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The Effects of Heterogeneity Corrections on Lung Photon Plans

Bobby Waldrip

DOS 523 Treatment Planning and Calculations

University of Wisconsin-La Crosse

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I. Process

The aim of this project is to show the differences between plans utilizing tissue
heterogeneity corrections versus no heterogeneity corrections within the Raystation treatment
planning system for lung treatment. The plans utilized an anonymized computed tomography
(CT) data set and associated contours that included a body, right/left lung, spinal cord, heart, and
a tumor planning target volume (PTV). The beam angles used for this study were 2 parallel-
opposed anterior/posterior (AP) and posterior/anterior (PA) beams with 6 MV photon energy.
The isocenter of the beam was established to be the center of the PTV and a multi-leaf collimator
(MLC) margin of 1 cm was placed around the treatment target. A prescribed dose of 60 Gy total
dose (200 cGy daily dose) over the course of 30 fractions was applied because it is a standard
dose regimen seen in radiation oncology for lung tumor control. A plan was constructed utilizing
the heterogeneity correction function inherent within Raystation version 12A. Since there is no
practical way to turn the heterogeneity correction feature off in Raystation, another plan was
prepared with the body contour density changed to that of a homogenous, water-equivalent
medium, essentially negating the tissue inhomogeneity of the lung and bone located within the
treatment area. Traditionally, the means to predict actual dose to a patient was to assume the
entire patient’s body was a homogenous water medium and then calculate the dose multiplied
with a tissue heterogeneity factor.1 After calculation, each beam was weighted to achieve a more
homogenous isodose distribution throughout the treated volume for both plans.

Figure 1.

Beam weighting for the plan with heterogeneity corrections

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Figure 2.

Beam weighting for the plan without heterogeneity corrections

II. Research and Findings

One of the main differences between the 2 plans worth noting are the changes in the
isodose distributions based on inhomogeneity differences calculated with heterogeneity
correction versus no correction. The plan with the heterogeneity correction took into account the
reduction in the attenuation of the beam due to the lower density of the lung.2 This lower density
lung tissue allows secondary electrons to travel greater distances away from the central axis of
the beam, which leads to a higher dose within the lung tissue itself but a reduced dose to the
beam target.3 Another factor that should be considered when treating through lung tissue is the
fact the dose buildup region occurs on the surface, chest wall region causing the 6 MV beam to
deposit maximum dose at a depth of 1.5 cm. When the beam passes from the chest wall into the
low density lung tissue, the percentage depth dose is reduced abruptly, due to a loss of electron
equilibrium, and then the loss becomes less gradual throughout the lung tissue as compared to
water.2 Once the beam reaches the target, the density is transferred from lung to water-equivalent
and a re-buildup of the dose occurs starting at the tumor interface.2 It is because of this re-
buildup region, the periphery of the tumor volume around the target interface has a lower dose as
maximum dose with depth is reestablished.4 The beam penumbra is also increased by a factor of
2.5 compared to water at the edge of the beam between the 50% and 90% isodose lines.2 The
increase in volumetric lung dose and a decrease in the target dose are apparent when comparing
the 2 plans. Clinical goals were established for the PTV and organs at risk (OAR) volumes for
both plans to compare these differences. The plan with heterogeneity corrections exhibited a
higher volume of the left lung treated to 2000 cGy compared to the plan without heterogeneity
corrections. This further validates what researchers have found regarding a higher distribution of
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secondary electron absorption in lung material due to a greater electron path length away from
the central axis. The clinical goal set for the PTV is 95% of the volume receiving 100% of the
dose for both plans. The PTV received a considerably lower dose in the plan with the
heterogeneity correction by approximately 326 cGy when compared to the plan without.
However, do keep in mind that the plans are weighted differently to establish a more
homogenous isodose distribution across the treated volume using 2 fields. Target dose is reduced
with the heterogeneity correction primarily due to the greater secondary electron range and the
re-buildup phenomenon.3 The dose volume histogram (DVH) also reveals the same trend
between the PTV and left lung doses. The greatest volume of the PTV receiving the most dose
was seen with the plan having no heterogeneity correction while the highest volume of left lung
dose was received with the heterogeneity correction, especially on the lower end of the dose
spectrum. The right lung also received more dose from the corrected plan due to the increased
secondary electron range caused from passing through the lower lung density from the
contralateral side.

Figure 3.

Isodose distribution with heterogeneity corrections (Transverse CT).

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Figure 4.

Isodose distribution without heterogeneity corrections (Transverse CT)

Figure 5.

