DOS 523-501Treatment and Planning

Lung Lab
Kristen Eberhard

I. Lab Prep
This project involves planning a lung tumor case with heterogeneity correction and without
heterogeneity correction. You will need to understand how this affects planning and the pros and
cons of using this technique. Do you ever change the density of any area of the lung when
planning? Why or why not? Feel free to discuss this with your classmates in the general
discussion forum.

Guide:
1. Tumor must be in the lung and not in the mediastinum.
2. Contours required: patient, right lung, left lung, spinal cord, tumor, heart
3. Beams used for plan: anterior and posterior. This is not to meant to obtain a good plan, it is
solely for the purpose of seeing the effect of heterogeneity corrections within the lung.
4. Energy: lowest energy possible (preferably 6MV)
5. Margins: use what the physician would use for planning; or 2 cm auto margin.
6. Print out: axial, sagittal, and coronal (all should be through the tumor level); MU printout;
DVH
7. Do one plan with the heterogeneity on and then the same with heterogeneity off
8. Compare both plans and present your findings in addition to the additional research and
reading you have done. You need to demonstrate that you know how this affects planning, you
understand the principles in Khan, and you have done additional research. You should include
how heterogeneity affects dose accuracy with metal artifacts such as hip prosthesis or dental
fillings. You should also comment on how body inhomogeneities such as sinus cavities and
breast/lung interfaces can the affect dose. Finally, be sure to include dose inaccuracies that may
be present such as metal streaking and other contrast artifacts. Your paper should demonstrate
how you have learned and researched while also able to connect to the plan printouts which
display the principles learned.
9. Additional research should include two to three additional sources in addition to Khan. Your
works cited section should include Khan.
10. Your paper is required to be in AMA format.
11. See the rubric provided for how your paper will be graded. Content should include your
process, research, findings, and summary. Be able to connect with your plan printouts. I
want to see that your overall understanding of the technique is demonstrated and that you
know.

I have prepared two plans according to the instructions given. One plan consists of heterogenous

tissues, and the second plan has the heterogeneity turned off; therefore, the treatment planning

system (TPS) reads the tissues as homogenous densities. Both plans use a 6 MV beam with an

AP/PA, Parallel-Opposed, beam arrangement, with a 2 cm margin around the target volume.

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Kristen Eberhard

II. Lab Findings

The different densities between the lung and soft tissue create an hourglass shaped field in both

lung plans, however, with heterogeneity it is seen with a greater effect. This is shown in Figure

1.

Figure 1. Hourglass shaped field for both the heterogenous (Left) and homogenous (Right) plans.

Using Parallel Opposed beams (POP) is advantageous because it is a highly reproducible setup

that is a more laxed setup compared to other methods. This is due to the divergence of the beams

overlapping meaning there can be a minor deviation in the daily setup without worry of a

geometric miss of the target; and faster treatment times are produced with its simplicity. Another

advantage is that a POP arrangement will deliver a homogenous dose to the tumor. This

technique is best suited for the treatment of midline structures. A uniform dose of +/- 5-10 % is

given to a very large volume from Dmax on the entrance of the AP beam all the way to the

Dmax on the entrance of the PA. An important key to remember is that the field size must be

large enough to cover the entire target volume laterally. 1

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As the lung, and other air cavities, consists of lower densities because they are made of air, in the

homogeneity plan, a loss of both electronic equilibrium and dose build-up occurs. Electronic

equilibrium, caused by photon interactions, happens when the number of electrons leaving an

area is equal to the number of electrons entering the area. Because there are less electrons to set

in motion in air compared to higher density materials, there is a loss of electronic equilibrium.

The disequilibrium causes increased penumbra which makes the dose profiles less sharp because

the photon can spread beyond the treatment field. Also, greater penumbra is caused by higher

energy beams. Going a step farther, if a field size at or under 5x5 cm2 is defined for the lung

treatment, electronic equilibrium can also be lost on the central axis which decreases the depth

dose drastically.2,3 When treating within an air cavity, such as the nasal cavity, the loss of

electronic equilibrium occurs at the cavity surface. This can cause lower doses to the tissues

beyond the air cavity.1

When considering the depth of tumor, the loss of electronic equilibrium also causes a buildup

dose at the depth of the tumor, especially when the electronic equilibrium is reestablished. The

restored equilibrium happens after the photons travel through the air-filled lung and interact with

higher density tissues. If the beam energy is increased, more forward moving photons are

produced, causing an underdosing of the target volume along the peripherals due to the reduction

in lateral scattering. Also, because the depth in the tumor at which equilibrium is reestablished is

greater for high energy photons, in comparison to lower energies, the target will be underdosed.

