Treatment Planning Project 1

Treatment Planning Project

Jose L. Olmos

University of Wisconsin- La Crosse

DOS 523- Treatment Planning in Medical Dosimetry

Spring 2024
Treatment Planning Project 2

Objective: To observe and describe the differences in a lung tumor treatment cases planned with

and without heterogeneity correction

Purpose: The desired goal when designing a treatment plan is to ensure proper dosing of our

target volume, while sparing and minimizing dose to healthy surrounding tissuess and organs at

risk. As beams of radiation penetrate the body, they usually travel through inhomogeneous

tissues on their way to the treatment site. Tissues such as fat, muscle, bone and even air, all have

different densities, which causes different beam interactions. In photon treatments, Compton

scatter is the predominant mode of interactions that contribute dose, so beams traveling through

low-density lung are attenuated less and generate less scatter, affecting overall isodose

distributions.1 Treatment planning software must also account for the heterogeneity of tissues in

order to properly model isodose distribution. This is why CT scans, whose imaging data is

comprised of Hounsfield Units (HU) and assigns theses values to the different densities of tissue,

is preferred. Treatment planning software use these units in their algorithms to accurately

represent what happens to the beam as it penetrates a patient. It is also possible to turn off the

heterogeneity correction factors within a treatment planning software assuming a homogeneous

tissue distribution throughout the body. In this project, we generate plans with and without the

heterogeneity correction factor to compare the two techniques for treatment of a lung tumor.

Methods and Materials: In this case I have a patient with a tumor of a left lung. Using Varian’s

Eclipse treatment planning software, version 16.1.2, I created two plans with an AP field along

with an opposite opposed PA field. There is 1 cm margin all the way around the target PTV.

Both beams are set to 6MV energy and are equally weighted with the isocenter placed in the

center of the PTV. The prescribed dose is 60Gy to be given in 30 fx, with 200cGy per fx. Both

plans are normalized for 100% of the dose to cover 95% of the PTV. The plan labeled
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“TrPlanProjON” (the ON plan) is calculated using Varian’s Anisotropic Analytical Algorithm

(AAA) in their software, as the default setting with heterogeneity correction turned ON, while

the “TrPlanProjOFF” (the OFF plan) is calculated with heterogeneity correction turned OFF.

Results:

Figure 1.1: Isodose distribution for TrPlanProjON: AP/PA fields with heterogeneity correction

Figure 1.2: Isodose distribution for TrPlanProjOFF: AP/PA fields without heterogeneity correction
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Figure 2.1: DVH for TrPlanProjON: AP/PA fields with heterogeneity correction

Figure 2.2: DVH for TrPlanProjOFF: AP/PA fields without heterogeneity correction

Analysis: Comparing the two plans, TrPlanProjON where we have the heterogeneity corrections

ON gives us a plan with a dose maximum of 129.6% as well as an AP beam requiring 130 MU

and a PA field requiring 138 MU. Turning OFF the heterogeneity correction as we did for
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TrPlanProjOFF nets us a plan with a dose maximum at 126.1% with an AP beam requiring 141

MU and 154 MU for the PA field. There is certainly a visual difference between both plans as

the 95% and 100% isodose lines pass through the patient much more evenly, as if it is

unobstructed, in the plan with the correction turned off. In the plan with the correction turned on,

these lines attempt to contour around the target. I believe this is due to the fact that our ON plan

is set to normalize 95% of our target with 100% of the dose, therefore the algorithm tries to

accomplish this as much as possible with the data that it is receiving at the calculation point. Our

OFF plan however, does not show this as it just assumes that the entire tissue is made up of the

exact same density material.