Isodose distribution with heterogeneity corrections (Sagittal CT)

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Figure 6.

Isodose distribution without heterogeneity corrections (Sagittal CT)

Figure 7.

Isodose distribution with heterogeneity corrections (Frontal CT)

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Figure 8.

Isodose distribution with heterogeneity corrections (Frontal CT)

Figure 9.

Clinical goals with heterogeneity corrections

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Figure 10.

Clinical goals without heterogeneity corrections

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Figure 11.

DVH with heterogeneity corrections

Figure 12.

DVH without heterogeneity corrections

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The next difference discovered during planning was the fact the total monitor units (MU)
was higher with the uncorrected treatment plan versus the corrected plan. This happens because
MU must be increased to try and get dose to the prescription point across a medium that has a
water equivalent density where lower densities are not accounted for. This can lead to a target
overdose because the planning system optimizes beam paths assuming there is more attenuation
than what occurs.1 The heterogeneity correction accounts for the lung density being lower than
that of soft tissue or water and does not need to increase the MU to try and get dose to the
prescription point. The reason for the lower PTV dose in this situation is caused by the loss of
secondary electrons in soft tissue beyond the lung volume.4 An MU calculation software
program, Radcalc, was also used to observe the MU changes because it featured an option to add
heterogeneity corrections or remove them from plan data. The MU calculation performed in
Radcalc yielded even higher results in MU differences compared to what was seen with the beam
MU information between the plans in Raystation.

Figure 13.

Beams with MU data for each field with heterogeneity corrections (Total MU=247.84)

Figure 14.

Beams with MU data for each field without heterogeneity corrections (Total MU=288.84)
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Figure 15.

AP beam with heterogeneity corrections from Radcalc

Figure 16.

AP beam without heterogeneity corrections from Radcalc

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Figure 17.

PA beam with heterogeneity corrections from Radcalc

Figure 18.

PA beam without heterogeneity corrections from Radcalc

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III. Conclusion

The effect heterogeneity corrections have on treatment plans increase dose accuracy to
the target and the OAR. The change in tissue densities across the treated volume becomes
apparent when looking at the isodose distribution, DVH, and total MU delivered. The lower
density of lung tissue allows a greater number of electrons to travel outside the geometric limits
of the beam which causes an increase in lung dose.4 However, this same phenomenon causes a
greater loss of laterally scattered electrons decreasing the dose along the beam axis.4 This also
leads to a potential underdose to the tumor because of the lack of scattered electrons contributing
dose to the site.4 There is also a decrease in dose to the periphery of the target volume due to the
re-buildup in dose that must take place beyond the volume of lung in soft tissue.2,4 A higher
number of MU must also be utilized in order to ensure dose reaches the prescription point when
no heterogeneity correction is applied. High density tissues and artifacts should also be
considered when performing plans with heterogeneity corrections. A higher density tissue, such
as bone, attenuates photons more readily than less dense tissues leading to a higher absorption of
radiation within or in the immediate vicinity surrounding it.4 Bone has a higher electron density
which means the dose will be reduced to a target beyond the bone. Metal objects cause
distortions in the Hounsfield units needed for accurate dose calculations from CT data by
producing artifacts in the form of noise or scatter.5 These artifacts produce inaccurate electron
density values in the planning software that leads to distorted dose distributions5 Density
overrides have to be performed in the TPS to correct for this and it becomes a reason why
heterogeneity corrections are not accounted for in some circumstances.
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References

1. De La Fuente Herman T, Gabrish H, Herman TS, Vlachaki MT, Ahmad S. Impact of

tissue heterogeneity corrections in stereotactic body radiation therapy treatment plans for
lung cancer. J Med Phys. 2010;35(3):170-173. doi:10.4103/0971-6203.62133.
2. Mayles P, Williams P. Megavoltage photon beams. In: Mayles P, Nahum A, Rosenwald
JC, eds. Handbook of Radiotherapy Physics. Taylor and Francis Group, LLC; 2007:463-
465.
3. Khan FZ, MM Videtic G, Kotecha R, Woody NM, Stephans KL. Cancers of the
thorax/lungs. In: Sperduto PW, Gibbons JP, eds. Khan’s Treatment Planning in
Radiation Oncology. 5Th ed. Wolters Kluwer; 2021:143.
4. Khan FZ, Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th ed. Lippincott
Williams & Wilkins; 2019.
5. 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. J Appl Med Phys. 2018;19(3):227-233.
doi:https://doi.org/10.1002/acm2.12325.