1

Jackie Palermino
Treatment Planning
April 20, 2018

Heterogeneity versus Homogeneity in Treatment Planning

Introduction: Tissue inhomogeneities can significantly affect dose distribution within a patient
and should be considered during the treatment planning process. When a radiation beam passes
through a patient, it interacts with tissues of different densities such as fat, muscle, bone, and air.
Tissues of lower density, such as the lung, give rise to higher doses within and beyond the lung
because the radiation from the primary beam is attenuated less than in comparison to tissues of
higher density.1 As a result, this causes isodose lines to shift deeper within the patient, whereas
with higher density tissues, isodose lines shift towards the area of heterogeneity.

During treatment planning, it is important to correct for tissue inhomogeneities because

they can influence the absorption of the primary beam, the patterns of scatter, and the secondary
electron fluence.2 Historically, heterogeneity corrections were not taken into consideration during
treatment planning and isodose distributions were calculated based on the assumption that the
patient was composed entirely of water.3 Today, modern treatment planning systems (TPS) have
the capability of performing heterogeneous corrections using algorithms to account for the
differences in tissue densities for dose calculations. The objective of this project is to evaluate
how heterogeneity corrections play a role in radiation treatment planning and how the dose
distribution is altered with and without correcting for tissue densities in the treatment planning of
a lung tumor.

Methods and Materials: To compare the dose distribution with and without the use of
heterogeneity corrections, two treatment plans using the same parameters were evaluated. A
virtual simulation was initially completed for a patient with squamous cell carcinoma of the right
upper lobe of the lung. The patient was positioned supine with her arms above her head in an
alpha cradle. A planning CT scan was performed to help define the volume of interest and
nearby critical structures for treatment planning. The planning CT scan was imported into a
Pinnacle3 14.0 TPS where the gross tumor volume (GTV), planning target volume (PTV), and
any organ at risk (OAR) was contoured by the radiation oncologist and medical dosimetrist. The
GTV contour encompassed the demonstrable extent and location of the tumor and the PTV
 2

contour consisted of an additional 1.0 cm margin around the GTV to account for setup error.2
The OARs contoured included the spinal cord, heart, and the right and left lungs.

For treatment planning, the isocenter was placed in the center of the PTV and a 1.5 cm
margin was placed around the PTV using multi-leaf collimators (MLC). The prescription was
specified for the patient to receive 30 Gy at 3 Gy per fraction for a total of 10 fractions. Plan
normalization was set to 100% at isocenter and an anteroposterior (AP) and posteroanterior (PA)
beam arrangement with equal beam weighting was used for treatment planning. Two separate
plans were generated using the same CT data set. The first plan was calculated with a
heterogeneous correction and the second plan was calculated with a homogeneous correction.
Both plans were evaluated and compared.

Results: Between the two plans, there were notable differences in dose distribution. In the
heterogenous plan, the isodose lines showed a non-uniform distribution, forming an hour glass
shape with higher doses being deposited closer to the anterior and posterior surfaces of the
patient (Figure 1). In contrast, the homogeneous plan, produced a more uniform and conformal
dose distribution (Figure 2). Along with differences in the isodose distribution, the number of
monitor units required for treatment delivery were evaluated. In reviewing each plan, there was a
10.4% increase in the MU calculation for the homogeneous plan. The treatment plan summaries,
shown in Figure 3 and 4, demonstrate the total number of MUs required to deliver 30 Gy to the
PTV. The total MUs needed for the homogeneous plan was 390.4 versus 353.6 for the
heterogeneous plan. A final analysis was completed using a DVH to compare the percentage of
the PTV volume receiving the prescribed dose of 30 Gy and the total OAR dose for each
structure within both plans (Figure 5). A DVH was used for evaluation because it graphically
summarizes 3-dimensional (3D) dose data into single curves for regions of interest and can be
compared with other plans.4 In reviewing the DVH for each plan, the homogeneous plan showed
14.61% of the PTV volume receiving the prescribed dose of 30 Gy, whereas in the
heterogeneous plan 0.46% of the PTV volume received 30 Gy (Figure 6 and 7). At 28.5 Gy,
there was a significant increase in PTV coverage with the homogeneous plan, with 100% of the
PTV volume receiving 95% of the prescribed dose. In contrast, the heterogeneous plan increased
slightly with 29.32% of the PTV volume receiving 95% of the prescribed dose at 28.5 Gy. In
evaluation of the OARs, the homogenous plan showed higher maximum dosages for all
 3