To correct this, a lung tumor would need larger treatment margins, giving more dose to normal

tissues unnecessarily. Therefore, it is better to use lower energy photons compared to higher

energies when planning near air cavities, such as the lung or sinus cavities.1,2,3

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Looking at both the heterogenous and homogenous plans, the heterogeneous plan will be the

more accurate plan, dosimetrically, although less conformal. This is because when using

heterogeneity, it accounts for all the true variations in tissue densities. A more dosimetrically

accurate plan can, therefore, be developed. The hotspot shown is in CT axial slice in the midline

anteriorly in the soft tissue because the patient’s chest slopes downward towards the neck. Thus,

the separation of the body is smaller superiorly, so the dose received to underlying structures

increases. The isodose lines, tumor coverage, and hotspot of the more accurate heterogenous plan

is shown in Figure 2.

Figure 2. Target is underdosed in the peripherals due to lack of lateral scattering and electronic
disequilibrium in the lung with a 6MV beam with heterogeneity turned on, giving more accurate
dosimetric information.
When turning off the heterogeneity and creating a homogenous patient model within the TPS, all

tissue values are changed to the same density (usually “0” representing water) which is not a true

representation of the patient anatomy. The dose is more conformal in the homogeneity plan

because the TPS assumes that there is dense tissue (more electrons present), lateral scatter, and

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electronic equilibrium. This is shown in Figure 3. To keep the most accurate information, for the

most dosimetrically accurate calculations, the density of the lung is never changed to

homogeneity for planning purposes.

Figure 3. Homogenous calculated dose with override of the TPS.

Also, because air is less dense, and unchanged in density, the heterogeneity plan has accurately

calculated less Monitor Units (MU) required for dose delivery. The AP field requires 113 MU,

while the PA requires 126 MU. When overriding the TPS, and creating a homogenous patient,

the TPS calculates that it will need to deliver more MU to deliver higher dose through the denser

tissues that the TPS now recognizes. The homogenous plan calculated a requirement of 143 MU

for the AP field, and 133 MU for the PA beam. This will overdose the patient and could cause

radiation induced toxicity and unnecessary dose to normal tissues and critical organs. These

results can be seen in the calculation of the Monitor Units in the TPS when comparing plans. The

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heterogenous calculated MU from Eclipse is shown in Figure 4. The homogenous calculation is

shown in Figure 5. The plan MU printouts can be found at the end of this paper, as references.

Figure 4. Axial, Sagittal, Coronal views of the heterogenous plan coverage with MU calculations.

Figure 5. Axial, Sagittal, Coronal views of the Homogenous plan coverage and MU calculation

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To calculate dosimetric accuracy, the TPS must have accurate data input into the system. During

machine calibration, a water phantom is used with a 10 x 10 cm2 field size, 100SSD, and

measurements are taken with an ion chamber or diode measurements from the linear accelerator

(LINAC). All equipment used is calibrated at a national level by a recognized Accredited

Dosimetric Calibration Lab (ADCL) and the equipment is used by a qualified Medical Physicist.

Calibration protocols are set by The American Association of Medical Physics (AAPM) TG-51

report. Once the measurements are taken, the physicist inputs the information into

the TPS using algorithms, allowing the calculation of dose to the target and critical structures.

To verify all the new information at commissioning or machine reset, another check is

performed. Using an electrometer and an A19 ion chamber, which is a Farmer’s Type, absolute

dose and Energy checks are completed. Manual measurements of the room temperature and

pressure must be taken. The A19 ion chamber, with a graphite tip, is placed inside a phantom

cavity and connected to wiring leading to the outside of the room. The wiring allows an

electrometer to attach the A19 chamber for real time measurements. The LINAC is beamed on,

and the electrometer supplies 300V to the ion chamber and the electrometer also collects the

charge. Readings from the electrometer are in nanocoulomb’s and nanoamperes. The machine is

then calibrated to deliver 1 cGy per 1 MU.

