1 Adriana Dalea DOS 523 Treatment Planning March 8, 2014 Lung Treatment Planning Project The human body

is made from tissues with different electron densities. In the radiation therapy field, it is mandatory to consider these densities in order to properly deliver the prescribed dose to a tumor, and create a good and accurate treatment plan. These tissues have different absorption characteristics; the radiation beam is attenuated when passing through the body, the various tissues have different physical and radiological properties.1 The goal in treatment planning is to deliver the prescribed dose to the target and to minimize the dose to the other tissues. Form a dosimetric point of view, in order to obtain the best outcome, we need to consider the tissues inhomogeneities. When the treated volume is not heterogeneous, there should be corrections applied. Until 1970, the radiation treatments were performed and the doses were calculated assuming that the body is entirely made of water. Later on, when the computed tomography (CT) started being utilized regularly, the tissues electron densities were determined and incorporated in the dose calculation process. The reconstruction of an image in CT is a complex mathematical algorithm that generates the CT numbers, which are related to the attenuation coefficients.2 The CT numbers have a range between -1000 for air to +1000 for bone, with water set at 0. There is a linear relationship between the CT numbers and the attenuation coefficients. For the megavoltage beams, the Compton effect is predominant, and there may be loss of electronic equilibrium close to the margins of the low-density materials or the air cavities (like in the lung). For the orthovoltage and superficial X-rays, the absorbed dose within the bone or its immediate vicinity may be substantially higher than the dose in soft tissue. This increase in energy absorption is due to the increase electron fluence from the photoelectric effect in bone. The isodose curves are changed when inhomogeneity correction is applied in a plan, and this is very well demonstrated in the treatment of the lung for example. The proximal areas could

2 be under dosed up to 30 percent, if the lung tissue is not considered in the calculation.3This depends on the beam energy, field size and the geometry of the inhomogeneity. When treating the lung, without the heterogeneity corrections applied, the plan will overdose the target because the planning system optimized the beam paths assuming more attenuation than actually occurs. There are several methods used in inhomogeneity corrections, but the most commonly used are: power law tissue air ratio (TAR) this is a TAR correction method that takes in consideration the relative location of the point of calculation with respect to the inhomogeneity, the equivalent TAR method considers the effects of heterogeneities on scatter, and also on the primary beam, here the field size and the depth are scaled to account for the presence of heterogeneities;4(Washington) the generalized Batho method is a generalized power law method to allow for dose calculations at points within the heterogeneity. This method is best suited for the beams in the high energy range, higher than 10 MV.1 In order to better understand the effect of the heterogeneity correction, I created a plan for a lung patient; the prescribed dose was 6000 cGy, with 200 cGy daily fractions, total of 30 fractions. The right lung was treated. I created two fields, anterior-posterior AP and posterioranterior PA. In the first case the plan was made without the correction. The images with the isodose lines distribution are in Figure 1. The fields weight was 46.9% for the AP and 53.1 % for the PA. For the AP field the plan calculated 110 MU/fraction, and for the PA 116 MU/fraction. The plan printout is in figure 2. The dose volume histogram is demonstrated in figure 3. The monitor unit verification was done with Rad Calc. (Figure 4). The second plan was created with the heterogeneity correction. The images with the isodose lines, the printout of the plan, DVH and the monitor unit sheet, are below, in figures 5,6,7, and 8, respectively. In the first plan, the isodose lines are more uniformly distributed than the second plan. When the plan is without the heterogeneity correction, there is a 109% hot spot in the anterior portion of the right lung, opposed to the second plan, when there is a 116.8% hotspot situated posteriorly. If we would want to make the second plan to look more like the first one, we would have first to change the beams weighting and then the normalization of the plan. For example from 100 % to the target volume, to 95%,

3 When treating the lung, we have to consider the organs included in the field that might be affected by the radiation. For the lung, the maximum tolerated dose TD5/5 or TD 50/5, 5% or 50% risk at five years are 1750 cGy or 2450 cGy for the whole lung. Over these limits there is the risk of pneumonitis. For the spinal cord, the TD5/5 is 4700 cGy for a 20 cm volume, with the risk of developing myelitis necrosis if these limits are broken.5 For these two plans the analytic anisotropic algorithm (AAA) Varian Eclipse system with Modified Batho Power Law for tissue heterogeneity was used. The MBPL method is different than the original Batho by its definition of depth. It uses the descending part of the TMR curves by adding to the depth of maximum dose.6

Hand calculations: The MU calculation formula is:

MU prescribed dose , where Cf is the calibration factor, Sc Sp TPR Cf OAF ISFxAtten. fact .

OAF the off axis factor, ISF the inverse square factor. The depths are: for the AP field 12.1 cm, for the PA field 7.9 cm. The equivalent square: 12.26. Calculations without the heterogeneity correction:
MU AP 93 .8cGy = 107 1.012 1.011 0.953 0.9cGy / MU 0.997 1

For the PA field, the couch attenuation factor is: 0.960

MU PA 106 .2cGy = 115 1.012 1.011 1.048 0.9cGy / MU 0.995 1 0.960

Calculations with the heterogeneity correction:

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MU prescribed dose Sc Sp TPR Cf OAF ISF In hom . factor 93 .8cGy = 92 1.012 1.011 0.953 0.9cGy / MU 0.997 1 1.167 106 .2cGy = 105 1.012 1.011 1.048 0.9cGy / MU 0.995 1 1.056

MU AP

MU PA

Figures

Figure 1. Isodose lines distribution without the heterogeneity correction.

Figure 2. Plan without heterogeneity correction.

Figure 3. Dose volume histogram without heterogeneity correction. (Red PTV; dark blue RT lung; pink heart; green LT lung; light blue cord).

Figure 4. Rad Calc without the heterogeneity correction.

Figure 5. Isodose lines distribution with the heterogeneity correction.

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Figure 6. Plan with heterogeneity correction.

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Figure 7. Dose volume histogram with heterogeneity correction. (Red PTV; dark blue RT lung; pink heart; green LT lung; light blue cord).

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Figure 8. Rad Calc with the heterogeneity correction.

13 References 1. Papanikolaou N, Battista JJ, Boyer AL, et al. Tissue inhomogeneity corrections for megavoltage photon beams. AAPM report no.85. American Association of Physicists in Medicine. Published August, 2004. https://www.aapm.org/pubs/reports/rpt_85.pdf. Accessed March 8, 2014. 2. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2012. 3. Bentel, G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996. 4. Washington CM, Leaver D. Principles and Practice of Radiation Therapy.3rd ed. St. Louis, MO: Mosby Elsevier; 2010. 5. Marks LB. Predicting normal tissue injury in the modern era: A Review of QUANTEC. AAPM Web site. http://www.aapm.org/meetings/amos2/pdf/59-17107-99588-657.pdf. 2014. Accessed March 8, 2014. 6. De La Fuente Herman T, Gabrish H, Ahmad S. Impact of tissue heterogeneity corrections in stereotactic body radiation therapy treatment plans for lung cancer. Journal of Medical Physics. 2010; 35(3): 170-173. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936187/.2010. Accessed March 8, 2014.