1

Landon Brown

Treatment Planning Project

April 25, 2023

Heterogeneity Correction Factor On versus Off for Lung Treatment Planning

INTRODUCTION

More times than not, when a beam passes through a patient's body it will be traveling
through multiple different tissues and organs with very different densities. This can cause a wide
array of issues with the dose absorption and distribution since the beam itself is unable to tell the
difference.1 There are two categories effected by this, changes in the primary beam and the
associated pattern of scattered photons and the changes in the secondary electron fluence.1
Luckily, modern treatment planning systems can account for this and it uses a computer
algorithm that takes into account the different densities and compositions of tissues within the
body. The resulting dose distribution map considers the different densities and compositions of
tissues within the body, providing a more accurate estimate of the dose received by the patient
during radiation therapy. This helps to ensure that the patient receives an effective and safe dose
of radiation, which can improve the success of the treatment and minimize side effects. Since I
am only in the program part time, I have not started planning patients yet, and this was my first
attempt. It did seem to help make sense of many of the concepts I have learned thus far, and I
look forward to applying these concepts in the future when I start clinicals.

PLAN PARAMETERS

The plan I chose to do was on a small (0.9 cm x 0.8 cm x 1.6 cm) tumor in the right
middle lobe of the lung. It is a stage 1A2 non-small cell adenocarcinoma. This patient’s actual
treatment plan was for a breath hold SBRT lung treatment of 5000 cGy in 5 fractions. The two
plans I created each used an AP/PA parallel opposed field with a 6 MV energy bean and a 2.0 cm
margin around the primary tumor volume (PTV). They were planned for 3000 cGy over 10
fractions with the normalization set to 100% of the dose covering 95% of the treatment volume.
Given these plans' simplistic nature, they were not a good, treatable plan, but it was interesting to
see how the heterogeneity correction impacted them.
 2

HETEROGENEITY ON

The first plan I did was with the heterogeneity correction on, as it is for all our treatment
plans at my clinic site. This plan is called “(PRACTICE W)". This plan was very hot with a max
dose of 153.7%. This hot spot was found in the posterior portion of the patient primarily from the
PA beam. At my clinic site the doctors prefer the treatment plan to be at or under 110%.
However, as I mentioned above, this is to be expected given the fact this target volume and
location was not optimal for a parallel opposed field with equal weighting. The max dose for the
PTV was 116.2%, the minimum dose was 96.8%, and the mean dose was 108.1%. The isodose
lines were fairly conformal throughout the lung but were affected when the heart and liver were
involved as seen in figures 1-3. Figure 4 shows the final DVH for this plan which I will discuss
in a section below. The AP beam used 179 MU, while the PA beam used 240 MU as seen in
figure 5.

HETEROGENEITY OFF

The second plan I did was with the heterogeneity correction off. This plan is called
“(PRACTICE WO)”. This plan was also very hot with a max dose of 160.9%. This hot spot was
found in the same spot in the patient as the previous plan. The max dose for the PTV was
102.5%, the minimum dose was 99.3%, and the mean dose was 101.1%. The isodose lines were
not as conformal as seen in figures 6-8. Figure 9 shows the final DVH for this plan which I will
also discuss in a section below. The AP beam used 168 MU, while the PA beam used 292 MU as
seen in figure 10.

COMPARISON

These plans were identical in every aspect other than the heterogeneity correction, but
that one change was enough to alter the dose distribution quite drastically. One of the most
drastic changes I noticed was the difference in isodose lines. This was to be expected due to the
treatment planning system using an entirely different algorithm for each plan. I found that the
isodose lines that were 70% or lower had very little differences in them. The noticeable changes
began around the 80% isodose line and continued to get more drastic at the higher levels. One of
the biggest differences I noticed for the plan (PRACTICE W), the isodose lines were mostly
conformal while dose is passing through the lung, but once the dose hits the heart you can see it
 3

attenuate and actually bulge out slightly. This is because the planning software recognizes the
difference in tissue density which causes more attenuation. In the same spot that the dose bulges
out on the (PRACTICE W) plan, the 100% isodose line does the opposite for plan (PRACTICE
WO) and starts to curl inwards slightly. I was initially very confused by this as I was assuming
the dose would be very conformal and uniform throughout, but then I realized that the tissue
slopes in both the AP and PA fields which causes this bend in the dose. The patient’s tissue acts
almost as a wedge. The 100% isodose line is in red and made bold on figure 11 to emphasize this
important difference.

Although the max dose was somewhat similar with the (PRACTICE WO) plan being
160.9% and the (PRACTICE W) plan being 153.7%, the actual attenuation each beam had was
significantly different. As I mentioned earlier, the doctors at my clinic prefer their patients plans
to be at or under 110%. As you can see in figure 12, the color wash dose distribution shows all
the dose that exceeds this 110% goal. The (PRACTICE W) plan’s highest isodose line to travel
completely through the lung was the 110% while plan (PRACTICE WO) had the 100% isodose
line as the highest to travel completely through the lung. This major difference is due to the
treatment planning system knowing that the (PRACTICE W) plan was going through a lower
density organ in the lung which attenuates much less of the beam while thinking that the entire
beam is going through the same higher density tissue on the (PRACTICE WO) plan causing it to
be attenuated much more. This is the main reason for the disparity in MUs for each plan’s PA
field. The PA field for (PRACTICE W) was 240 MU, which was much lower than the 292 MU
in the (PRACTICE WO) plan. (PRACTICE WO) plan’s isodose lines are very unrealistic to
what would actually happen in the patient’s body.