structures except the heart. The cord, right lung, and left lung showed an increase in maximum
dose by 35%, 0.6%, and 39% respectively. The heterogeneous plan showed a 2.2% increase in
maximum dose to the heart.

Discussion: This project demonstrates the importance of heterogeneity corrections in treatment

planning and how isodose distributions are altered when treating near tissue interfaces of varying
densities. A comparison between the homogeneous and heterogenous plans was performed using
isodose distribution curves, total monitor units (MU) needed for treatment delivery, and dose-
volume histograms (DVH). In the heterogenous plan, the isodose lines showed a non-uniform
distribution, forming an hour glass shape with a lower dose being delivered to the tumor volume
than in the homogeneous plan. This effect is due to the changes in the attenuation of the primary
beam as well as scattering characteristscs.1 In the heterogeneous plan, the differences in tissue
densities were accounted for and a loss of lateral electronic equilibrium caused the isodose lines
to bow inward towards the middle of the patient. This results in a dose reduction near the beam
edge. In the homogeneous plan, the TPS assumes that all tissues have the same unit density of
1.0 g/cm3. However, this is not accurate when treating through the lung because the lung tissue is
seen as having a higher density than it actually has. In reality, lung tissue has a lower density
than that of soft tissue and can vary from 0.25 to 1.0 g/cm3 depending on the amount of air that is
in the lung.1 Due to the assumption of higher density in the lung tissue, the homogenous plan
shows an increase in scatter dose throughout the patient, allowing for better dose distribution
(Figures 8-10). Although the homogeneous plan provides better coverage of the PTV due to the
increase in scatter dose, it is not a true representation of what happens when a radiation beam
passes through a patient.

Previous studies have been performed evaluating dose calculation algorithms and the
significant impact tissue heterogeneity can have on dose distribution. A study by Chaikh et al,5
measured the differences in dose computations with and without heterogeneity corrections for
planning target volumes and OARs. This study compared 3 treatment plans using different
methods of dose calculation algorithms: pencil beam convolution (PBC) method without
heterogeneity correction, Modified Batho method (PBC-MB) with heterogeneity correction, and
PBC-MB method using the same monitor units as the PBC algorithm without correction. Chaikh
at el explained that the PBC-MB method is not an accurate calculation method for tissue
 4

heterogeneity because it does not take into account the changes in lateral electron transport,
causing an impact on the PTV and normal lung tissue. The results of the study showed an
increase in MUs for the PBC plan without the use of a heterogeneity correction. Within this
study, the authors state that the difference in MUs depends on the site location, PTV volume, and
field size. As seen in this project when evaluating the two plans, the homogeneous plan required
more MUs to get the prescribed dose to isocenter. This is due to the location of the tumor and the
presence of a uniform density. The need for an increase in MUs is partly due to some attenuation
of the primary beam within the higher density tissues. The TPS assumes that the radiation beam
is passing through a homogeneous medium of higher density rather than through the lung of
lesser density. In the heterogeneous plan with the density correction used for treatment planning,
the lower tissue density of the lung is accounted for, requiring less MUs to get the correct dose to
isocenter.

Other studies have been performed to evaluate the effect heterogeneity corrections have
on target volumes and OARs. The study by Herman et al,6 compared stereotactic body radiation
therapy (SBRT) lung plans with and without heterogeneity corrections using the pencil beam
convolution (PBC) dose calculation algorithm. All plans were evaluated keeping the identical
beam arrangements, field fluences, and monitor units. The results showed lower average
minimum, mean, and maximum tumor doses for the non-corrected plan. Unfortunately, this
study does not justify what really happens within a patient receiving radiation treatments.
Without the correction for the difference in tissue density, the dose distribution produced is not
necessarily an accurate measurement of the received dose.

