A.J.

Kressin Treatment Planning Project Accounting for Heterogeneities in Lung Cancer Treatment Plans Introduction: There have been numerous studies done over the years about the effects of accounting for tissue heterogeneities when calculating dose. Many have noted that heterogeneity corrections for lung cancer treatments are of high importance.1 Nakayama and Yoshida et al showed that when treating thoracic esophageal cancers with anterior to posterior and posterior to anterior (AP/PA) opposed beams, there was a significant difference in the volume of lung receiving low doses between plans that did account for and plans that did not account for tissue inhomogeneities. It was shown that the volume of lung receiving low doses, especially below 10 Gray (Gy), was much larger when heterogeneities were taken into account. Accuracies of modeling heterogeneities can vary from algorithm to algorithm, so the user must be aware of which algorithm their treatment planning system (TPS) uses.2,3 One must also be aware that how accurately the TPS calculates dose in the presence of inhomogeneities may also depend on field sizes and the type of inhomogeneities the radiation beam traverses.2,4,5 For this project, the Philips Pinnacle version 9.0 TPS was used. Pinnacle uses a convolution/superposition algorithm to perform dose calculations.6 This type of algorithm uses density-scaled kernels in order to model the effects of heterogeneities. The construction of these kernels is based on energy fluence along the beams central axis. Pinnacle also attempts to account for the increased amount of scatter from modifying devices when they are used in a treatment plan. The physics manual notes that Pinnacle models the effects of lateral scatter from various heterogeneities. Experimental process: A treatment plan was created for a patient with a tumor in the right lung. The gross tumor volume (GTV) and heart were contoured by the physician. The medical dosimetrist contoured the body, spinal cord, and both lungs. The TPS automatically placed the isocenter in the center of the GTV. There was no contour labeled planning target volume (PTV) so the GTV plus a margin was used for planning. Two parallel opposed 15 megavolt (MV) photon beams in the AP/PA orientation were used with a 1.5 centimeter (cm) margin around the GTV. The AP beam had a weight of 44.4% and the PA beam had a weight of 55.6%. A daily

dose of 2.5 Gy was prescribed for 18 fractions for a total of 45 Gy. The prescription was normalized to the 97.4% isodose line. The first plan (Plan 1) was computed without the use of heterogeneity corrections. A second plan (Plan 2) was made by copying Plan 1 and then computed without changing anything except for turning on the heterogeneity corrections. The two plans were compared. Second checks for monitor unit (MU) calculations were carried out for each plan using MUcheck version 8.2.0. Hand calculations for the MUs in each plan were also performed. Summary: As seen in the transverse, sagittal, and coronal views, and dose volume histograms (DVHs), dose coverage of the GTV appeared to be better with the heterogeneity corrections turned off (Figures 1-4). Note however, that the plan was initially optimized without the heterogeneity corrections turned on and no changes were made to Plan 2 once the heterogeneity corrections were turned on. The max doses for Plan1 and Plan 2 were both 5.03, but the max dose for Plan 1 was located in the anterior chest wall, while the max dose for Plan 2 was located in the posterior chest wall. In Plan 1, the TPS calculated 128.6 MUs from the AP direction and 161 MUs from the PA direction (Figures 5 and 6). For Plan 2 the TPS calculated 121.06 MUs from the AP direction and 151.6 MUs from the PA (Figures 7 and 8). MUcheck and the hand calculations performed showed agreement with the TPS calculations within 5% (Figures 9-12). One thing to notice is that Plan 2 used fewer MUs than Plan 1 to deliver a greater dose. This is due the amount of lung tissue that the AP beam must travel through to get to the tumor. And since lung tissue has a relatively low electron density, fewer MUs are needed in order to deliver the prescribed dose when heterogeneities are taken into account.4,5 Plan 1 made the assumption that the lung tissue had a density of water, and, therefore, recognized that more MUs were required due to greater attenuation of the beam by the presumed uniformal water-equivalent tissue between the patients skin surface and the tumor. This might also partially explain why there is seemingly better dose coverage of the GTV in Plan 1. With the assumption of homogeneous tissue, there is assumed to be more scatter, and hence, more dose deposited laterally and better dose coverage to the GTV. It is interesting that the TPS calculated fewer MUs in Plan 2 compared to Plan 1 for the PA beam. Since the tumor volume hugs the posterior chest wall, the PA beam does not have to travel through the vast amount of lung tissue that the AP beam does. Therefore, one might expect the

MUs in Plan 2 to be slightly higher or similar to the MUs calculated for Plan 1. One might also expect that since the beam is traversing through rib bones and a small amount of vertebrae, the MUs in Plan 2 should be higher than in Plan 1. However, the rib bones are relatively thin so the attenuation from them is probably relatively small. One of the more likely reasons for the decrease in MUs in Plan 2 is the fact that the effective depth for the PA beam is slightly smaller than the reference depth (Figure 8). When heterogeneity corrections are turned on, the TPS takes into account the effective depth, whereas under the homogeneous assumption, the reference depth is used for calculations. Another possibility is that since there is some bone present in the path of the beam and the tumor lies close on the transmission side of the bone, scatter is being accounted for. More dose is likely being delivered to the GTV with fewer MUs in the presence of scatter.

Figure 1. Isodose distribution for Plan1.

Figure 2. Isodose distribution for Plan 2.

Figure 3. DVH for Plan 1.

Figure 4. DVH for Plan 2.

Figure 5. MUs calculated by the Pinnacle TPS for the AP beam in Plan 1.

Figure 6. MUs calculated by the Pinnacle TPS for the PA beam in Plan 1.

Figure 7. MUs calculated by the Pinnacle TPS for the AP beam in Plan 2.

Figure 8. MUs calculated by the Pinnacle TPS for the PA beam in Plan 2.

Figure 9. MU calculations in MUcheck for Plan 1.

Figure 10. MU calculations in MUcheck for Plan 2.

Figure 11. Hand calculations of MUs and percent differences from TPS MUs for Plan 1.

Figure 12. Hand calculations of MUs and percent differences from TPS MUs for Plan 2.

References 1. Nakayama M, Yoshida K, Nishimura H, et al. Effect of heterogeneity correction on dosimetric parameters of radiotherapy planning for thoracic esophageal cancer. Med Dos. 2014;39(1):31-33. Published Spring 2014. Accessed February 25, 2014. 2. Suresh RB. Dose prediction accuracy of anisotropic analytical algorithm and pencil beam convolution algorithm beyond high density heterogeneity interface. J Rad Research. 2013;2(1):26-30. Published January 11, 2013. Accessed February 25, 2014. 3. Akino Y, Das IJ, Cardenes HR, and Desrosiers CM. Correlation between target volume and electron transport effects affect heterogeneity corrections in stereotactic boy radiotherapy for lung cancer. J Rad Research. 2014:1-7. Published February 11, 2014. Accessed February 25, 2014. 4. Kahn FM. In: Treatment planning II: patient, data, corrections, and setup. Pine J, Murphy J,Larkin J, eds. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010: 224-229. 5. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996: 4143. 6. Philips Medical Systems. Pinnacle Physics Reference Guide. Fitchburg, WI: Philips Medical Systems; 2009.