Another noticeable difference between the two plans is the DVH curve for the PTV. The

PTV curve drops off much more sharply in the plan with the correction turned OFF, then it does

in the plant with it ON. This may give the appearance that the plan without heterogeneity

correction would the better choice of the two. The problem is that in reality, that plan does not

accurate depict how radiation actually travels through the body. According to Gibbons, dose in

lung tissue is governed by its density, and the lower-density lung tissue gives rise to higher

doses.1 In other words, as radiation travels through the lung, it acts differently than it would

traveling through bone or muscle, as it is primarily filled with air, making it a type of tissue that

is lower in density. This is accounted for in our ON plan as it needs fewer MU in order to satisfy

the requirements, compared to our OFF plan which requires a much higher amount of MU to do

the same thing. These results match the conclusions from a study by Sinousy et al2, which

examined the use of heterogeneity correction for breast conformal radiotherapy.

Bottom line is that heterogeneity correction should be included in the planning

algorithms. The body is simply not composed of homogenous tissues with the same density, and
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planning with such assumptions will lead to inaccurate dosing of tumor volumes, as concluded

by Sinousy et al.2

AAPM TG-65 determined the need for tissue inhomogeneity correction factors and that

computed dose distributions should be within 1-2% accuracy.3 Relative doses depend on two

factors, homogenous tissue calculations and tissue inhomogeneity corrections, so both should be

within 1.4% uncertainty.3 Although the group notes that current calculation algorithms may

overestimate or underestimate inhomogeneity correction, it is still more accurate to include the

correction than not including it into the calculations.

There is, however, a circumstance where there is a common source of tissue

inhomogeneity and that is in the presence of metal objects, such as orthopedic implants, teeth

fillings, and pacemakers, in the body. AAPM TG-63 reported on the dosimetric considerations

for patients with hip prostheses undergoing pelvic radiation. 4 The presence of metals within the

body can either affect the dose delivered to the prescription point or can absorb shielding tissues

which may be sitting behind the metal. The report recommends editing electron densities for the

streak artifacts within the planning CT, since streak artifacts can cause normal tissues

surrounding the metal to appear with different densities thsn they normally would have. The

Eclipse treatment planning software allows for editing electron densities, so this would be a

scenario in which it is necessary to override the default homogeneity corrections within the

calculation algorithm. The only problem being the inability to accurately assign an electron

density value that best resembles the surrounding tissue. There is no way to know for certain

what tiny inhomogeneous tissues might lie within the normal tissue structures surrounding the

artifact. It is essentially, an educated guess at that point. To combat this, the TG-63 report

suggests beam arrangements that avoid the prosthesis, if possible.4 even without the presence of
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beams through the implant, the tissue surrounding the implant must have altered correction

factors in place to properly distribute dose to the target.

Conclusion: The body is made up of different tissue densities, so a heterogeneity correction

factor must be included into the treatment planning algorithm to more accurately calculate the

dose distribution. For lung tumor treatments when beams must travel through the low-density

lung, there is less beam attenuation and less scatter dose, which means less MU are needed to

deliver dose to the target. The presence of metal within the body from implants, fillings or any

other medical metal object, requires an additional correction for density due to the artifact streaks

they cause during the planning CT scan. The artifacts can alter the automatic density readings of

normal tissues, causing the appear with an inaccurate density. Although algorithms may over or

underestimate the scatter dose, it is more accurate to include heterogeneity correction factors to

ensure more overall accurate dosing to our target.

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References

1. Gibbons JP, Khan FM. Khan’s the Physics of Radiation Therapy. Wolters Kluwer; 2020.

2. Sinousy DM, Attalla EM, Hanafy MS, Abouelenein HS, Abdelmajeed M, & Osama

M.Dosimetric study of tissue heterogeneity correction for breast conformal

radiotherapy. Iranian Journal of Medical Physics. 2019; 16(2):179-188

3. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections

formegavoltage photon beams. AAPM Task Group 65. 2004; 65: 1-142.

4. Reft C, Alecu R, Das IJ, et al. Dosimetric considerations for patients with HIP

prosthesesundergoing pelvic irradiation. Report of the AAPM Radiation Therapy Committee

TaskGroup 63. Med Phys. 2003; 30(6): 1162-1182. https://dx.doi.org/10.1118/1.1565113