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Carissa Rivinius
DOS 523 – Treatment Planning
March 27, 2022

Introduction
The overall goal in treatment planning is to create a plan that accurately and precisely
delivers the prescribed radiation dose to the target while sparing as much normal tissue as low as
reasonably achievable (ALARA). A patient’s treatment is dependent on the accuracy of the dose
calculation. In the earlier years the treatment planning systems calculated dose assuming all the
various body tissues were equivalent to water.1 The density of tissue has a large impact on how
radiation interacts with the patient, assuming all tissue is the same density will show a difference
in expected versus actual dose delivered to the patient. As treatment techniques and technology
has advanced, the dose calculation algorithms are increasing their complexity and improving the
accuracy of treatment delivery. In the 1970s computed tomography (CT) was introduced
allowing for patient specific electron density information to be obtained.2 This allowed for the
heterogenous tissues of the body such as soft tissue, lung, fat, bone, and muscle to be sufficiently
accounted for in the dose calculation algorithm giving a more accurate dose calculation. Metallic
implants such as dental fillings or prosthetic devices can contribute to heterogeneity as well. It is
crucial to account for the differences because the ability of a photon to interact with tissue and
deposit dose is largely dependent on the density of the tissue it passes through.

The most recent treatment planning systems allow for heterogeneity corrections to be
turned on or off. Default settings are set to use heterogeneity corrections as it is turned on for
almost all treatment planning. As margins decrease and conformity of treatment plans increase
around the target, accurate dose calculation is even more important to ensure adequate target
coverage.2 It is known that current algorithms may overestimate or underestimate dose but
utilizing heterogeneity corrections is more accurate than not applying any correction factor at
all.2 This project seeks to demonstrate heterogeneity corrections and its usefulness in accurate
dose calculations.

Methods and Materials

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For this project I selected a patient with a 2.6cm tumor in the upper lobe of the left lung.
When the simulation was performed a 4DCT scan was acquired to evaluate the respiratory
motion and the effect on the target volume. The physician contoured the target structures based
off of the average phase of the 4DCT including the internal target volume (ITV) and the planning
target volume (PTV). The following organs at risk were contoured for planning and used for
dose reporting purposes: external, spinal cord, heart, left lung, right lung, and combo lung.

I utilized the Monaco treatment planning system (TPS) at my clinical site to create two
treatment plans for comparison. Both plans used the same anonymized patient image data set
using an anterior and posterior parallel opposed beam arrangement. The prescription was set to
deliver 60Gy in 30 fractions to the isocenter which is located in the center of the PTV. The
beams were equally weighted using 6MV photons with a normalization value of 100%. The
multi-leaf collimators (MLC) were set to a 1cm margin around the PTV. There are no artifacts
present on the planning CT. The only difference between the two plans was the use of a
heterogeneity correction. Plan A has a heterogeneity correction turned on verses Plan B that has
the heterogeneity correction turned off. The purpose of this project is to analyze the dose
calculation differences when turning the heterogeneity correction off.

Results

There are several differences seen in the dose distribution when comparing Plan A, with
the heterogeneity correction to Plan B, without the heterogeneity correction. The amount of PTV
coverage by the 100% isodose line (IDL) is higher on Plan B. Plan A has 6.39% of the PTV
covered by the 100% IDL whereas Plan B has 43.6% of the PTV covered (figure 1 and figure 2).
The 95% IDL on Plan A appears to have an hourglass shape around the PTV without breaking
up within the PTV. The 6.39% of PTV coverage by the 100% IDL is located in the middle of the
soft tissue mass in plan A. The periphery of the soft tissue tumor is cooler. The 70% to 90% IDL
still appear to have an hourglass shape and bow in towards the PTV. The lower dose IDL around
25% up to70%, form more of a box shape around the PTV volume (figures 3-5). Plan B still
appears to have an hourglass shape for the 100% IDL around the PTV volume but a box shape
for the 25-95% IDL around the PTV (figures 6-8).
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The hot spots in both plans are located posterior in the soft tissue. This can be best
visualized on the axial and sagittal slices of the plan (figures 3-8). Plan A has more 105% and
110% in the plan as compared to Plan B. The maximum dose for plan A is 7105.7cGy and
7225.5cGy for plan B making Plan A around 2% hotter.

