Alex Kehren

DOS 523-501
Treatment Planning Lab/Paper

Introduction
As treatment planning continues to get more complex, dose calculation algorithms need
to continue to be developed to better display the dose distribution in treatment media. Treatment
plans are created using CT scans and with the addition of tissue heterogeneity correction factors,
we can better estimate what the radiation dose will do traveling through high- and low-density
tissues. To better understand these factors used in the algorithms, we were assigned this case
study which will compare dose distributions between identical lung plans which were calculated
with the heterogeneity corrections turned on and then turned off.

Research
In this case study where the Compton effect is the predominant interaction mechanism
due to the energy of the beam, the attenuation is determined by the electron density of the
material.1 As a result, an effective depth is used to calculate how the beam penetrates through
materials that are not equivalent to water.1 However, near boundaries or interfaces, the
distribution of the beam becomes more complex. 1 Tissues beyond lower density heterogeneities,
such as an air cavity or lung, receive a greater dose because of the reduced absorption of the lung
tissue.2 This case study should help provide us with an opportunity to see how this correction
factor changes the dose distribution first hand.
Treatment planning systems use Hounsfield Units (HU) to measure density, and these
HU’s are calculated from the simulation CT scan. Air is measured to be approximately -1000,
water is approximately 0, and bone is approximately 1000 depending on bone type and the
energy of the CT scanner.1 The HU’s are used by the calculation algorithm to reflect what the
dose distribution will look like in heterogeneous tissues. By removing the HU’s from the
equation, the treatment planning software will be forced to act as if the tissue was homogenous
and therefore produce a less accurate dose distribution.
There are instances where the HU’s given by the CT scanner are inaccurate. If the patient
has metal hardware in the scan, whether in the oral cavity from dental fillings or a hip prosthesis,
the CT image will contain scatter and appear grainy.3 This can be seen on Figures 12 and 13
below. The grainy image will not provide accurate HU’s for tissues near the hardware. This is
due to the metal attenuating a lot of the radiation, and very little radiation reaching the image
Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

detector. Also, if the patient received oral contrast to better distinguish the bowel from other soft
tissue, dosimetrists will need to override the HU of the contrast and change it back to 0 HU.
Because the patient won’t be receiving oral contrast daily for treatment, the HU of the contrast
on the planning image needs to be overridden to better reflect an accurate dose distribution.

Process
I used anonymized patient data for a case involving a left-sided lung tumor. The
treatment plan was set up using two fields: one anterior-posterior (AP) field with a 0-degree
gantry rotation and one posterior-anterior (PA) field using a 180-degree gantry rotation. Both
fields were weighted 0.500 using 6 MeV energies. Multileaf Collimators (MLC) with a 1.0 cm
margin directed at the isocenter in the center of the Planning Treatment Volume (PTV) were
used. It was planned with a prescription of 200 cGy per fraction for 30 fractions totaling 6000
cGy to the PTV. After the initial setup, I copied and pasted Plan 1 and removed the
heterogeneity correction factor for Plan 2. Both plans were normalized so that the 100% isodose
line covered 95% of the treatment volume and calculated using the Analytical Anisotropic
Algorithm (AAA) calculation algorithm. This ensured that both plans were as similar as possible
to minimize variables outside of the heterogeneity correction factor. Organs At Risk (OAR)
structures contoured included the left and right lungs, spinal cord, and heart. Both plans were
evaluated based on their dose-volume histograms (DVH), isodose lines, and monitor units (MU).