To maintain accuracy, daily Quality Assurance (QA) is tested by the radiation therapists before

starting patient treatments and using different methods. An SSD and ODI check are performed

using a Front Pointer Assay. This device consists of a mounting frame with a metal pointer with

100 cm etched in the pointer. The mounting unit is placed in the treatment head and the pointer

is then placed inside the mount. The treatment couch is brought up to the pointer and a read of

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the ODI should be at 100 cm and the pointer should match. This must be no greater or less than a

2 mm difference.

Field size must also be checked daily by using an Isocentric Beam Checker II (IBC II). Lines are

engraved into the board, representing different field sizes. Tungsten is placed in the center of the

field, and at all corners to allow sharp image on the verification films.4 This difference should be

no greater or less than 1 mm.

To check isocenter, a Winston Lutz test is performed. When the LINAC is used in SRT and SRS

treatments isocenter is critical. The therapist uses the On-Board Imaging (OBI) in the LINAC to

image a small sphere locked in place on the treatment couch and lined up to the room lasers,

marking the set isocenter. The sphere is then irradiated at different angles of the gantry and the

couch. Using manufacturer software, the image is checked to create shifts. The differences

should be less than 1 mm to avoid dose errors when treatment is delivered.5 The drawback of this

test is that it cannot accurately give feedback of the dose delivered.6 Due to the high dose being

delivered per treatment, the risks of SRS and SRT is severe. Other methods must be used to

check the delivered dose.

After dosimetry creates a patient’s IMRT/VMAT/SBRT treatment plan, an ArcCheck is

performed before the patient’s first treatment. ArcCheck was designed to identify errors in

rotational delivery. This test will give the absolute dose being delivered to the patient. It

monitors all angles of the plan, and the entrance/exit dose to be delivered in those angles. It is

verifying that the dose is not too hot or too cold in the given treatment parameters. It also uses

has an electrometer, working in Real-Time, to gather this information.8

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For IMRT/VMAT/CBCT and other image guided treatments, a Machine Performance Check, or

MPC test, is also required every day. This test checks multiple equipment functions, such as: the

collimator, MLC’s, treatment couch, Port films, and isocenter. The support devices being tested,

in turn monitors the beams output, uniformity, and isocenter against baselines created in

software.7 Testing these functions evaluates the geometric accuracy as shifts are often

incorporated into the daily treatment for tumor localization accuracy. A phantom is used by

locking into a specific bracket on the treatment couch. It is then irradiated with kV beams for

imaging and MV beams for treatment. As the beams are on, information is automatically

transferred to manufacturer software to guarantee accuracy.7

A multi-use QA3 board is also used daily by the therapists. This board uses both sealed ion

chambers and diode detectors, totaling 25 detectors, without the use of bolus/buildup

material. This no longer requires manual readings of the room temperature and pressure because

it is automatically corrected for by the QA3. This device is used for multiple beam quality

checks using predetermined information set by the physicist. The five beam checks it can

perform are: output, flatness, symmetry, field size, and energy. It can be used with Flattening

Filters in place or Flattening Filter Free (FFF).9

Monthly checks involve an IC Profiler. It can also be used when problems occur. Using the

Profiler on top of a 2.0 cm water equivalent phantom (to allow for detection of the backscatter

contributing dose), placed in the gradient field light, the beam is tested in real time for all

energies at 100 cm SSD. Beam symmetry, horn difference, and flatness is tested along with

output.10

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For the patient data in the TPS, DICOM, or DICOM-RT, images must be used for the CT

simulation 3D images. Sometimes images from different modalities are fused with the CT Sim

images, allowing for better tumor visualization and localization. For instance, MRI will be used

for brain tumors due to its ability for the user to better visualize soft tissues and delineate tumor

volumes. A CT must always be used in conjunction with the other modality.11

CT is the modality of choice for treatment planning because the data collected produces

Hounsfield Units (HU) which helps calculate the given dose to the irradiated tissues. It also has

the most spatial accuracy. Lastly, digitally reconstructed radiographs (DRR) can be produced

with the CT image data set. The HU’s are important because it gives accurate radiologic

information regarding electron density and the stopping power of electrons of the body tissues.