Conclusion: The primary goal of radiation therapy is to deliver the optimal amount of radiation
to the area of concern while minimizing dose to the surrounding normal tissues. When creating
treatment plans, it is important to understand how different tissues can affect dose distribution
within the patient. With advancements in treatment planning, there are several inhomogeneity
correction algorithms used for planning. By using these algorithms, tissue inhomogeneities
located within the path of the radiation beam can be accounted for to accurately calculate the
dose being delivered to target volumes and surrounding tissues. This project has shown that the
inhomogeneity of the tissues within the path of the beam can have a significant impact on dose
distribution and therefore should always be taken into consideration for treatment planning. It is
 5

important to correct for these areas to ensure accurate coverage of the target volume and dose
distribution within the patient.
 6

References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
2. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott, Williams, and Wilkins; 2014.
3. Papanikolaou N, Battista JJ, Boyer AL, et al. TG-85: Tissue inhomogeneity corrections
for megavoltage photon beams. American Association of Physicists in Medicine.
https://www.aapm.org/pubs/reports/RPT_85.pdf. 2004. Accessed April 16, 2018.
4. Prado KL, Starkschall G, Mohan R. Three-dimensional conformal radiation therapy. In:
Khan FM, Gerbi BJ, eds. Treatment Planning in Radiation Oncology. 3rd ed.
Philadelphia, PA: Lippincott, Williams, and Wilkins; 2012: 169-200.
5. Chaikh A, Giraud J, Balosso J. A method to quantify and assess the dosimetric and
clinical impact resulting from the heterogeneity correction in radiotherapy for lung
cancer. Int J Cancer Ther Oncol. 2014;2(1):020110.
http://dx.doi.org/10.14319/ijcto.0201.10.
6. Herman T, Gabrish H, Herman TS, et al. Impact of tissue heterogeneity corrections in
stereotactic body radiation therapy treatment plans for lung cancer. J Med Phys.
2010;35(3):170-173. https://doi.org/10.4103/0971-6203.62133.
 7

Figures

Figure 1. Transverse, sagittal, and coronal views of isodose distribution at isocenter derived
from the heterogenous plan. The color-washed purple structure is the PTV, and the thick green
isodose line is the prescription dose of 30 Gy.

Figure 2. Transverse, sagittal, and coronal views of isodose distribution at isocenter derived
from the homogeneous plan. The color-washed purple structure is the PTV, and the thick green
isodose line is the prescription dose of 30 Gy.
 8

Figure 3. MU calculation for heterogenous plan.

Figure 4. MU calculation for homogeneous plan.

 9

Figure 5. DVH comparison for heterogeneous plan and homogeneous plan. The PTV and organs
at risk are displayed. The heterogeneous plan is represented as the solid line and the
homogeneous plan is represented as the dashed line.
 10

Figure 6. DVH for heterogeneous plan with specified maximum dose of 30 Gy. The PTV and
organs at risk are displayed. The arrow shows the percentage of the PTV volume receiving 30
Gy.
 11

Figure 7. DVH for homogeneous plan with specified maximum dose of 30 Gy. The PTV and
organs at risk are displayed. The arrow shows the percentage of the PTV volume receiving 30
Gy.
 12

Figure 8. Transverse view of isodose distribution at isocenter comparing PTV coverage between
the heterogenous plan (on the left) and the homogeneous plan (on the right). The color-washed
purple structure is the PTV, and the thick green isodose line is the prescription dose of 30 Gy.

Figure 9. Sagittal view of isodose distribution at isocenter comparing PTV coverage between the
heterogenous plan (on the left) and the homogeneous plan (on the right).
 13

Figure 10. Coronal view of isodose distribution at isocenter comparing PTV coverage between
the heterogenous plan (on the left) and the homogeneous plan (on the right).