Heterogeneity Correction versus Homogeneity Lung Treatment Planning

Tamara Eng
March 12, 2016

1
Lung cancer is the second most common cancer and the leading cause of cancer related

deaths in the United States for both men and women alike.1 Once diagnosed with lung cancer,
there are different treatment paths depending on the type of lung cancer and the stage of the
cancer. The different treatments include: surgery, chemotherapy, radiation therapy, and targeted
therapy or the use of pharmaceuticals.1 The following discussion will focus on optimizing the
treatment option of radiation therapy. The objective of radiation therapy is to deliver radiation to
cancerous tissues while sparing normal tissues and structures.2 My analysis will explore whether
treatment planning that takes heterogeneity corrections into account is superior to traditional
homogeneity treatment planning.
Standard isodose charts, as well as, depth dose tables are created with the assumption of a
homogeneous unit density medium.3 However, the human anatomy is complex with a number of
different tissue and cavities of varying physical and radiological properties.4 On its path through
the body, a beam may travel through layers of material of different densities, such as fat, bone,
muscle, lung, and air. Depending on both the amount and type of matter present and the quality
of radiation, these tissue and structure inhomogeneities affect the dose distribution within a
patient.3,4 In regard to the lung, dose within this structure is mostly affected by its density.
Namely, lower lung density will give rise to a higher dose both within the lung itself and in the
material beyond the lung. However, the immediate layers of soft tissue beyond a lung of
sizeable thickness will exhibit a loss of secondary electrons.3 When a high-energy photon beam
traverses lung tissue, there is a loss of lateral electronic equilibrium. The lower density of the
lung causes a larger amount of electrons to travel outside the geometric limits of the beam.
Thus, the dose profile decreases in sharpness. This also results in a larger decrease in laterally
scattered electrons and thus a lessening in dose along the beam axis. This is more pronounced
for smaller field sizes and higher energies. Therefore, when treating a lung, there is the potential
to underdose the patient in the periphery of his or her tumor.3 Furthermore, according to the
American Association of Physicists in Medicine (AAPM), since treatments are continuously
becoming more conformal, the chance for geographic misses of the target volume as a result of
incorrect isodose coverage is increased.4 Thus, it is imperative to take these inhomogeneities
into account with the goal of creating the optimal treatment plan for the best patient outcome.
Before the introduction of computed tomography (CT) in the 1970s, dose distributions
largely assumed the patient consisted only of water. In other words, most clinics did not take

inhomogeneities into account in the creation of treatment plans. CT made it possible to collect
data regarding the electron density within a patient. This information could be utilized in the
dose calculation process to yield a more accurate dose, which took the heterogeneity of human
tissue into consideration.4 Today, there are conflicting views about the best practice. Some
radiation oncology clinics still create plans without taking inhomogeneities into consideration.
Other clinics take heterogeneity corrections into account when creating treatment plans for the
lung. Among the later clinics is the Minneapolis Veterans Affairs Medical Center (VAMC).
VAMC agrees that the best practice is to consider the effect of tissue inhomogeneities and uses
heterogeneity corrections. This is the centers standard operating procedure because it allows the
dosimetrists to account for the differences in attenuation of the various tissues and structures.
Not taking inhomogeneities into account, as shown above, could affect the dose distributions and
lead to deficiencies in patient treatment (Joseph Lynch, CMD, oral communication, January 26,
2016).
The effect of ignoring inhomogeneities within the patient is demonstrated below via two
palliative lung treatment plans. Both plans were created on the Pinnacle3 9.8 treatment planning
system (TPS). The first plan, Heterogeneity TE, was created using heterogeneity corrections.
The second plan, Homogeneity TE, is identical to the first plan in all aspects except that it does
not correct for inhomogeneities. In other words, the heterogeneity option in the TPS was turned
off, thus the TPS overrides the density of the patients CT. Overriding the density of a (CT) scan
means assigning the same density to all tissues and structures in the CT scan. In this case all
tissues and structures were assigned the same CT number or Hounsfield units (HUs) and thus the
same density. CT numbers or HUs are attenuation rates, which are displayed as pixels of varying
shades of grey. The HUs range from -1000 for air to +1000 for dense bone. Water is
represented as 0.5 In the second plan, the TPS viewed all structures as having the same density
with a value of 1. The plan was created for a 66 year-old male patient that presented with Stage
IV non-small cell lung cancer. The patient did not tolerate chemotherapy due to profound
thrombocytopenia. Thus, the radiation oncologist recommended palliative radiotherapy to the
left chest wall for pain control. The patient was simulated, using a Philips Brilliance Big Bore
CT scanner, in the treatment position, supine with his arms down along the sides of his body.
The physician prescribed a total dose of 2000 cGy delivered via 400 cGy per fraction to the 95%
isodose line for 5 fractions. Contoured structures included: the external or body, right lung, left

