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Treatment Planning Paper

Chelsea Gehrig
University of Wisconsin- La Crosse
Dos 523 Treatment Planning
04/25/2021
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Process:
There are many tissue and density variations throughout the body that cause the dose
distribution in radiation therapy planning to drastically alter depending on the treatment site. A
correction for these heterogeneities is often used in order to develop a treatment plan reflecting
accurate dose distribution and attenuation throughout the beam. In this treatment planning
project, two treatment plans were created for a lung tumor; one excluding the use of a
heterogeneity correction and one with the correction. This lung tumor was centrally located
within the left lung and the plan included contours for the body, right lung, left lung, spinal cord,
tumor, and heart. The field arrangement was AP/PA with the lowest energy available, 6MV.
Research:
Tissue inhomogeneity in treatment planning may cause a change in the absorption of the
primary beam and scattered photons, or a change in the secondary electron fluence.1 Attenuation
of the primary beam is the predominant affect for treating lesions beyond the inhomogeneity,
whereas changes in the secondary electron fluence are mostly caused when the dose is targeted
within the homogeneity or at its boundary. A correction for tissue heterogeneities is created from
an electron density matrix derived from a CT value matrix.2 An improved algorithm accounts for
the different densities and reduces the uncertainties in absolute dose. Since lung tissue is mostly
air, it is significantly less dense than many other body tissues. If heterogeneity correction is not
used for a lung treatment plan, the target will be overdosed because the treatment planning
system will assume there is more attenuation than what actually occurs. The lower lung density
results in a higher dose delivered within and beyond the lung.1 Even though the dose distribution
in a homogenous plan may look adequate on the treatment planning system, the PTV coverage
will usually be so poor that it decreases tumor control probability.2
Air cavities are another example of a tissue variation that may cause issues in radiation
therapy treatment planning.1 There is a partial loss of electronic equilibrium at air cavity surfaces
which causes the actual dose in front of the cavity to be significantly less than expected, as well
as to the tissue beyond it. It has been proven that the most substantial decrease in dose occurs in
the smallest field size (4 x 4 cm) and when the cavity is at least 4 cm deep or greater. As the
energy of the radiation increases, the under-dosage is expected to increase.
Although most treatment plans utilize the heterogeneity correction, there are some cases
in which homogeneity is preferred. One example includes a simple AP/PA treatment plan for
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Heterotopic Ossification (HO) patients.3 These patients receive radiation therapy either within 24
hours preoperatively or within 72 hours postoperatively. Since these patients have a hip
prosthesis, a significant artifact is created from the CT scan. If we were to use the heterogeneity
correction for these plans, the dose would be forced much higher at the central axis with a lower
dose to surrounding tissue since the treatment planning system would accommodate the
difference. We do not need this variation in dose in these types of plans, therefore, we turn off
the heterogeneity correction to create a homogenous dose throughout the plan.
There are a few different correction algorithms that are utilized for heterogeneity
corrections. These include an empirical method based on the effective path length correction, an
analytical approximation for density-dependent radiation transport, and a Monte Carlo method.4
The Monte Carlo method samples all of the possible physical interactions of tissues with
radiation and has been proven to be the most precise as it most accurately reflects the tissue
heterogeneity effect.
Findings:
The first treatment plan created without the heterogeneity correction resulted in a mean
dose of 99.7% to the PTV with a maximum dose at 101.9%. The mean dose to the organs at risk
are as follows: heart- 1.5%, right lung- 0.5%, left lung- 28.8%, and spinal cord- 1.7%. The dose
distribution through mid-PTV shows the 100% isodose line creating an hourglass shape from
anterior to posterior. The monitor units needed to deliver 2 Gy/fx for 30 fractions were 135 from
the AP and 145 from the PA.
The second treatment plan that was created with the heterogeneity correction resulted in a
mean dose of 95.9% to the PTV with a maximum dose at 101.4%. The mean dose to the organs
at risk are as follows: heart- 0.8%, right lung- 0.2%, left lung- 26.4%, and spinal cord- 0.8%. The
dose distribution through mid-PTV shows a small area of the PTV covered by the 100% isodose
line centrally, with the 90% covering the majority of the PTV. The 100% and 95% isodose lines
breakup through the patient and the 90% isodose line creates an hourglass shape from anterior to
posterior. The monitor units needed to deliver 2 Gy/fx for 30 fractions were 117 from the AP and
121 from the PA.
Summary:
Since the heterogeneity correction was not used in the first plan, the treatment planning
system could not accurately accommodate for the tissue variation across the patient, resulting in
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a dose distribution that was seemingly more homogenous than the second plan. The planning
system showed the PTV was covered by 99.7% of the prescription dose, while it more accurately
received 95.9% of the dose displayed in plan 2. The monitor units were calculated to be higher in
the plan 1 because the different tissue densities were not recognized and the treatment planning
system calculated for a higher attenuation than what would actually occur. The monitor units
calculated in plan 2 were lower as they more accurately represent the dose that was attenuated by
the low-density lung tissue. This treatment planning project demonstrates the need to use a
heterogeneity correction factor when designing a radiation therapy treatment plan for certain
treatment sites since various tissue densities can significantly impact the attenuation and dose
distribution.

Plan 1 images (no heterogeneity correction):

Figure 1. Axial plane in plan 1.
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Figure 2. Frontal plane in plan 1.

Figure 3. Sagittal plane in plan 1.

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Figure 4. DVH with labels for plan 1.

Figure 5. Plan 1 report displaying the MUs per field.

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Plan 2 images (heterogeneity correction):

Figure 6. Axial plane in plan 2.

Figure 7. Frontal plane in plan 2.

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Figure 8. Sagittal plane in plan 2.

Figure 9. DVH with labels for plan 2.

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Figure 10. Plan 2 report displaying MUs per field.

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References

1. Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th Philadelphia, PA: Wolters

Kluwer Health; 2020.
2. Herman TDLF, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of tissue
heterogeneity corrections in stereotactic body radiation therapy treatment plans for lung
cancer. J Med Phys. 2010;35(3):170-173. doi:10.4103/0971-6203.62133.
3. Lee A, Maani EV, A NP. Radiation Therapy for Heterotopc Ossificaiton Prophylaxis.
October 7, 2020. PMID: 29630207. Accessed Apr 12, 2021.
4. Kang KM, Jeong BK, Choi HS, et al. Combination effects of tissue heterogeneity and
geometric targeting error in stereotactic body radiotherapy for lung cancer using
CyberKnife. J App Med Phys. 2015;16(5):193-204. doi:10.1120/jacmp.v16i5.5397.