With the advent of intensity-modulated radiation therapy (IMRT), the inclusion of heterogeneity corrections is further complicated by the conformal delivery of many small beams forming steep dose gradients. Radiation treatment planning has evolved to take into account even small changes in tissue density so that the dose to tumor can be further optimized. However, different treatment planning systems incorporate different heterogeneity correction algorithms, and it is unclear whether any of these algorithms are superior to others in terms of accurately predicting delivered radiation doses relative to measurement in a clinical setting. The purpose of this study was to determine the accuracy of heterogeneity dose calculations from two widely used IMRT treatment planning systems (Pinnacle and Corvus) against measurement. These two systems handle heterogeneity dose corrections by means of a collapsed-cone convolution superposition algorithm and a finite-size pencil-beam algorithm with one-dimensional depth scaling correction, respectively. Treatment plans were generated by each system using an anthropomorphic thorax phantom, routine clinical lung tumor constraints, and a common prescribed dose. Dose measurements made by thermoluminescent detectors (TLDs) and radiochromic film positioned within the phantom's lung and offset tumor insert were then compared with the calculated values. The collapsed cone convolution superposition dose calculation algorithm provided clinically acceptable results (±5% of the normalization dose or 3 mm distance to agreement) in the designed treatment plan and delivery. The pencil-beam algorithm with an effective pathlength correction showed reasonable agreement within the gross tumor volume, overestimated dose within a majority of the planning target volume, and underestimated the extent of the penumbral broadening, yielding only about 60% accuracy when judged by the above criterion. Even judged by a more generous criterion (±7%7 mm), the results were clinically unfavorable (at only about 80% accuracy). To ascertain the dose in heterogeneous regions such as the tumor-lung interface and the peripheral lung dose near the tumor, the superposition convolution algorithm that accounts for lateral scatter and electron transport should be used. The use of the pencil-beam algorithm with only an effective pathlength correction may result in the dose to the target being overestimated. As a result, a full understanding of any treatment planning system's heterogeneity algorithm is required prior to clinical implementation.
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