When evaluating the dose volume histogram (DVH), we can graphically visualize the
decrease in dose to most of the organs at risk (OAR) in Plan A that has the heterogeneities
accounted for. More specifically, the maximum and mean doses to most of the OARs is lower on
Plan A compared to Plan B (figures 1-2). After calculating the plans, the number of monitor units
(MU) calculated for Plan A is lower compared to Plan B (figure 9-10). Plan A has a total of
269.39MU calculated with 127.18MU delivered from the anterior beam and 142.21MU delivered
from the posterior beam. In Plan B, there was a total 284.37MU computed with 131.32MU and
153.05MU from the anterior and posterior beam respectively. The total monitor units in Plan B
were 6% higher than Plan A. This is due to Plan B needing more modulation to reach the target
as it is not accounting for the beam traversing through low density lung tissue. Please refer to
Figure 11 for an axial slice comparison and DVH of Plan A with the heterogeneity accounted for
versus Plan B where the heterogeneity is not taken into account.

Discussion

The human body is made up of numerous inhomogeneities including bone, fat, muscle,
air cavities, and sometimes high-density material such as metal protheses from a hip replacement
or dental fillings. These inhomogeneities can affect the absorption of the primary beam and
scatter as well as secondary electrons that are set in motion.3,4

Plan A, which had the heterogeneity corrections turned on resulted in decreased PTV
coverage as well as a decrease in dose to the OARs. The monitor units calculated were lower
than Plan B also. This result is from the TPS taking the heterogeneity of tissues into account.
According to Kahn3, the attenuation of a megavoltage photon beam is dependent on the electron
density of the material it is traveling through. The electron density of bone is much higher
compared to water whereas lung tissue is much lower giving you a different dose distribution. To
be specific the relative electron density of lung tissue and cortical bone are as follows, 0.25 and
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1.7.4 Lung tissue results in less attenuation of the photon beam as compared to bone. The
secondary electrons from a Compton interaction are also scattered further in low density lung
tissue and more electrons are scattered outside the field borders. There is a loss of electronic
equilibrium which can result in a reduction in dose, especially in the periphery. There is
increased penumbra due to the increase in the range of the secondary electrons.3 These effects
escalate as photon energy increases and field size decreases. As demonstrated on Plan A there is
loss of reduction in dose in the periphery of the target and increased penumbra on the beam
edges. The low dose IDL shows increased width representing greater penumbra than with Plan
B. A study done by Osei et al found that 6,10, and 18MV beams required 2.5, 3, and 3.5cm
margins in order for the 95% IDL to encompass the PTV surrounded by lung tissue.5

For Plan B the heterogeneity correction is turned off and the TPS assumed the patients
entire body density is equivalent to water. With the TPS viewing the entire volume as a
homogeneous density equivalent to water the MU is increased assuming there is more
attenuation. This is where the problem lies because the assumption of attenuation and need for an
increase in monitor units is not reality. Lung tissue in reality attenuates the beam less and the
photon beam travels further through the lung. This makes the resulting increase in MU an
unnecessary dose being delivered to the patient. With the heterogeneity correction factor turned
off in Plan B it results in the true dose being delivered to the patient to be unknown.

There are other body inhomogeneities that have a similar effect to the dose distribution
compared to this lung tumor project presented. Areas such as the trachea and sinus cavities are
also air cavities that can affect dose distribution in the head and neck region. At my clinical site
the physician will sometimes have the patient not swallow during treatment for larynx cancer to
gain a more accurate dose distribution during treatment comparable to the initial scan when the
same technique was performed and with the airway open. Another example when the dose
distribution can be affected is when treating a tangential breast case and the low density of lung
will result in an increased dose to the breast tissue beyond the lung.2 This is due to the proximity
of the breast tissue with the lung tissue.

Metal prosthetics also affect the heterogeneity of a dose distribution and requires
consideration when treatment planning. A metal prosthetic used for a hip replacement can have a
varying density depending on the manufacturer material such as titanium or stainless steel. These
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values are found by the physicist at my clinical site and accounted for in the treatment plan.
Artifacts such as streaking can be caused by a metal object on a planning CT which is caused by
beam hardening, scatter, and photon starvation.6 These artifacts can hamper ones ability to
visualize and delineate contours accurately along with misrepresenting densities. Dosimetrists
can manually contour streaking artifacts and assign a density to mimic similar surrounding
tissues. Modern CT scanners are also equipped with metal artifact reducing techniques such as
OMAR (orthopedic metal artifact reduction) which is utilized at my clinical site. Inaccurate dose
calculations would be given if heterogeneity corrections were not utilized when metal implants
or artifacts caused by the implants were present.7

Contrast agents can also influence calculating dose based on attenuation. Contrast is
utilized to better visualize structures such as the bladder and rectum interface on the CT planning
scan for pelvic radiation. Ercan et al8 reported significant dose distribution changes due to
contrast agents in postoperative volumetric modulated arc therapy (VMAT) planning for prostate
cancer. More specifically, the mean, max, and minimum dose to the PTV decreased. Therefore, it
is recommended to contour the contrast area and assign an appropriate HU value for an accurate
dose calculation.

