Evangelia Andrews

DOS 523: Treatment Planning in Medical Dosimetry

March 18, 2022

Heterogeneity Corrections
The human body is a spectacular phenomenon. Every single one of us are different in our
own way. From the outside there are many physical differences that we might share and differ
from one another. Identical twins are very peculiar because it’s not often we see two people that
are the exact same—at least from the outside. The differences of our internal anatomy are much
more unknown, and in day to day life it doesn’t make a difference if your lungs are larger than
your neighbors, or if your heart lies closer to your chest wall than your sisters’. However, in the
field of medicine these internal differences make a great deal of difference when providing care,
especially for the treatment of radiation therapy.

When producing a treatment plan for a patient, it is imperative to consider all the internal
differences of the body. The plan must have realistic implications of how radiation will travel
through all the different parts of the body. Thankfully, technology continues to advance so that
these differences are able to be treated with an optimal treatment planning system (TPS). The
TPS has the ability to recognize the varying densities within the body and can utilize this in the
needed calculations.

Heterogeneity corrections are used to show a more realistic turnout of radiation traveling
through the body in the TPS. The way that this can be calculated is from the Hounsfield Unit
(HU) given by the computed tomography (CT) dataset. HU gives the material of each pixel from
the CT, a value relative to water1. The values are a range of -1,000 to even greater than 3,000.
The value of -1,000 represents air, where there is little no interaction with radiation. HU of 0 is
of water, and ranges around 1,000 are most similar to bone. When the HU value is up to 3,000,
we can assume that the patient has an implant with metal in it. These numbers are crucial
information in the for the TPS as it gives information of how radiation will be affected by these
different densities in our body.1 The effects are classified into two categories: changes in the
absorption of the primary beam and the associated pattern of scattered photons and changes in
the secondary electron fluence.2
 It is very common that dosimetrists encounter a situation where a patient has certain
metallic objects or devices in the body that the radiation will come in contact with. These
devices, such as a hip prostheses or dental fillings, are made from high atomic number elements.
The high atomic number density attenuates a significant amount of dose as well as scatters the
dose.3 The appearance of metal in a CT scan is considered a “star artifact” as it resembles a star
and is also very easy to identify.4 In these cases, the dosimetrists will override the density of the
streaking and assign it a value that more closely resembles the tissue surrounding that area.

Methods/Materials

For this project, I used a CT data set of an anonymized patient that has a tumor located in
the left lung. The plan includes AP/PA fields and the structures contoured are the patient’s
external body surface, left lung, right lung, spinal cord, heart, and planning target volume (PTV).
No artifacts were present within the treatment area, therefore, no density overrides were needed
for any structures. MLCs were placed using a 1 centimeter blocking margin around the PTV of
the target. I used 6 MV energy for both fields and kept them equally weighted. The dose
prescribed is 200cGy x 30 fractions for a total dose of 60Gy, normalized to the target structure. I
created two separate plans, one calculated with heterogeneity on and the other with heterogeneity
off. The comparison of the two will show the difference between the two corrections and how
they individually affect the dose distribution.

Results

The following is the plan with heterogeneity corrections turned on:

Image 1: Axial view with heterogeneity corrections on.

Image 2: Coronal view with heterogeneity corrections on.

Image 3: Sagittal view with heterogeneity corrections on.

Image 4: MU printout with heterogeneity corrections on.

Image 5: DVH with heterogeneity corrections on.

The following is the plan with heterogeneity corrections turned off:

Image 6: Axial view with heterogeneity corrections off.

Image 7: Coronal view with heterogeneity corrections off.

Image 8: Sagittal view with heterogeneity corrections off.

Image 9: MU with heterogeneity corrections off.

Image 10: DVH with heterogeneity corrections turned off.

Image 11: DVH plan comparison with PTV structures to show the most significant structure
difference.

Discussion

With the heterogeneity corrections off, the TPS believes the entirety of the volume is
equivalent to water. Therefore, comparing the display of images and data of both plans using
the heterogeneity correction tool, it is clear to see that planning on a homogeneous body will
provide a better and more even dose distribution to the target volume. However, in reality our
internal anatomy densities are not all equivalent to water. With the heterogeneity correction
turned off, the plan does not account for the low density in the lung. A lower density causes more
electron scatter from the tumor, so in the plan with heterogeneity correction on there is a loss of
coverage laterality.1

Analyzing the data from image 11, we are able to come to the conclusion that the PTV is
well covered for both plans. In the plan with heterogeneity corrections turned on, we can see that
the dose slowly travels downward. Since lungs consists mostly of air, radiation encounters little
to no attenuation. This is why we see the dose traveling beyond that of the PTV and why the
dose is hotter with heterogeneity corrections. With the heterogeneity corrections off, the
coverage is met, and the dose dramatically falls off after reaching the desired dose to the PTV.
This would make sense considering the TPS believes the entirety of the patient is water.

Another notable difference between plans is the amount of MU. In the plan with
heterogeneity on, the AP field has 133 MU and the PA field has 155 MU. With heterogeneity
corrections turned off, the AP field has 145 and the PA field has 184 MU. This is exactly what
we would expect considering the purpose of these corrections. Since the lung is mostly made up
of air, radiation is able to travel further with less attenuation which in turn results in less required
MU.

Conclusion

Considering all of the findings from this project, it can be concluded that having
heterogeneity correction capabilities in a treatment planning system is crucial. Without this
capability, patients would not be receiving the correct dose needed to treat the heterogenous
body. With technology continuing to advance, we are able to have confidence in the amount of
radiation a patient is receiving due to more accurate calculation algorithms.
 References

1. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. St. Louis,
MO: Elsevier Mosby; 2016: 323-337
2. Gibbons, J. Khan’s The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Wolters
Kluwer Health; 2020
3. Reft C, Alecu R, Das IJ, et al. Dosimetric considerations for patients with HIP prostheses
undergoing pelvic irradiation. Report of the AAPM Radiation Therapy Committee Task
Group 63. American Association of Physicists in Medicine
(AAPM).https://aapm.onlinelibrary.wiley.com/doi/abs/10.1118/1.1565113. Published
May 30,2003. Accessed May 4, 2020.

4. Kofler J. Identifying image artifacts, their causes, and how to fix them: computed
tomography. AAPM. http://amos3.aapm.org/abstracts/pdf/115-31943-387514-118256-
734581750.pdf. Published 2016. Accessed March 27, 2022.