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Jenny Huang
Treatment Planning Project
April 22, 2018

Heterogeneity versus Homogeneity in Lung Treatment Planning

Introduction
Standard isodose chart assumes that human body is composed entirely of water with equal
density or homogeneous. In fact, human body is made up of different tissue with different
physical and radiological properties. Within a patient are air, lung, fat, muscle, and bone, which
attenuate and scatter the beam differently. The difference in density within these tissues alters
dose distribution when planning radiation treatment. In fact, treatment planning is increasingly
becoming conformal and thus increases the chance for missing the target because of incorrect
isodose coverage of the target.¹ To maximize the accuracy of treatment dose delivery, it is
important to correctly calculate tissue inhomogeneity. When we deliver treatment to the thoracic
region, it is very important to consider many different types of tissues and organs where the
densities change dramatically and occupies a large volume. Therefore, it is crucial to correct for
the inhomogeneity of a patient’s different types of tissue and organs. This project discusses the
dose distribution between heterogeneity and homogeneity plans on lung treatment with the
beams projected at anterior-posterior and posterior-anterior.

Methods and Materials

This patient had a lung cancer located in the hilar portion of the middle lobe of the right lung.
The measurement of the circular shaped tumor was 3.54 x 2.92 x 3.73 cm. The radiation
oncologist contoured the clinical target volume (CTV) and prescribed a total dose of 4500 cGy
for 25 fractions.
Organ at risk (OAR) structures were contoured, including the right lung, the left lung,
heart and the spinal cord. I created an internal target volume (ITV) by expanding the CTV per
physician’s order by 0.3 cm left/ right, 0.3 cm anterior/ posterior and 0.5 cm superior/ inferior to
compensate for internal physiologic movements and variations in size, shape and position of the
CTV during treatment. I also created a planning target volume (PTV) by expanding the ITV by a
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uniform margin of 0.5 to compensate for internal movements, patient movement and setup
uncertainties.
The isocenter of these treatment fields was at the center of the PTV. The calculation point
is a point dose located at the isocenter so that the depth of the calculation point were 10.53 cm
and 10.38 cm for the AP and PA beams respectively.
I placed an anterior beam. Multi-leaf collimator (MLC) were fitted with 2.0 cm margin
around the PTV to ensure proper delivery. I copied and opposed the anterior beam to create a
posterior beam. Both anterior and posterior beam had the energies of 6 MV and the beams were
equally weighted at 50% to maintain simplicity in this project. I used a Pinnacle Treatment
Planning System (TPS) and normalized both plans to 100% of the prescribe dose to be delivered
to the calculation point.

Results:
After obtaining both dataset, the results between the heterogeneity on and off were considerably
obvious. The TPS recognized that the beams penetrated to tissue and organ with different
densities. The heterogeneous plan was not distributing proper dose coverage to the PTV tumor.
Since lung was mostly air, there was a dose build-up on the anterior and posterior part of the
patient. As the beam penetrated deeper into less dense tissue such as lung, there was decreased
attenuation of the primary beam, which in turn caused to decreased production of scattered
photon. A loss of electronic equilibrium also occurred within the lung. Figure 1 was the
heterogeneous plan showing the isodose lines that are irregular, less uniform and few bulging
areas within the lung. This can be seen in the axial and sagittal scan. The homogeneous plan
showed a classic hour glass appearance that was very typical in parallel opposed beams (see
figure 2). The 4410 and 4500 cGy lines were curved smoothly toward the isocenter. Also there
were two large hot spot areas on the anterior and posterior aspects of the patient.
When evaluating the Dose Volume Histogram (DVH) for both plans, one can notice a
significant point. Figure 3 was the DVH for the heterogeneous plan in which 48% of the PTV
received 100% of the dose. On the other hand, in homogeneous plan, 51% of the PTV receives
100% of the dose (figure 4). This was expected because the TPS saw the entire volume of the
lung as one density.
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Another noticeable difference of the two plans was the dose received by the cord, the
heart and the esophagus. All of these organ at risk received higher dose in the homogeneous plan
(figure 4).
Mah K and Van Dyk J2 conducted a study on the impact of inhomogeneity corrections on
thoracic cases. Correction factors were generated with equivalent tissue-air ratio (TAR). The
authors indicated that when patients were treated with similar radiation techniques and radiation
energy, correction factors were varied. The study concluded that the anatomy, geometry and
density of the patients confirmed the need of accurate dose calculations. The authors stated that
parallel-opposed fields that encompassed the mediastinal and bilateral lung region needed
corrections at the point of absorbed dose and number could be between 5 to 16% for Co-60 and
25 MV.
The point doses between the heterogeneous and homogeneous plans of this project were
4520 cGy and 4501 cGy respectively and the difference was very small about 0.4%. This small
number could be due to the location of tumor that did not extend extensively to the mediastinum
and the left lung.
When planning a radiation therapy treatment plan with the heterogeneity correction on,
all these different tissue densities will be taken into account. The monitor units to achieve this
dose distribution was 100 anteriorly and 108 posteriorly (figure 5). For the plan with the
heterogeneity off, both anterior and posterior MUs were 114 (figure 6). It could be seen that the
homogeneous plan required more MU to deliver the same amount of dose.