For these reasons, CT is the gold standard for images used in creating treatment plans. However,

when imaging areas where metal artifacts are present, the HU’s and densities will be drastically

affected by the scatter produced on the Xray based images. Scatter is produced when the

electrons react with the patient through Compton interactions. The interaction causes the

electron’s path to be changed and the electron then reacts with the detector in undesirable ways.

The best electron path is to directly hit the detector, but instead high amounts of scatter is

produced causing noise. Noise is the random dark or light thin streaking throughout the images.

The streaking can obscure anatomy such as soft tissue and hide diagnostic information or

produce incorrect HU data.12

When there are artifacts made of high Z materials, such as a titanium prosthetic hip or a dental

implant, the beam is affected. High Z materials attenuate low energy photons, increasing the

average beam energy. This effect is known as beam hardening. Beam hardening creates flashes

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Kristen Eberhard

of high absorption at the artifact. Consequently, creating unreliability in the treatment plan

calculation. In these circumstances, it is appropriate to change the heterogeneity to homogeneity

to gain accurate dose calculations. At St. Luke’s Cancer Center, the tissue value is changed

when appropriate, to zero, which represents the HU of water. It should also be noted that during

planning, the beams are directed (when possible) in ways that do not treat through the High Z

prosthetic to avoid beam hardening, scatter, and overriding the TPS.12

Another method to correct the scatter and streaking, is by using software to reduce the scatter.

Although, the software created, called Metal Artifact Reduction, does not clean up the scatter

entirely, it is very helpful in reducing streaking caused by the unwanted scatter. Hence, when

scatter is still present, it is important that dosimetrists contour the scatter outside of the prosthesis

or implant and override the HU to zero when planning allowing the calculation to be more

accurate. The true tissue density within the scatter cannot effectively be determined so zero is

used, again, to represent water.

The results of irradiating tissues in the patient can be seen in the Dose Volume Histogram

(DVH). The DVH gives the dosimetrist, and oncology team, depth dose data, dose to the target

and critical structures, and are represented by the volume, in percentages, the dose received by

the organ. The DVH is critical in analyzing the treatment plan, or comparing plans to see which

would deliver the best dose to the PTV while maintaining the constraints to normal tissues. The

X Axis in the DVH represents the absolute dose delivered in centi-gray; while the Y Axis

represents the organ’s volume of tissue irradiated in percentages. Other data can be monitored

through the DVH, such as the minimum, maximum, modal, and mean doses, along with the

acceptable standard deviations. Although, the dosimetrist can determine if an organ is receiving

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too high or low of a dose (known as a hotspot and cold spot respectively) by reviewing the DVH,

the DVH cannot pinpoint where the over coverage or lack of coverage is located. The

comparison DVH of the heterogenous and homogenous plans is shown in Figure 6.

Figure 6. Comparison Dose Volume Histogram of the heterogenous and homogenous plans to allow
the most optimal plan to be selected for the most optimal treatment delivery.

Therefore, it is best to visualize and inspect the individual CT slices with dose applied. This

visualization allows the treatment team to evaluate the dose and coverage, slice by slice, to create

the best possible treatment plan.

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III. Conclusion

There are many working parts to a radiation oncology team. From medical physics, radiation

oncologists, radiation therapists, dosimetrists, nurses, social workers, to dieticians; all play a

critical role in keeping the patient healthy and/or comfortable during radiation treatments.

As a dosimetrist, one must understand how the LINAC and radiation produced will effect a

patients well-being. This encompasses a broad spectrum such as how the radiation is produced,

its interactions with the patient, how radiation is monitored, and understanding the principles of

radiation effects. Equally, a dosimetrist must also know the TPS concepts of dose calculation,

image registration, and how to utilize the tools within the software to create the most effective

and normal tissue sparing radiation treatment plans.

When evaluating dosimetric radiation plans, there are many factors that need to be accounted for

such as tumor location, the dose delivered to all structures of the body, and how the dose is

determined and maintained. A collaborative agreement on a beneficial and effective plan

between the team present at the treatment planning process helps provide the best overall patient

care.

