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Treatment Planning Paper

Marissa Pringle
University of Wisconsin – La Crosse
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Introduction
Tumor localization and accurate dose distribution are crucial in creating quality radiation
treatment plans. It is known that the density of an object correlates to the amount of radiation that
is absorbed and scattered. The human body is a compilation of soft tissue, bones, and cavities all
having different densities, however this hasn’t always been reflected in treatment planning
systems (TPS). Up until the1970s, dose was calculated assuming patients were composed of only
water. The use of computed tomography (CT) based planning has helped better map and
demonstrate the effect of inhomogeneities within a radiation beam, transforming the way
radiation treatments are planned.1 The purpose of this paper is to demonstrate what common
inhomogeneities are and their effect on the treatment planning process.
The study of radiation physics explains how megavoltage (MV) beams are affected by
inhomogeneities in a radiation beams path. Compton scattering is the primary reaction in MV
beams, and therefore any attenuation of the beam is based off electron density, or number of
electrons per cm3.2 The lack of electron density information before CT scans meant radiation
beams were calibrated in a uniform water-like phantom.1 The human body is not homogeneous,
as there is air in the lungs or sinuses, dense bones, or metal implants. To obtain an accurate dose
calculation, changes in electron density must be accounted for.

Methods and Materials

The goal of this study was to evaluate how heterogeneity corrections affect different
aspects of treatment planning. The purpose was to calculate a basic plan with the lowest energy
available, using a patient who had a tumor in the lung. The scan used for this study was from a
lung patient that was prescribed 6000cGy in 30 fractions, receiving 200cGy per fraction. The
planning target volume (PTV) and internal target volume (ITV) were contoured and located near
the middle of the left lung. Organs at risk (OAR) contoured included the left and right lung,
heart, esophagus, spinal canal, trachea, and primary bronchus. Isocenter was set in the middle of
the PTV. Anteroposterior (AP) and posteroanterior (PA) 6MV beams were created and weighted
equally. Multileaf collimator (MLC) were added and fitted to a uniform 1cm margin around the
PTV. No normalization was applied. The plan was calculated with heterogeneity correction using
the AAA calculation model. This plan was then copied and recalculated with the heterogeneity
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correction turned off. By turning the heterogeneity correction off, the TPS assumes all tissue has
the Hounsfield Unit (HU) of 0, or equal to water.

Results
When comparing Figures 2 and 3, it is clear the plan with heterogeneity correction off
was much warmer and had a more homogenous dose distribution. The dose volume histogram
(DVH) shows that with the heterogeneity correction on, only about 6.1% of the PTV is being
covered by 100% (Figure 8). The plan with no heterogeneity correction (Figure 9) has 47% of
the PTV being covered by the 100% isodose line. We can also compare OAR doses to see how
the heterogeneity correction affected their doses. The OAR in the plan with no heterogeneity
correction received overall higher doses. For example, only .4% of the left lung received
prescription dose with the heterogeneity correction on. With the heterogeneity correction off, that
number increased to 13.5%. When looking at the lower doses, such as the V10 of the left lung,
the plan with heterogeneity on has a higher value. About 33.5% of the left lung is receiving
10Gy, whereas when the heterogeneity is turned off only 31% is getting 10Gy. All OAR follow
this trend; however, it is most pronounced in the left lung where the PTV is located (Figures 8
and 9).
We can also compare the maximum doses for each plan. The global maximum dose was
114.5% for the plan with heterogeneity correction, and 119.6% for the plan without
heterogeneity correction. As with all parallel opposed beams, the dose distribution was hourglass
shaped with increased dose at the entrance and exits of the beam, however Figures 2-7 show in
all planes that dose throughout the beams is much cooler for the plan with heterogeneity
correction. Both plans had the maximum hot spot near the entrance of the posterior beam. The
area 110% of the prescription dose is covering a much larger area in the plan with no
heterogeneity correction. As seen in Figure 3 and 7, part of the 110% isodose line extends into
the lung, whereas the plan with heterogeneity correction does not have this. The number of
monitor units (MU) also changed between plans, as Table 2 shows. The plan with no
heterogeneity correction had higher monitor units than the plan with the correction on.