Findings and Discussion

The Monitor Units (MU) for Plan 1 totaled 266 MU with 131 MU of those coming from
the AP field, and 135 MU coming from the PA field. The MU for Plan 2 totaled 291 MU with
140 MU coming from the AP field, and 151 MU coming from the PA field. When comparing the
total MU from both plans, Plan 2 with the heterogeneity correction factor turned off required
approximately 10% more MU. This is mostly likely due to the amount of air that the beam
travels through to get to the targeted volume, and only Plan 1 took that air into account. Without
the heterogeneity correction factor, the treatment planning system didn’t recognize the changes
in electron density in the lung that leads to less beam attenuation. Plan 2 assumed that the lung
was equivalent to water and consequently increased the MU to get coverage to the target.
Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

When comparing the isodose lines, Plan 2 had isodose lines that were hourglass shaped
and uniformly stepped down as they approached the PTV. Plan 1 gave us an irregular hourglass
shape that widened near the treatment volume. Plan 1 also had an increased amount of 105%
posteriorly in the patient’s body which was likely due to the increase in bone and soft tissue
located in the path of the PA beam. Plan 1 also gave us a global hotspot of 128.6% compared to
123.7% from Plan 2. This increased global hotspot is due to the added attenuation from the bone
and soft tissue in the path of the PA beam and was located near the dmax.
The hotspot in the PTV from Plan 1 was 113.5% compared to 105.3% from Plan 2. Plan
1 had a lot harder time getting the coverage due to the lack of electron density in the lung. As
high-energy photons pass through lower density lung tissue, there is a loss of secondary
electrons.1 This means that fewer electrons are available to deposit energy in the target. After the
beam gets to the soft tissue of the target, there is a second build up region. 1 Because Plan 1 had
to consider and deal with those complexities, the final plan had an increased hotspot in the PTV.
By comparing the 100% isodose lines, Plan 1 struggled to put dose laterally at the
periphery of the target volume. On the other hand, plan 2 easily distributed dose uniformly. The
complexities of delivering dose to the PTV in Plan 1 was also evident with the amount of 105%
in the target volume. Plan 1 ended up with 73.7% of the PTV with 105% prescription compared
to plan 2 with only 0.68%. This can also be seen on Figure 5 below. The PTV has a long tail
which, in contrast, isn’t present on Figure 10. The overall doses to the heart, right lung, and
spinal cord were all very similar between the two plans.

Conclusion
The results from this comparison lead to the conclusion that the heterogeneity correction
factor significantly affects the final plan. When quickly glancing between both plans, Plan 2
without the correction factor looked far better and more homogenous than Plan 1, but the dose
distribution was inaccurate. What the plan looked like and what would be delivered during
treatment would have differed greatly. Delivering dose into a lung target is extremely complex,
and the correction factor is needed to best visualize dose distribution to the target and measure
risk to OAR. Neglecting the heterogeneity correction factor can lead to suboptimal plans and
increased risk to our patients.
Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

References

1. Gibbons JP. Khan's the physics of radiation therapy. 6th ed. Walter Kluwer
Health; 2020.
2. Washington CM, Leaver D. Electron beams in radiation therapy. St. Louis, MO:
Mosby Elsevier; 2010.
3. Gjesteby L, Man BD, et al. Metal artifact reduction in CT: where are we after
four decades? IEEE. 2016; 4:2169-3536.
https://doi.org/10.1109/ACCESS.2016.2608621
Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

Figure 1: Plan 1 axial isodose lines.

Figure 2: Plan 1 coronal isodose lines

Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

Figure 3: Plan 1 sagittal isodose lines

Figure 4: Plan 1 MU’s

Figure 5: Plan 1 DVH

Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

Figure 6: Plan 2 axial isodose lines.

Figure 7: Plan 2 coronal isodose lines

Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

Figure 8: Plan 2 sagittal isodose lines

Figure 9: Plan 2 MU’s

Figure 10: Plan 2 DVH

Alex Kehren
DOS 523-501
Treatment Planning Lab/Paper

Figure 11: Comparing the dose distribution in color wash for Plan 1 on the left to Plan 2 on the
right. Note the differences laterally in the target volume.

Figure 12: Notice the high-density material streaking laterally away from the posterior teeth.
This does not accurately represent the soft tissue in that area and would require additional
imaging and/or the contouring of a new structure that will have an overridden HU for the soft
tissue misrepresented by the artifact.

Figure 13: This is a grainy image due to hardware in the patient’s femur. Notice that there are
black spots lateral to the bone that appear very dark. This is due to the metal artifact and not an
accurate representation of the soft tissue in that area.