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References:

1. Khan FM, Gibbons JP. Khan’s Physics of Radiation Therapy. 6th edition. Wolters Kluwer
Health. 2020:187-262.

2. Pitfalls in the Use of High Energy X Rays to Treat Tumors in the Lung. Ekstrand,
Kenneth E. and Barnes, Walter H. Int J Radiation Oncology &al Phys., Vol. 18, pp. 249-
252: January 1990, Volume 18, Number 1.

3. The influence of lateral electronic disequilibrium on the radiation treatment planning for
lung cancer irradiation. Fu, Weihua and Dai, Jianrong. The influence of lateral electronic
disequilibrium on the radiation treatment planning for lung cancer irradiation
(researchgate.net)Links to an external site. Researchgate. February 2004; 14(1): 123-6.
Accessed March 18, 2023.

4. Isocentric Beam Checker, PermaDoc, MultiDoc™, Reinstein Phantoms.

https://www.micknuclear.com/home/products/quality_assurance_tools/ . Accessed
09/28/2022.

5. Off-Isocenter Winston-Lutz Test for Stereotactic Radiosurgery/Stereotactic Body

Radiotherapy.
https://www.scirp.org/journal/paperinformation.aspx?paperid=66783#:~:text=The%20
Winston%2DLutz%20test%2C%20originally,linear%20accelerator%2Dbased%20SRS%20
system. Accessed 09/28/2022.

6. A closer look at the conventional Winston-Lutz test: Analysis in terms of dose.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6651855/ . Accessed 09/28/2022.

7. Evaluation of the truebeam machine performance check (MPC) geometric checks for daily
IGRTgeometricaccuracyqualityassurance.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5689847/. Accessed 09/28/2022.

8. ArcCHECK® - Sun Nuclear. https://www.sunnuclear.com/products/arccheck. Accessed

09/28/2022.

9. Daily QA™ 3 - Sun Nuclear. https://www.sunnuclear.com/products/daily-qa-3. Accessed

09/28/2022.

10. IC PROFILER™ - Sun Nuclear. https://www.sunnuclear.com/products/ic-profiler

11. The Role of Image Fusion in Medical Dosimetry. Nishele Lenards, MS, CMD, RT(R)(T)

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12. CT artifacts: causes and reduction techniques. Boas, Edward and Fleischmann,
Dominick. Imaging in Medicine (2012) Volume 4, Issue 2.
https://www.openaccessjournals.com/articles/ct-artifacts-causes-and-reduction-
techniques.html. Accessed April 30, 2023
13. Current and Novel Techniques for Metal Artifact Reduction at CT: Practical Guide
for Radiologists. Katsura, Masaki, Masaaki Akahane, Jiro Sato, Kunimatsu, Akira,
Abe, Osamu. Radiographics J. Vol. 38, No. 2. Published March 2018. Accessed April
30, 2023

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External Beam Planning

External Beam Planning 16.1.4 St. Luke's Cancer Institute - Treasure Valley, Treasure Valley

TREATMENT PLAN REPORT

Patient
Name: IDs:

Birthdate: Sex: Female

Primary Oncologist: Timothy Sawyer Primary Physician: -

Primary Oncologist ID: 8919 Primary Physician ID: -

Plan
Plan ID: studenthetero Plan Intent: Curative

Course ID: student lab Course Intent:

Image ID: Hetero-Homo

Structure Set ID: Hetero/Homo

Treatment Orientation: Head First-Supine Image Origin: User origin DICOM

offset = (-1.58cm, 0.06cm, -120.55cm)

Dose Prescription
Target Structure: PTV Primary Reference Point:
PTV_studentlab (100.0 %)

Total Dose: 4320.0 cGy (180.0 cGy / fraction) Planned Dose per Fraction: 180.0
cGy

Number of Fractions: 24 Planned Total Dose: 4320.0 cGy

Treatment Percentage: 100.0 %

Plan Normalization Value: 100.0 %

Fields
ID Machine Energy Scale Weight Size Gantry Collimator
Table X Y Z Calculated SSD MU Grp Wedge