lung, spinal cord, the heart, and the gross tumor volume (GTV). Per the physician, a 2 cm auto
margin was created around the GTV via multi-leaf collimator (MLC) blocking. Both the couch
position and collimator settings were 0 degrees for all treatment fields. Two fields were used,
one anterior beam (1a) and one posterior beam (1b). Both beams utilized the lowest energy of 6
megavolts (MV). The anterior beam had a 30-degree wedge oriented with the thick end of the
wedge toward the left lateral portion of the patient. The wedge was placed to compensate for the
slope of the body. The anterior beam was weighted 49% and the posterior beam was weighted
51%. Beam weights were adjusted to achieve the lowest possible hot spot. The dose was
calculated via the Collapsed Cone Convolution Superposition algorithm.
The results of the two trials are presented below in Figures 1-6. Figures 1, 2, and 3
display data for the first trial, Heterogeneity TE. Figure 1 displays the dose distribution via
isodose curves in the transverse, sagittal, and coronal planes. Figure 2 is the dose volume
histogram (DVH). Figure 3 is the monitor unit (MU) calculation sheet. Figures 4, 5, and 6
display data for the second trial, Homogeneity TE. Figure 4 displays the dose distribution via
isodose curves in the transverse, sagittal, and coronal planes. Figure 5 is the dose volume
histogram (DVH). Figure 6 is the monitor unit (MU) calculation sheet.
The comparison of the dose distributions of the Heterogeneity TE plan (Figure 1) and
Homogeneity TE plan (Figure 4) demonstrates, with all other treatment planning parameters held
constant, creating a plan with or without heterogeneity corrections effects the TPS dose
distributions. Figure 1 and Figure 4 demonstrate the difference in dose distribution. In the
Heterogeneity TE plan, the green 95% isodose curve bows inward and misses complete coverage
of the GTV. The 95% isodose curve overlaps with the lateral border of the tumor in both the
transverse and coronal images. In this plan, the TPS took tissue inhomogeneities into account,
for example, the lower density of the lung. As mentioned above, the lower density of the lung
results in more electrons traveling outside the geometric limits of the beam, which caused the
decrease in sharpness of the dose profile.3 Furthermore, it also resulted in a greater decrease in
laterally scattered electrons, which reduced the dose along the beam axis. This all resulted in the
inward bowing of the 95% isodose curve and hence the patient would be underdosed in the left
lateral periphery of his tumor.3 In contrast, for the Homogeneity TE trial, the green 95% isodose
curve provides complete coverage of the GTV. However, the isodose curves displayed in the
Homogeneity TE plan do not represent the true dose distribution nor the true tumor coverage.

As discussed above, since the TPS views all tissues as having the same density, in this case with
a value of 1 for tissue, it does not correctly depict the actual interactions of the beams, such as
beam attenuation, as they traverse through the patient. Thus, while this plan appears to provide
complete coverage of the tumor with the 95% isodose curve, in reality the patient will receive a
lower dose than depicted as the beam will actually interact differently as it travels through tissues
of varying densities.3,4
When comparing the DVHs (Figures 3 and 6), the Heterogeneity TE plan displays a
higher maximum dose of 2346.4 cGy compared to the maximum dose of 2185.8 for the
Homogeneity TE plan. The hot spot in the heterogeneity plan was located in the anterior portion
of the patient anterior to the lung. In general, a smaller tissue thickness will be hotter, or more
specifically, it will yield a higher maximum dose. In the plan that takes inhomogeneities into
account, the TPS viewed the beams as traversing a thin thickness of tissue before it enters the
lung, which consists mostly of air and thus has a low density. This accounts for the anterior
beams contribution to the maximum dose. In contrast, since the Homogeneity TE plan did not
take inhomogeneities into account, the TPS viewed the beam traversing a thicker amount of
material with a higher density, namely a HU of 1. The increase in thickness decreased the
maximum dose. (James Schmitz, AAS, CMD, oral communication, March 1, 2016).
Furthermore, the lower lung density gives rise to a higher dose in the material beyond the lung.3
This accounts for the posterior beams contribution to the hot spot in the heterogeneity plan. The
doses to the organs at risk are different for the two plans as seen in Figures 3 and 6. The
Heterogeneity TE plan delivered lower maximum doses to the spinal cord and total lung volume
minus the GTV. The Homogeneity TE plan delivered a lower maximum dose to the heart.
However, again without accounting for the differing densities, this does not truly depict the
actual dose delivered to the organs at risk in the homogeneity plan as all tissue and structures are
viewed as having the same density. This does not take into account how the beam actually
interacts in the tissues of varying densities within the patient.
When comparing MU, the Heterogeneous TE plan utilized less MUs, 502 MUs and 268
MUs for the anterior and posterior beams respectively. In contrast, the Homogeneous TE plan
used 552 MUs and 282 MUs for the anterior and posterior beams respectively. The difference in
monitor units can be explained again by how the TPS views the tissue densities. The
heterogeneous plan takes into account the lower density of the lung. On the other hand, the

