‭Treatment Planning Lab/Paper‬

‭The patient that was selected had a lung tumor that was located in the center of the left‬

‭lung and the surrounding structures that were contoured were the left and right lungs, spinal‬

‭cord, and heart. The treatment plan was created with an AP/PA arrangement and the beam‬

‭weighting was equal for both plans. A 6MV beam was selected for the plan as well as a 1 cm‬

‭margin around the Planning Target Volume (PTV) for both beams. The plans were normalized to‬

‭isocenter which were placed in the center of the target volume. The 100% line is represented by‬

‭the yellow line, the 95% line is the green and the 90% line is the blue.‬

‭Figure 1 - Axial view with heterogeneity correction on‬

‭Figure 2 - Coronal view with heterogeneity correction on‬
‭Figure 3 - Sagittal view with heterogeneity correction on‬

‭Figure 4 - DVH of plan with heterogeneity correction on‬

‭Figure 5 - Dose values for each structure for plan with heterogeneity correction on‬

‭Figure 6 - Plan parameters for plan with heterogeneity correction on‬

‭Figure 7 - Axial view with heterogeneity correction off‬
‭Figure 8 - Coronal view with heterogeneity correction off‬
‭Figure 9 - Sagittal view with heterogeneity correction off‬
‭Figure 10 - DVH of plan with heterogeneity correction off‬

‭Figure 11 - Dose values for each structure for plan with heterogeneity correction off‬

‭Figure 12 - Plan parameters for plan with heterogeneity correction off‬

‭When treating/planning lung treatments, there are many aspects to consider for the plan.‬

‭One of the biggest differences between lung planning versus any other type of planning‬

‭throughout the body is the tissue density. While the Hounsfield Unit value of muscle is around‬

‭40 and water is around 0, lung has a value of around -800. This means that the dose distribution‬

‭will be much different through this area of the body as compared to the rest of the body. The‬

‭lower density that a lung has, the higher the dose will be in and through the rest of the lung.‬‭1‬

‭As shown in figures above for my patient, the monitor units and the hot spot are greater for the‬

‭plan that has the heterogeneity turned off. This goes to show that when the density is less, the‬

‭dose in and throughout the area is higher.‬

‭Since lungs are a structure that is very low density, there are other problems that can arise‬

‭in treatment planning. One of these problems is the energy selection that is used to treat the‬

‭tumor. Since the tumor is oftentimes located deep in the lung, the thought would be to use a‬

‭higher energy beam. However, the higher the beam energy when treating through a low density‬

‭material like lung, the more lateral electron scatter one will have.‬‭1‬‭Therefore, the plans that were‬

‭created above both used the lowest energy that available for the treatment plan. The lateral‬

‭electron scatter also plays a big role when there is a change in heterogeneity. In the first plan‬

‭when the heterogeneity is on, the dose distribution builds up in an odd way with the 100% line‬
‭covering the body upon entrance. The dose then scatters a bit more with the low density material‬

‭and then builds back up when it hits the tumor. In the other plan when the heterogeneity was‬

‭turned off, the isodose lines have no problem staying consistent through the patient as well as‬

‭having more lateral scatter.‬

‭One major aspect between the two plans is the difference in the body inhomogeneities. In‬

‭the first plan when the heterogeneity is on, the beam first has to travel through soft tissue and‬

‭some bone and then has to traverse through the lung tissue. When the heterogeneity is off in the‬

‭second plan, there is no difference to how the beam is traversing between any of the tissue. This‬

‭difference in body inhomogeneity plays a huge role in how the dose will actually get to the target‬

‭volume and how the beam will be absorbed throughout the tissue.‬‭1‬ ‭This is also one of the two‬

‭categories that can be an effect of tissue inhomogeneities. The other being the secondary electron‬

‭fluence changes. As shown between the two plans, the monitor units are a bit higher for the plan‬

‭that has the heterogeneity turned off. Since there is no difference in the tissue the beam is‬

‭traveling though, there will be an overestimation of the amount of dose the tumor is actually‬

‭getting. The same thing can be said for when higher energy beams are used. The increase in‬

‭energy causes more lateral scatter which also causes more dose and a lower amount of coverage‬

‭to the actual tumor.‬‭2‬ ‭The difference in body inhomogeneities‬‭can also cause complications to the‬

‭surrounding tissue. If the value of the tissue is not correct, then the surrounding tissue could be‬

‭getting more dose than it will actually be given.‬

‭Dose accuracy is an important aspect of any treatment plan. One of the biggest‬

‭differences in heterogeneity in general is when metal artifact is in the path of the beam. Metal‬

‭artifact is usually set to an electron density of around 1.8 which is similar to the density of bone.‬‭3‬

‭This is a much higher electron density than soft tissue which means that it needs to be accounted‬
‭for when creating a treatment plan. The monitor units can change in a plan by up to 3MU for‬

‭each fraction that the metal artifact is not corrected for.‬‭3‬ ‭This means that the patient could be‬

‭receiving more dose than what was actually prescribed. The same idea can be applied to lungs.‬

‭The electron density is much lower than soft tissue and can cause a big difference in the dose‬

‭distribution. If the heterogeneity is turned off, the beam has only one electron density to travel‬

‭through versus the multiple densities it travels through when the heterogeneity is turned on. This‬

‭can cause a change in the monitor units that are used as well as the total dose that the patient is‬

‭receiving.‬

‭This same principle can also be applied to when there is metal streaking from a prosthetic‬

‭or other metal object within the body. Metal streaking can cause the scanner to pick up a higher‬

‭density in an area than what is actually there. This is oftentimes corrected to a general value that‬

‭resembles the tissue around it. This can also be related to the two different plans above. There are‬

‭times that the lung is corrected or overridden because there could be a change in density or to‬

‭make the dose to the area more accurate to what it will actually be.‬

‭When it comes to planning lungs, I do not correct for any difference in tissue densities.‬

‭When the heterogeneity correction is turned on, it gives a more accurate plan as well as an‬

‭accurate representation of how the dose adds up for the other structures. The differences in the‬

‭two plans above show how important it is to make sure all tissue densities are correct. Having the‬

‭correct monitor units to make sure the dose is what is expected is vital as well as ensuring that‬

‭the coverage on the tumor is what is expected. All in all, heterogeneity correction is important‬

‭regardless of where the target volume is, but it is especially important when it comes to lung‬

‭planning due to the vast differences in tissue densities.‬

‭References‬

‭1.‬ ‭Khan FM, Gibbons JP.‬‭Khan’s the Physics of Radiation‬‭Therapy.‬‭5th ed. Philadelphia,‬

‭PA:Wolters Kluwer; 2014.‬

‭2.‬ ‭Wang L, Yorke E, Desobry G, et al. Dosimetric advantage of using 6 MV over 15 MV‬

‭photons in conformal therapy of lung cancer: Monte Carlo studies in patient geometries. J‬

‭Appl Clin Med Phys.2002;3(1):51-59. doi: 10.1120/jacmp.v3i1.2592‬

‭3.‬ ‭Banaee N, Barough MS, Asgari S, Hosseinzadeh E, Salimi E. Evaluating the effects of‬

‭metal artifacts on dose distribution of the pelvic region.‬‭J Cancer Res Ther‬‭.‬

‭2021;17(2):450-454. doi:10.4103/jcrt.JCRT_786_19‬