01AP 2933_TB_BOI 6X IEC61217 0.500 11.0 cm x 9.4 cm(Asym) 0.0 deg 0.0 deg
0.0 deg -5.00 cm -0.00 cm 9.00 cm 85.3 cm 113 MU I
02pa 2933_TB_BOI 6X IEC61217 0.500 10.8 cm x 9.4 cm(Asym) 180.0 deg 0.0 deg
0.0 deg -5.00 cm -0.00 cm 9.00 cm 85.3 cm 126 MU I

Eclipse MU calculations for heterogeneity plan

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Calculation Errors And Warnings:

Patient: Printed Thursday, April 20, 2023 11:57:59 AM by Kristen Eberhard

Course: student lab

Plan: studenthetero - Unapproved Page: 1/2

External Beam Planning

External Beam Planning 16.1.4 St. Luke's Cancer Institute - Treasure Valley, Treasure Valley

Reference Points
Point 3D-coordinates Planned Dose Planned Reference
ID X Y Z per Fraction Total Dose Type
PTV_studentlab - - - 180.0 cGy 4320.0 cGy Target

Approval
Plan Created: Wednesday, April 5, 2023 11:27:09 AM by Kristen Eberhard
Unapproved: Wednesday, April 5, 2023 11:27:09 AM by Kristen Eberhard

Patient: Printed Thursday, April 20, 2023 11:57:59 AM by Kristen Eberhard

Course: student lab
Plan: studenthetero - Unapproved Page: 2/2

Eclipse prescribed dose calculations for heterogeneity plan.

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External Beam Planning

External Beam Planning 16.1.4 St. Luke's Cancer Institute - Treasure Valley, Treasure Valley

TREATMENT PLAN REPORT

Patient
Name: IDs:

Birthdate: Sex: Female

Primary Oncologist: Timothy Sawyer Primary Physician: -

Primary Oncologist ID: 8919 Primary Physician ID: -

Plan
Plan ID: studenthomog Plan Intent: Curative

Course ID: student lab Course Intent:

Image ID: Hetero-Homo

Structure Set ID: Hetero/Homo

Treatment Orientation: Head First-Supine Image Origin: User origin DICOM

offset = (-1.58cm, 0.06cm, -120.55cm)

Dose Prescription
Target Structure: PTV Primary Reference Point:
PTV_studentlab (100.0 %)

Total Dose: 4320.0 cGy (180.0 cGy / fraction) Planned Dose per Fraction: 180.0
cGy

Number of Fractions: 24 Planned Total Dose: 4320.0 cGy

Treatment Percentage: 100.0 %

Plan Normalization Value: 100.0 %

Fields
ID Machine Energy Scale Weight Size Gantry Collimator
Table X Y Z Calculated SSD MU Grp Wedge

01AP 2933_TB_BOI 6X IEC61217 0.500 11.0 cm x 9.4 cm(Asym) 0.0 deg 0.0 deg
0.0 deg -5.00 cm -0.00 cm 9.00 cm 85.3 cm 143 MU I
02pa 2933_TB_BOI 6X IEC61217 0.500 10.8 cm x 9.4 cm(Asym) 180.0 deg 0.0 deg
0.0 deg -5.00 cm -0.00 cm 9.00 cm 85.3 cm 133 MU I

Eclipse MU calculations for homogeneity plan

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Calculation Errors And Warnings:

Patient: Printed Thursday, April 20, 2023 11:59:26 AM by Kristen Eberhard

Course: student lab

Plan: studenthomog - Unapproved Page: 1/2

External Beam Planning

External Beam Planning 16.1.4 St. Luke's Cancer Institute - Treasure Valley, Treasure Valley

Reference Points
Point 3D-coordinates Planned Dose Planned Reference
ID X Y Z per Fraction Total Dose Type
PTV_studentlab - - - 180.0 cGy 4320.0 cGy Target

Approval
Plan Created: Wednesday, April 5, 2023 11:45:52 AM by Kristen Eberhard
Unapproved: Wednesday, April 5, 2023 11:45:52 AM by Kristen Eberhard

Patient: Printed Thursday, April 20, 2023 11:59:26 AM by Kristen Eberhard

Course: student lab
Plan: studenthomog - Unapproved Page: 2/2

Eclipse MU calculations for homogeneity plan

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