in after the beam has passed through an area

of low density and under calculates dose of a beam prior to entering an area of high density. Knowing an accurate dose in these areas is important because many areas, especially critical structures or OAR (organs at risk) will have constrains on the amount of dose they are able to receive. For standard lung treatments the constraints to some critical structures would be as follows. Table 1: Dose constraints for critical structures Total Lung *Complications that may occur past these doses include pneumonitis Less than 150cGy Less than 200cGy Less than 50cGy

Mean dose 35% of total volume 65% of total volume

Heart

Mean dose 50% of total volume 35% of total volume

*Complications that may occur past these doses include pericarditis and pancarditis Less than 300cGy Less than 300cGy Less than 400cGy

Spine

20cGy per fraction or less 25 or 30cGy per fraction 40cGy per faction

*Complications that may occur past these doses include necrosis Less than or equal to 450cGy Less than or equal to 360cGy Less than or equal to 200cGy

To visualize the changes that the heterogeneity correction has on a lung tumor plan, two calculations will be done on the same plan. First the plan will be created and perfected without heterogeneity correction. Then the same plan will be recalculated, with no changes made, other than turning on the heterogeneity correction on in the treatment planning system. For this

particular plan the patient received a CT scan in the treatment position, the scan was then loaded into Varians Eclipse TPS and several critical structures were drawn. The GTV (gross tumor volume) was drawn by the physician with a request to use the GTV plus 1cm margin to create the PTV (planned tumor volume). This was done by dosimetry as well as drawing the heart, both lungs, and spinal cord in preparation for planning. The flowing plan was created (Figure 1) for this patient with a script of 360cGy in 30Cgy fractions. This was designed to be a palliative treatment with no MLCs (Multiple Leaf Collimator) used to create these fields, the jaws were adjusted to give 1.5cm margin to the PTV, only anterior and posterior fields were used, slightly weighted and one wedge used as a tissue compensator. Figure 1: Treatment Plan with no heterogeneity correction

Figure 2: DVH (dose volume histogram) for initial plan with no heterogeneity correction

Following the TPS calculation a hand calculation was also done using the calibration for the treatment machines at the University of Michigan Radiation Oncology Department of 0.8mu/cGy and the appropriate tables. With the plan being slightly weighted the hand calculation had to adjust for that as well and was performed as follows. AP field without heterogeneity correction (30cGy) (.546 weighted) = 163.8cGy ___________Dose_______________ (calibration)(Sc)(Sp)(TMR)(ISF)(WF) ________163.8__________ (.8)(1)(1)(1.1024)(1)(.712) = 261 MU

PA field without heterogeneity correction (30cGy) (.454 weighted) = 1.362cGy ___________Dose___________ (calibration)(Sc)(Sp)(TMR)(ISF) ______136.2____ (.8)(1)(1)(.9688)(1) = 176 MU

Compared to the MUs calculated by the TPS (shown towards the lower right hand corner of figure 1) each beam is off by 2 MUs equaling a 1% difference. This plan was also sent through a computerized double checked system, Mobius. The results are in Figure 3. Figure 3: Report from Mobius (computerized 2nd check for TPS plans) of initial plan with no heterogeneity correction.
Beam AP PA

Energy (MV) TPS MU M3D MU TPS Beam Dose (cGy) M3D Beam Dose (cGy) Dose Difference Segments X1 / X2 Jaws (cm)

6 263 262 164 164 0.4% 1 4.9 5.6

6 174 162 136 146 7.5% 1 5.5 5.0 4.7 5.0 None

Y1 / Y2 Jaws (cm)

4.5 4.9

Wedge

Physical W15R30, 15.0

MLC Rotation Gantry Collimator Couch Gantry Clearance (cm) Deliverable

Static Static 0.0 0.0 0.0 -Yes

Static Static 180.0 0.0 0.0 -Yes

According to the Mobius report the AP beam has a dose difference of 0.4%, though it shows the PA beam to have a dose difference of 7.5%. Upon investigating this discrepancy it was determined by a staff physicist as The University of Michigan, that the Mobius 2nd check program always has density correction on, even though the plan was calculated in the TPS without it. This explains why the PA beam has such a dose difference, but leaves the question as to why it wasnt as apparent in the AP beam. Taking a closer look at the plan the explanation becomes clear. The AP beam is traveling through much less lung compared to the PA beam before reaching the target. With the majority of the AP beam traveling through a homogeneous path and only a small portion of the beam having less attenuation through the lower density area of the lung, the change in the MUs are practically negligible. A greater discrepancy is noticed with the PA beam considering nearly half the beams travel length is though the low density lung. With Mobius always having heterogeneity correction on, the report for the plan with heterogeneity correction turned on, Figure 6, should be more accurate. Now that the initial plan, calculated with no heterogeneity correction, was complete, it was copied and calculated again with heterogeneity correction turned on, Figure 4. Figure 4: Initial plan recalculated with heterogeneity correction turned on

