Paula Paez

Treatment Planning Paper

Heterogenity corrections in radiation treatment and planning are critical to ensure that

dose measurements and dose delivered to a patient is accurate. If heterogeneity corrections are

not done the treatment planning system assumes that each patient is made up of the same tissue

density. 1 The density of tissue will have an important impact on how radiation interacts with the

patient tissue and therefore how dose will deliver. For example, bone and dense material will

attenuate the beam more, and therefore, delivering less dose to those tissues next to it. 2 Imaging

systems such as Computed Tomography (CT) scanners can accurately measure tissue density and

display it in Hounsfield Units (HU). 2

In terms of Hounsfield units, artifact can show up on the treatment planning system with

a higher HU. It is important to contour and override the artifact as the HU is incorrect for what is

there versus what appears on the image. Artifacts can appear as both bright and dark on CT

images. Using bone window level helps differentiate between what is bone, prothesis, and

artifact. This is important because the treatment planning system bases its dose distribution and

how dose is attenuated based on what the HU value is. If the HU values are incorrect, the dose

distribution of the plan is incorrect, which can lead to organs at risk getting more dose or the

PTV not getting the appropriate coverage. To assure that the computer sees the correct density,

you have to manually input the correct electron density for the area of artifact. At my clinic a

great feature our treatment planning system has is that once the density is overridden it changes

the appearance of the artifact to match the corrected density value, which allows for a second

check to make sure the density has been overridden.

 In this class we have been asked to complete a lung plan with heterogeneity corrections

and one without heterogeneity corrections. I used the CT set of an lung case that was previously

planned. The prescription for this plan was 60 Gy delivered in 30 fractions. The plan was also

normalized so that 95% of the target received 100% of the dose. This plan was completed on

Tomotherapy Volo Ultra with energy of 6MV, both plans used PA/AP techniques. Volo Ultra

does not have a function to turn off or on heterogeneity corrections; for this paper’s purpose the

body density was turned to 1 on the homogenous plan. have attached screenshots below to

display my findings.

Plan with Heterogeneity corrections:

Axial View
Sagittal view:

Coronal View:
DVH:

Homogenous Plan:
Axial View
Sagittal View:

Coronal View:
DVH:

Here is an evaluation of both plans side by side:

Some of the differences in the plans I found was the amount of 125% present on the

surface of the patient. The homogenous plan had 115% of the dose distributed in an hourglass

shape throughout; where the plan with heterogeneity correction did not. The heterogeneity plan

had two spots of 115% anterior and posterior with a little leakage from the anterior side into the

lung. The treatment planning system had to work harder to get dose through the homogenous
plan as the system is not accounting that the beam will be traveling through areas of less dense

material such as the lung to reach the target.

Heterogeneity can also affect dose distribution and accuracy with metal artifacts such as

hip prosthesis because if the dose enters through the prosthesis, it will be attenuated by the beam

and therefore, the target will not receive the required dose. Choosing appropriate objectives in

the treatment planning system is imperative in achieving the desired dose to the target area while

limiting dose to normal tissue as much as possible.3 Using avoidance sectors such as “never” or

“exit only” on the prosthesis avoids direct radiation to enter through this sector of the

plan.3 From my experience in the clinic and using Tomotherapy, in these cases we would use

“exit only” under beam intersection for the prosthesis. The dose in these cases is not conformal

around the PTV and there is spillage of high and intermediate dose.

Body inhomogeneities can also affect dose distribution when treating other parts of the

body such as sinus cavities and breast as the beam would also be traveling through areas of low

density. Radiation beams passing through different types of tissues experience varying degrees

of attenuation or absorption.4 Lung tissue, which is less dense compared to other tissues like

muscle or bone, has a lower density and different radiation absorption characteristics. 4 When a

radiation beam encounters lung tissue, it experiences less attenuation compared to denser tissues

like bone or muscle. This means that a portion of the radiation beam passes through with less

absorption.
References:

1. Price R, Xiong W, Li J, Ma C. SU-FF-T-356: From Unit Density to Heterogeneity

Corrected Treatment Planning for Lung Cancer: A Monte Carlo-Based Dosimetric
Analysis of the Effects On Prescription Dose. Medical Physics. 2005;32(6Part12):2032-
2032. doi:https://doi.org/10.1118/1.1998085

2. Khan, FM. The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2019.

3. 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. Journal of Applied Clinical Medical Physics. 2018;19(3):227-233.
doi:https://doi.org/10.1002/acm2.12325

4. M. Zabihzadeh, Ghahremani Z, S.M. Hoseini, Shahbazian H, M. Hoseini Ghahfarokhi.

Effect of lung inhomogeneity on dose distribution during radiotherapy of patient with
lung cancer. 2020;18(3):579-586. doi:https://doi.org/10.18869/acadpub.ijrr.18.3.579