Conclusion

This project is demonstrating the benefits of utilizing heterogeneity corrections in terms

of accurate dose calculations and patient safety. The goal of this experiment was not to create the
most conformal plan, but to quantify the effect heterogeneity corrections or lack thereof can have
on treatment calculations. With the heterogeneity correction turned off the dose to the target and
surrounding OARs is unknown and inaccurate. The dose displayed on the treatment plan would
be overdosing the patient. The Association of Physicists in Medicine Task Group 65 recognizes
the importance of heterogeneity corrections recommending correction for tissue inhomogeneity
be within 2% accuracy.2 The AAPM Task Group 65 acknowledges the fact that some algorithms
may over or underestimate corrections, but the dose calculation is still improved compared to no
heterogeneity correction at all.2
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Figure 1: Plan A- Dose volume histogram (with heterogeneity correction)

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Figure 2: Plan B- Dose volume histogram (without heterogeneity correction)

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Figure 3: Plan A- Dose distribution in the axial plane (with heterogeneity correction)

Figure 4: Plan A- Dose distribution in the sagittal plane (with heterogeneity correction)
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Figure 5: Plan A- Dose distribution in the coronal plane (with heterogeneity correction)

Figure 6: Plan B- Dose distribution in the axial plane (without heterogeneity correction)
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Figure 7: Plan B- Dose distribution in the sagittal plane (without heterogeneity correction)

Figure 8: Plan B- Dose distribution in the coronal plane (without heterogeneity correction)
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Figure 9: Plan A-Monitor units (with heterogeneity correction)

Figure 10: Plan B- Monitor units (without heterogeneity correction)

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Figure 11: Plan A(with heterogeneity correction-bottom axial picture) dvh and axial slice
comparison to Plan B (without heterogeneity correction-top axial picture) Plan A-solid line on
DVH, Plan B-dashed line on DVH

References

1. Papanikolaou N, Stathakis S. Dose-calculation algorithms in the context of inhomogeneity

corrections for high energy photon beams.  Med Phys. 2009;36(10):4765-4775.
https://doi.org/10.1118/1.3213523

2. American Association of Physicists in Medicine. AAPM Report No 85. Tissue

inhomogeneity for megavoltage photon beams.
https://www.aapm.org/pubs/reports/RPT_85.pdf. Published August 2004. Accessed
March16, 2021.
3. Gibbons JP.  Khan’s The Physics of Radiation Therapy. 6th Philadelphia, PA: Lippincott
Williams & Wilkins; 2020
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4. McDermott PN, Orton CG. The Physics and Technology of Radiation Therapy.

Madison,WI: Medical Physics Publishing; 2010.
5. Osei EK, Darko J, Mosseri A, Jezioranski J. EGSNRC Monte Carlo study of the effect of
photon energy and field margin in phantoms simulating small lung lesions. Med Phys.
2003;30(10):2706-2714. http://doi.org/10.1118/1.1607551
6. Ziemann C, Stille M, Cremers F, Buzug TM, Rades D. Improvement of dose calculation
in radiation therapy due to metal artifact correction using the augmented likelihood image
reconstruction. J Appl Clin Med Phys.
2018;19(3):227-233.http://doi.org/10.1002/acm2.12325
7. Shen ZL, Xia P, Klahr P, Djemil T. Dosimetric impact of orthopedic metal artifact reduction
(O-MAR) on spine SBRT patients. J Appl Clin Med Phys. 2015;16(5):106116.
http://doi.org/10.1120/jacmp.v16i5.5356
8. Ercan T, İğdem Ş, Alço G. The effect of bladder contrast on dose calculation in volumetric
modulated arc therapy planning in patients treated for postoperative prostate cancer. Jpn J
Radiol. 2016;34(5):376-382. http://doi.org/10.1007/s11604-016-0523-9