Figure 5: DVH (dose volume histogram) of initial plan recalculated with heterogeneity correction turned on

To perform a hand calculation for a plan with heterogeneity correction the new depth must be calculated and new numbers derived from the charts. There is also a feature within Eclipse that will give you the water equivalent distance when drawn through any density. This tool can help you find numbers, but its always good to have an idea of what your number should be. Knowing that when drawing through a lung your number should be smaller than the actual distance; similar to when drawing through bone your number would be greater than the actual distance. Keeping this in mind will help prevent errors in calculations. AP field with heterogeneity correction ___________Dose_______________ (calibration)(Sc)(Sp)(TMR)(ISF)(WF) ________163.8__________ (.8)(1)(1)(1.11215)(1)(.712) = 259 MU

PA field with heterogeneity correction ___________Dose___________ (calibration)(Sc)(Sp)(TMR)(ISF) ______136.2____ (.8)(1)(1)(.84816)(1) = 161MU

Again the hand calculations differ minimally from the TPS MUs calculated and shown toward the lower right hand corner of figure 4. The plan was sent through the computerized double checked system, Mobius, and the Mobius report is shown in figure 6. Figure 6: Report from Mobius, computerized 2nd check for TPS plans, of initial plan with heterogeneity correction turned on.
Beam AP PA

Energy (MV) TPS MU M3D MU TPS Beam Dose (cGy) M3D Beam Dose (cGy) Dose Difference Segments X1 / X2 Jaws (cm)

6 260 262 164 162 -0.8% 1 4.9 5.6

6 164 162 136 137 0.8% 1 5.5 5.0 4.7 5.0 None

Y1 / Y2 Jaws (cm)

4.5 4.9

Wedge

Physical W15R30, 15.0

MLC Rotation Gantry Collimator Couch Gantry Clearance (cm) Deliverable

Static Static 0.0 0.0 0.0 -Yes

Static Static 180.0 0.0 0.0 -Yes

Now that both the TPS and the Mobius systems are calculating with heterogeneity correction turned on, they now have a dose difference of +/-.8% in each field. If you visually compare the isodose lines in figures 1 and 4 you may notice the orange 95% isodose line creating more of an hour glass shape in the axial slice for the plan with heterogeneity correction turned on (figure 4). This is due to the lower density lung not attenuating the beam and creating as much scatter which would help to create the higher does around the edges. Also in the coronal view you may notice that the PTVs (purple outlined figure) lateral aspect is more uniformly covered by the red 100% isodose line in the plan with heterogeneity correction turned on (figure 4) than it is in the no heterogeneity correction plan (figure 1). This is in part due to the fact that as the beam travels through the lung, which is of low density, the beam will experience very little attenuation and therefore the primary beam is stronger when it reaches the target then it would have been if it traveled the same distance through an area of higher density3. Also when reaching the target or higher density area the beam will create more scatter than when traveling through the low density area, this too will contribute to the greater dose coverage. For an easy visual of the differences in these two plans figure 7 shows a plan comparison DVH. Figure 7: Plan comparison DVH (Lines with correction on and the lines with representing the plan with heterogeneity

representing the plan without)

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In conclusion creating these plans and completing this project has helped me grasp the concept of heterogeneity correction. If different densities were not accounted for when planning the possibility of over dosing a critical structure or under dosing the target is much greater. In this particular case it also demonstrated how the amount of low density material that the beam travels through will affect the beam. The greater the amount of low density area traveled by the beam, the greater the difference is as compared to a beam traveling the same distance in a higher density material. Overall, areas of any density, whether it is air, water equivalent material or bone, will all affect the beam. If these discrepancies are not calculated for there is a greater margin for error, even if the plan may be visually appealing.

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References
1 2 3 4 Washington CM, and Leaver D. Principles and Practices of Radiation Therapy. 2nd ed. St Louis, Mo: Mosby-Elsevier; 2010 Khan F. The physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins. 2010 Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996. 41-43 Anisotropic analytical algorithm (AAA) for photons. In: Varian medical systems Eclipse Algorithms Reference Guide Eclipse. Palo Alto, CA: Varian Medical Systems, Inc; December 2011: 112-122 Ronde HS, and Hoffmann L. Validation of varian's AAA algorithm with focus on lung treatments. Acta Oncol. 2009; 48(2): 209-215. doi: 10.1080/02841860802287108 Robinson D. Inhomogeneity correction and the analytic anisotropic algorithm. Journal of applied Clinical Medical Physics. 2008; 9(2): 112-122