1

Todd Baumgartner
Dos 523 – Treatment Planning in Medical Dosimetry
03/23/2022
Treatment Planning Paper – Heterogeneity Correction

Introduction
After completing this assignment, a drastic change in dose distribution is observed when
utilizing dose heterogeneity correction in comparison to turning this function off. In
combination, tissue type as well as beam quality have a significant impact on dose distribution. 1
It can be concluded when comparing the two plans in figures 1-6, that the homogenous plan
contains isodose lines similar to that of a quality assurance water phantom. It also appears that
the only distortion to the homogenous isodose lines is caused by the patient’s body contour
irregularities, which could possibly be corrected with tissue compensators, however this was not
required for the purposes of this study. The test patient was chosen with a tumor close to the
center of the upper lobe of the left lung. The tumor location being within the lung and not within
the mediastinum was chosen as required by the assignment which exacerbates the effects of
heterogeneity correction in comparison to a homogenous treatment plan since a mediastinum
tumor may not possess the degree of variation in tissue densities compared to its surrounding
tissues.

Methods
The treatment planning software used for this plan comparison was Varian’s Eclipse.
There were two plans completed with an AP/PA beam arrangement, 6 MV photon energy, and
normalized so that 95% of the planned tumor volume (PTV) receives 95% of the prescription
dose of 3000 cGy divided by 10 fractions. The PTV was given 1 cm margins, congruent with the
3D conformal AP/PA standard at New York-Presbyterian Brooklyn Methodist Hospital. The
beams were weighted 52.8:47.2 for the AP and PA beams, respectively. This was done in an
attempt to keep dose distribution within the target volume as conformal as possible.

Results/Discussion
The major reason for differences between the two plans is that electron density of an
attenuating material is what ultimately determines the material’s attenuation capability. 1 Electron
 2

densities correspond with Hounsfield units, interpreted by a treatment planning software (TPS)
as specific densities.4 Bone’s electron density is higher than soft tissue, so it is a more effective
attenuator. It would then seem counterintuitive for the bone to have higher doses just before,
within, or past it in the path of a photon beam with heterogeneity correction, however this can be
seen when comparing the 110% isodose line in figures 1 and 2. This can be explained by the fact
that photon energies up to 10 MV tend to increase in dose at tissue-bone interfaces on the
entrance side of a beam from backscattering, and the forward-scattering electrons cause dose to
be higher within and past bone than in a homogenous scenario. On the other hand, the 110% and
105% isodose lines do not protrude as far into the lung on either the anterior or posterior beams
for the heterogeneous plan where there may be a loss of electronic equilibrium.1
The dose volume histograms (DVH’s) in figures 7 and 8 show that there is an appreciable
increase in dose at the PTV for the heterogeneous plan, such that 70% of the volume is receiving
100% of the prescription dose, whereas only 9% of the homogenous plan is receiving 100% of
the prescription dose. This is explained by the fact that dose inside the lung increases with the
beam’s distance into the organ. Since the homogenous plan is treating all tissues the same, there
is no buildup of dose. Instead, there appears to be constant attenuation as if the photon beam was
traversing a water phantom. Another notable difference between the two plans which can be
visualized by the isodose lines in figures 1-6 includes the drastic tapering inward of the isodose
lines in the heterogeneous plan as opposed to the more traditional shape of the homogenous plan.
This inward bowing seen with heterogeneity correction is caused by the loss of electronic
equilibrium the beam experiences as it traverses lung tissue. Electronic equilibrium exists when
the number of ionizing electrons entering a region due to photon interaction is equal to the
number of electrons leaving that same region, and in the case of lung radiotherapy there is a
significant loss of said electrons within the lung. It should also be noted that this loss of
electronic equilibrium decreases the inward lateral scatter of electrons, which makes the dose
along the beam axis lessened.1
Similar heterogeneity effects can be examined when treating other parts of the body.
Hunt et al. studied the effects of electronic equilibrium loss affecting treatments such as in
tangential breast irradiation. In their study they utilized tangential beams through a
polystyrene/cork phantom with the cork portion meant to replicate the density of lung, the field
edge in the cork, and the isocenter placed in the polystyrene portion. They compared ionization
 3