Discussion
According to Khan3, there are two general types of the effects of tissue inhomogeneities, which
are the changes in primary beam absorption and the pattern of scattered photon, and the changes
in secondary electron fluence. It is very important to know where the alterations take place. If the
alterations occur beyond the inhomogeneity, the predominant effect is the attenuation of the
primary beam. Also there is a greater effect caused by the distribution of the scattered photon. If
the alterations occur within the inhomogeneity and at the boundaries, the changes in the
secondary electron fluence affects the dose distribution in tissue.
For megavoltage energies, the electron density determine the attenuation from the
Compton effect. However, in areas of reduced density such as lung, there may be a loss of
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electronic equilibrium at the boundaries.3 This loss of electronic equilibrium can be observed in
the axial and sagittal planes of the heterogeneous plan. The 4725 cGy lines were reduced
significantly at both entrance points for both anterior and posterior beams.
The reduced density of lung caused higher dose within and beyond the lung and also
higher number of electrons move outside the beam and this caused the dose profile to become
less sharp. Another consequence is the dose reduction on the beam axis that is caused by
decreased scattered electron. Figure 1 shows the lateral aspects of the isodose lines receive less
dose and the 4500 cGy line bows inward toward the central axis of the beam.

Conclusion
Before the advance of the technology, treatment plans were created assuming all tissues density
were equal or homogenous and thus created a better dose distribution. In reality, these were not
the case; human body consists of many tissue with different densities. Creating a treatment plan
without putting inhomogeneity correction results in underdosing of tumor volume and
overdosing the adjacent healthy tissues. Moreover, inhomogeneity correction would result in an
underestimation of the risk for radiological radiation pneumonitis by an average of 7% and
maximal of 19%.2
This paper discusses the importance of the inhomogeneity correction in generating a lung
treatment plan to allow us to deliver the appropriate dose to patients. All individuals involved in
the patients’ treatments need to be aware and understand the effects of inhomogeneities on dose
distribution and isodose curve.
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References:
1. Papanikolaou N, Battista JJ, Boyer AL. Tissue inhomogeneity corrections for
megavoltage photon beams. AAPM Report No. 85. August 2004.
2. Mah K, Van Dyk J. On the impact of tissue inhomogeneity corrections in clinical thoracic
radiation therapy. Int J Radiat Oncol Biol Phys. 1991;21(5):1257-67. PMID: 1938524.
Accessed April 16, 2018.
3. Khan FM, Gibbons GP. Corrections for tissue inhomogeneities. The Physics of Radiation
Therapy. 5th Ed. Lippincott Williams & Wilkins. 2014;214-221.
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Figures

Figure 1. Dose distribution with the heterogeneity on in axial, sagittal and coronal views.
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Figure 2. Dose distribution with the heterogeneity off in axial, sagittal and coronal views.
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Figure 3. The Dose Volume Histogram (DVH) for the plan with the heterogeneity on.
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Figure 4. The Dose Volume Histogram (DVH) for the plan with the heterogeneity off.
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Figure 5. The treatment plan summary with Mus for the AP beam (top) and PA beam (bottom)
with the heterogeneity correction on.
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Figure 6. The treatment plan summary with Mus for the AP beam (top) and PA beam (bottom)
with the heterogeneity correction off.