Discussion
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The comparison of the two plans showed the large impact heterogeneity corrections can
have on a plan, especially in areas of inhomogeneities. With the heterogeneity correction off, the
TPS calculated dose as if the beam was only traveling through only water. Water is denser than
air, and as in Table 1 shows, it has a higher HU value. Therefore, the TPS system required more
MU to get dose to the same reference point. The increase in MU led to an overall increase in the
amount of radiation within the patient. All structures, OAR and PTV, had increased coverages for
the plan with the heterogeneity off.
As seen in Figures 5-7, the lower isodose lines such as the 500cGy are more conformal
with the heterogeneity correction off. They are less conformal with the heterogeneity on, which
is due to the electron density of the lung. The lower density of the lungs allows the electrons to
spread out further, making the beam less sharp. This loss of electronic equilibrium is seen on the
plan with the heterogeneity correction.2 This explains why the V10 of the left lung was higher for
the plan with the heterogeneity correction off.
The comparison between these two plans helps visualize that beam attenuation is affected
by the shape, size, and location of inhomogeneities. Areas that lie past an inhomogeneity are
more effected by the changes in the primary beam, often by the difference in scatter. For
example, bone, which is denser than water, attenuates part of the beam, causing dose to decrease
directly behind the bone. Isodose lines in the beam’s path shift closer to the entrance. Dose next
to the bone however is increased due to the lateral scatter of the bone. Air cavities such as the
sinuses are less dense than water. The beam is not attenuated as much. Dose is higher beyond the
air cavity, and there is no increase in lateral scatter.2 The further away a point is from the
inhomogeneity, the less it is affected by the scatter.3
There are two main ways to correct for electron density. The first is effective path length.
This method accounts for different electron densities along the path of the beam. For each
electron density that is different than water, the length of the inhomogeneity is multiplied by an
attenuation coefficient. Multiple inhomogeneities can be calculated and summed together to
come up with an equivalent path length. This type of correction is the power law and ratio of
TAR (rTAR) method. The second is the three-dimensional corrections method, which is based on
3D CT images. It takes electron density information from the 3D data set and calculates how it
changes the primary beam and scatter. This type is an example of equivalent tissue-air ratio
(ETAR) method. 1,2
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CT based planning has allowed for accurate calculations of electron densities, better
visualizing dose distribution changes within a beam as it passes through layers of fat, muscle,
bone, and air. It does this by analyzing the HU values from the CT scan. A HU is the quantitative
measurement of the radiodensity. This density is proportional to the amount of attenuation of
radiation. Table 1 shows HU values for different densities that are found within the human body.
Organs with lower densities include air and fat, whereas higher density mediums include bone
and metal.4
As stated above, higher electron densities such as bone or metal, absorb more dose when
compared to lower electron densities. The increased density means more interactions occur,
which harden the beam and cause more pronounced backscatter into the surrounding tissue. This
phenomenon is what causes streaking and artifacts on CT images.5 Figure 1 shows streaking on
the CT scan, caused by metal in the patient’s spine. The streaking can appear as areas of higher
or lower electron densities. When using CT based planning, accurately defining electron
densities is crucial to plan quality, as it affects how the TPS calculates the distribution of
radiation. New post processing software such as Siemens iterative Metal Artifact Reduction
(iMAR) helps reduce artifacts in the scan without increasing dose to the patient. 6 Contouring and
manually assigning an HU to metal implants and scatter is another way we can have accurate
electron densities in the TPS.
Lower electron densities, such as those found in the lung or sinuses, absorb less dose. The
low density of the lung allows more electrons to move outside the geometric limits of the beam.
This effect is more pronounced with higher energies and smaller field sizes.1 It also causes a less
sharp beam profile and requires the beam to go through another build up region as it reenters soft
tissue. When treating volumes in the lung, this effect can make it difficult to treat the periphery
of the tumor, and using a higher energy can result in increased volume of lung being treated. 3
Due to these effects, lower energies are usually preferred for lung plans.

Conclusion
The goal of this study was to analyze the differences in plans with and without
heterogeneity correction. As demonstrated by the values on the DVH and slices of the plan,
adjusting the heterogeneity correction setting has a major impact on the patient’s plan, and
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should be carefully applied in the clinical setting. Discussions with the physician and physicists
should be had before turning off this feature. As our technology advances, it allows us to more
accurately predict where radiation is being deposited, ensuring our patients get the best treatment
plan possible.
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References

1. Papanikolau N, Battista JJ, Boyer AL, et al. RTOG report 85 tissue inhomogeneity
corrections for megavoltage photon beams. Med Phys.2004; 1(1):1-135.
2. Mcdermott PN, Orton CG. The Physics & Technology of Radiation Therapy. Medical
Physics Publishing; 2010.
3. Gibbons JP, Khan FM. Khan’s the Physics of Radiation Therapy. Wolters Kluwer; 2014.
4. DenOtter TD, Schubert J. Hounsfield Unit. [Updated 2023 Mar 6]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK547721/
5. 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. Med Phys. 2003;30(6):1162-1182. doi:10.1118/1.1565113
6. Siemens Healthineers: iMAR. www.siemens-healthineers.com. Accessed April 28, 2024.
https://www.siemens-healthineers.com/en-us/computed-tomography/options-upgrades/
clinical-applications/imar#:~:text=iMAR%20reduces%20metal%20artifacts%20in
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Tables

Table 1. HU values of different materials commonly found in patients.

Material Hounsfield Unit
Water 0
Bone +1000
Air -1000
Fat -50

Table 2. A comparison of monitor units between plans

Field Name Heterogeneity Correction No Heterogeneity Correction
AP 117 MU 136
PA 120 MU 146
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Figures

Figure 1. Different HU values affected by scatter from hardware. As shown

above, the hardware in the patient causes a change in 183 HU.
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Figure 4. Heterogeneity correction on- coronal view.

Figure 5. Heterogeneity correction off- coronal view.

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Figure 6. Heterogeneity correction on- sagittal view.

Figure 7. Heterogeneity correction off- sagittal view.

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Figure 8. DVH of the plan with heterogeneity correction on.

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Figure 9. DVH of the plan with no heterogeneity correction.

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