chamber readings at the cork-polystyrene interface with readings in a homogenous phantom and
found that the interface was under dosed by 5% for a 6 MV beam and 8% for an 18 MV beam.
Therefore, it was determined that the electronic equilibrium loss from the electrons and scattered
photons traveling further in the lower density inhomogeneity at the soft tissue interface cause this
discrepancy, and the discrepancy increases with increased beam energy.2 This makes it is clear
why many lung cases are treated with lower photon energies.
Other sources of radiotherapy treatment planning difficulty when dealing with
heterogeneity include metal items within a patient’s body or the introduction of contrast media.3,4
Unlike the extreme low density of the lung, high density metallic implants can affect
visualization of important structures by way of their image artifacts. This can negatively impact
dose calculations by misreading CT numbers as incorrect densities. Solutions to these scenarios
can be accommodated by the use of modern technologies such as Philips’ CT correction
algorithm O-MAR. With such an algorithm, streaking caused by metallic dentures, spinal
hardware, or prostheses can be reduced by using surrounding tissue, unaffected by the artifact to
adjust the affected area. Though currently used TPS’s will use highly-accurate
convolution/superposition (C/S) methods within their algorithms, C/S still tends to misrepresent
dose in close proximity to the metal implant/tissue interface. This is partly due to the
conventional C/S method assuming the energy kernels are a result of the secondary photons and
electrons interacting with water rather than metal.3 In regard to CT contrast during lung planning,
a TPS’s heterogeneity correction can show a 200 HU increase which could skew calculated dose.
Situations where contrast affects dose calculation can be corrected for by planning with a
contrast scan along with a non-contrast scan but using the latter for the dose calculation.4
 4

Figure 1: Axial slice of the heterogeneity plan; beam arrangements and monitor units (MU) for
the AP (top row) and PA (bottom row) beams can be seen in the table below the CT

Figure 2: Axial slice of the homogenous plan; beam arrangements and MU’s for the AP (top
row) and PA (bottom row) beams can be seen in the table below the CT
 5

Figure 3: Coronal slice of the heterogeneity plan

Figure 4: Coronal slice of the homogenous plan

 6

Figure 5: Sagittal slice of the heterogeneous plan

Figure 6: Sigittal slice of the homogenous plan

 7

Figure 7: DVH of the heterogeneous plan

Figure 8: DVH of the homogenous plan

Conclusion
When it comes to radiation treatment planning, tissue heterogeneities can be quite
problematic. In regards to planning treatments in areas of low atomic density such as the lungs
the planner is faced with electronic equilibrium issues, and in treatments involving metallic
bodily implants or contrast media, density misreading and image artifacts come about.1,2,3,4 It is
clearly to the dosimetrist’s benefit that modern software has the capability to not only correct for
heterogeneity prior to the treatment plan, but also to account for it in the TPS.3,4
 8

References
1. Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th ed. Philadelphia: Wolters Kluwer
Health; 2020
2. Hunt MA, Desobry GE, Fowble B, Coia LR. Effect of low-density lateral interfaces on soft-
tissue doses. Int J Radiat Oncol Biol Phys. 1997:37(2):457-482.
https://doi.org/10.1016/S0360-3016(96)00499-3
3. Huang JY, Followill DS, Howell RM, et al. Approaches to reducing photon dose calculation
errors near metal implants. J Med Phys. 2016:43(9):5117-5130. https://doi-
org.libweb.uwlax.edu/10.1118/1.4960632
4. Burridge NA, Rowbottom CG, Burt PA. Effect of contrast-enhanced CT scans on
heterogeneity corrected dose computations in the lung. J Appl Clin Med Phys. 2006:7(4):1-
12. https://doi.org/10.1120/jacmp.v7i4.2240