Kearla Bentz Treatment Planning Project 1

Introduction

The patient discussed in this lab had a tumor mass located on the anterior and lateral

aspect of the right lower lung (RLL). A plan was created to follow the guidelines of this project

using an AP and PA beam only, at the lowest energy (6MV), and with clinic-standard margins.

Two different plans were created, one with heterogeneity correction on and one with

heterogeneity correction off in the calculation model algorithm. At Billings Clinic Cancer Center

the physicists prefer that 3D plans involving tumors located in lung tissue are calculated using

Acuros. Typically, all 3D plans are calculated using AAA algorithm, but the physicists state that

Acuros demonstrates a more accurate depiction of the interaction of photon beams within lung

tissue. Therefore, for this lab there were a total of four plans created to evaluate the difference of

heterogeneity correction within both calculation models.

Heterogeneity On Acuros
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Heterogeneity On AAA

Heterogeneity Off Acuros

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Heterogeneity Off AAA

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In comparing the differences of AAA and Acuros dose calculation algorithms with

heterogeneity corrections on and off, it appears that they are fairly similar. Although, there is a

significant difference with each of the calculations with heterogeneity corrections on or off.

Heterogeneity corrections are corrections in dose calculations that account for the presence of

irradiated material other than water.1 With heterogeneity corrections off, the isodose lines appear

sharp and seem to follow a pattern of fall off from each beam without interference from different

tissue densities in the path of the beam.

When heterogeneity corrections are applied, there are areas of increased dose where the

beams enter the patient, demonstrating dose buildup at the skin surface. This is also noticeable

on the tumor itself and can be attributed to absorption and scattered photons. Additionally, in

comparing the isodose distributions of these lung plans with heterogeneity on versus off, the

dose to the posterior lung is significantly lower with heterogeneity correction on. This occurs

because there is a loss of laterally scattered electrons in lung tissue because it has a lower

electron density and fewer electrons to scatter.

Artifacts and Other Inhomogeneities

Artifacts and inhomogeneities have a major impact on treatment planning and dose

calculations as well. The treatment planning CT (TPCT) of patients with metallic implants or

dental fillings exhibit severe streaking artifacts that make delineation difficult and can

compromise dose calculation outcomes.2 Large white streaks or black holes can appear from the

metal objects in the TPCT. This can make distinguishing structures near the metal difficult. Also,

the white streaks or black holes can create inaccurate dose calculations in the treatment planning

system (TPS). The new technology, such as iMAR, used in the TPCT when a patient has a metal
Kearla Bentz Treatment Planning Project 5

implant or dental filling can help reduce the artifact. It is also helpful to contour the artifact and

assign it a HU density similar to what would be expected from adjacent tissues. This helps the

treatment planning dose calculation perform a more accurate calculation, instead of calculating

misinformation from the streak artifacts.Furthermore, anytime irradiation conditions differ from

standard beam data obtained when a flat surfaced homogenous (water) material is irradiated

corrections must be applied to produce an accurate dose distribution. If a surface is not flat or the

angle of incidence of the beam is not 90 degrees, then obliquity or contour corrections must be

applied.1

Conclusion

When calculating treatment dose, it is important to factor in the presence of

inhomogeneities that will produce changes in the dose distribution. The two effects of

inhomogeneities are changes in absorption of the primary beam along with scattered photons and

changes in the secondary electron fluence. Points beyond the inhomogeneity are affected most by

attenuation changes of the primary beam, while points near the inhomogeneity are affected most

by changes in photon scatter distribution.2

The attenuation of megavoltage beams is determined by the electron density (number of

electrons per cubic centimeter) of the medium it traverses. When a megavoltage beam passes

through low-density materials or air cavities, there is a loss of electronic equilibrium close to the

boundaries of the low-density of air. This causes the dose profile to become less sharp because

an increasing number of electrons travel outside the geometric limits of the beam. Which

additionally causes a greater loss of laterally scattered electrons and reduction in dose on the

beam axis. The dose in the lower lung density causes higher dose within and beyond the lung,

but there is also a loss of secondary electrons in the first layers of tissue beyond lung which
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causes a slight decrease in dose. Smaller fields, larger air cavities, and higher energies increase

these effects and could lead to the potential of under dosage in the periphery of the tumor.2
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References

1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy (4th ed.) Mosby;

2016.

2. Bazalova M, Beaulieu L, Palefsky S, Verhaegen F. Correction of CT artifacts and its influence

on Monte Carlo dose calculations. Med Phys. 2007;36(6):2119-2132.

https://doi.org/10.1118/1.2736777

3. Gibbons JP. Khan’s the Physics of Radiation Therapy (6th ed). Wolters Kluwer Health; 2020.