homogeneous plan views all tissues having a value of 1 HU. Thus, the TPS believes more MUs
are required for the beam to traverse the tissue in the homogeneous plan, resulting in higher
calculated MUs. (Joseph Lynch, CMD, oral communication, February 29, 2016).
When comparing the dose to the 95% isodose line, the heterogeneity plan covered 86.3%
of the GTV, compared to the homogeneity plan, which covered 100% of the GTV. Thus, the
heterogeneity plan was 14.63% cooler. This is because the heterogeneity plan took into account
the attenuation from the different tissue densities versus the homogeneity plan, which viewed all
tissues and structures as having the same density. However, while the homogeneity plan appears
to provide superior coverage, in reality if a patient were treated with the homogeneity plan, the
GTV would be underdosed. This phenomenon was demonstrated in a study conducted at the
University of Texas M.D. Anderson Cancer Center in Houston, Texas. This study compared
treatment plans that took heterogeneity corrections into account with traditional homogeneity
point-dose prescription plans for inoperable Stage I/II non-small cell lung cancer. The studys
results confirmed that the treatment planning method, which takes heterogeneity corrections into
account, provide superior planning target volume (PTV) coverage.6 While the homogeneity plan
appears to provide better coverage, it actually falsely depicts the actual coverage as explained
above due to the fact that the plan ignores heterogeneity corrections and views all tissues as
having the same density. Thus, in order to best treat the patient, heterogeneity corrections should
be taken into account to represent the true interactions within the patient and dose delivered to
the tumor.
The ultimate goal of radiation therapy is to deliver the optimal amount of radiation to the
cancerous cells while minimizing radiation to normal tissues and structures. Therefore, it is
important to take the whole picture into consideration when creating a treatment plan. More
specifically, it is imperative to take tissue inhomogeneities into account when creating a lung
treatment plan. As displayed above, these tissue inhomogeneities have an impact on how the
beam interacts in the patient and thus impact how the dose is actually distributed within the
patient.4

Figure 1. Dose distribution in the transverse, sagittal, and coronal planes for Heterogeneity TE
plan.

Figure 2. DVH for Heterogeneity TE plan.

Figure 3. Monitor unit calculation sheet for Heterogeneity TE plan.

Figure 4. Dose distribution in the transverse, sagittal, and coronal planes for Homogeneity TE
plan.

Figure 5. DVH for Homogeneity TE plan.

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Figure 6. Monitor unit calculation sheet for Homogeneity TE plan.

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References

1. Lung Cancer. Centers for Disease Control and Prevention Web site.
http://www.cdc.gov/cancer/lung/. Updated January 19, 2016. Accessed March 1, 2016.

2. Kahn F, Gerbi B. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2012.
3. Khan F, Gibbons J. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2014.
4. Tissue inhomogeneity corrections for megavoltage photon beams. AAPM Report
85. Madison, WI: Medical Physics Publishing; 2004.
https://www.aapm.org.pubs.reports/rpt_85.pdf. Accessed March 1, 2016.
5. Washington, C & Leaver, D. Principles and Practice of Radiation Therapy. 4th ed.
St. Louis, MO: Mosby Elsevier; 2015.
6. Frank S, Forster K, Stevens C, et al. Treatment planning for lung cancer: traditional
homogeneous point-dose prescription compared with heterogeneity-corrected dose-volume
prescription. Int J Radiat Oncol Biol Phys. 2003;56(50:1308-1318.
http://dx.doi.org/10.1016/S0360-3016(03)00337-7