I found it interesting that different organs at risk (OAR) received such a different max
dose in each plan. In plan (PRACTICE W), the heart is the only OAR to receive the highest max
dose out of the two plans. It received a max dose of 112.7% while the heart only received a max
dose of 99.2% in the (PRACTICE WO) plan. This makes sense given the isodose lines being so
different around the heart on each plan. Other than the heart, the left lung, right lung, body, and
spinal cord all received the highest max dose in the (PRACTICE WO) plan. With the PTV
having better coverage and a more gradual dose fall off in the (PRACTICE W) plan. See figures
13 and table 14 for exact numbers.
 4

There have been many other studies conducted to verify that what I saw in my plans are
common findings throughout the radiation oncology world. A study done by Herman et al2,
found that by taking the heterogeneity correction factor off for an SBRT lung patient lowered the
average tumor doses by 13% for the minimum dose, 8% for the mean dose, and 6% for the max
dose. They found that using the heterogeneity correction factor was even more important for
higher doses and the more conformal the treatment is.2

My initial instinct is that these changes in dose are exacerbated by the major difference in
densities between soft tissue and the lungs. A study found in the International Journal of
Radiation Oncology found that tumors in the lung were the most impacted treatment site when
the homogeneity correction was removed, with areas like the breast and Hodgkins's disease
being less affected.3 To my surprise tumors found in the head and neck and abdomen were much
less affected even though there are still many different densities found in structures in those
respective areas.3 Homogeneity corrections are especially important when dealing with tumors in
the lungs.

OTHER FACTORS TO CONSIDER

There are many other factors to consider when treatment planning that did not factor into
these plans. Things such as a hip prosthesis or dental fillings along with other more natural
inhomogeneities like sinus cavities and breast/lung interfaces can cause changes in the dose
distribution as well. These structures also have differing densities along with high Z numbers
that need to be accounted for. Metal in the body tends to have high Z numbers which can
drastically alter dose distributions. With an increase in Z numbers there is an increase in pair
production which may reduce the proportion of Compton-scattered photons causing lots of
scatter and increasing radiation exposure.4 When it comes to metal in the treatment area there are
a few options to consider to help this issue. Many centers now use metal artifact reduction
(MAR) scans that drastically cut down on the amount of artifact on the CT image. This helps
reduce the streaking artifacts and allow the image to display a Hounsfield unit that is more
accurate. Another option is to manually assign the metal area a more accurate Hounsfield unit to
trick the planning system into ignoring it completely. Air cavities such as the sinus cavity can
cause issues as well with underdosing occurring at the proximal and distal ends of the cavities.4
This underdosing increases at higher energies.1
 5

CONCLUSION

In my opinion, heterogeneity correction in treatment planning systems is extremely

important to ensure accurate dose representation in patients. Each patient has a different body
type, cancer location, and specific needs that the treatment planning system must account for.
With the only difference in these two plans being the heterogeneity factor being removed, we
saw different OAR doses, PTV coverages, dose distributions, and even different monitor units.
The (PRACTICE WO) plan showed a very inaccurate representation of what is actually
happening in the patient and provides a great argument that homogeneity corrections are
essential for all treatment plans moving forward.

REFERENCES

1. Gibbons JP. Khan's the Physics of Radiation Therapy. Philadelphia: Wolters Kluwer; 2020.

2. Ahmad S, Herman TDL, Gabrish H, Herman T, Vlachaki M. Impact of tissue heterogeneity

corrections in stereotactic body radiation therapy treatment plans for lung cancer. Journal
of Medical Physics. 2010;35(3):170. doi:10.4103/0971-6203.62133

3. Role of inhomogeneity corrections in three-dimensional photon treatment planning.

International Journal of Radiation Oncology*Biology*Physics. 1991;21(1):59-69.
doi:10.1016/0360-3016(91)90167-3

4. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections for
megavoltage photon beams. 2004. doi:10.37206/86
 6

Figure 1. Axial view of isodose lines for the (PRACTICE W) plan.

 7

Figure 2. Coronal view of the isodose lines for plan (PRACTICE W).
 8

Figure 3. Sagittal view of the isodose lines for plan (PRACTICE W).
 9

Figure 4. The final DVH for plan (PRACTICE W).

Figure 5. The MU printout for plan (PRACTICE W).

 10

Figure 6. Axial view of the isodose line for plan (PRACTICE WO).
 11

Figure 7. Coronal view of the isodose line for plan (PRACTICE WO).
 12

Figure 8. Sagittal view of the isodose line for plan (PRACTICE WO).
 13

Figure 9 The final DVH for plan (PRACTICE WO).

Figure 10. The MU printout for plan (PRACTICE WO).

 14

Figure 11. Comparison of the 100% (bolded), 103%, and 105% isodose lines for each plan.

Figure 12. Comparison of the color wash of the dose that’s 110% and above for each plan.
 15

Figure 13. Comparison of the final DVH’s. Plan (PRACTICE W) has triangles on the line and
plan (PRACTICE WO) has squares on the line.

Structure (PRACTICE W) (PRACTICE WO)

Body 153.7% 160.9%
Left Lung 1.0% 1.6%
Heart 112.7% 99.2%
Right Lung 143% 150.3%
Spinal Cord 1.3% 3.0%
PTV 116.2% 102.5%
Table 14. Table of the OARs and PTV max doses for each plan.