Dosimetric errors during treatment of centrally located lung tumors with stereotactic body radiation therapy: Monte Carlo evaluation of tissue inhomogeneity corrections

Early experience with stereotactic body radiation therapy (SBRT) of centrally located lung tumors indicated increased rate of high-grade toxicity in the lungs. These clinical results were based on treatment plans that were computed using pencil beam-like algorithms and without tissue inhomogeneity corrections. In this study, we evaluated the dosimetric errors in plans with and without inhomogeneity corrections and with planning target volumes (PTVs) that were within the zone of the proximal bronchial tree (BT). For 10 patients, the PTV, lungs, and sections of the BT either inside or within 2cm of the PTV were delineated. Two treatment plans were generated for each patient using the following dose-calculation methods: (1) pencil beam (PB) algorithm without inhomogeneity correction (IC) (PB - IC) and (2) PB with inhomogeneity correction (PB + IC). Both plans had identical beam geometry but different beam segment shapes and monitor units (MU) to achieve similar conformal dose coverage of PTV. To obtain the baseline dose distributions, each plan was recalculated using a Monte Carlo (MC) algorithm by keeping MUs the same in the respective plans. The median maximum dose to the proximal BT and PTV dose coverage in the PB + IC plans were overestimated by 8% and 11%, respectively. However, the median maximum dose to the proximal BT and PTV dose coverage in PB - IC plans were underestimated by 15% and 9%. Similar trends were observed in low-dose regions of the lung within the irradiated volume. Our study indicates that dosimetric bias introduced by unit tissue density plans cannot be characterized as underestimation or overestimation of dose without taking the tumor location into account. This issue should be considered when analyzing clinical toxicity data from early lung SBRT trials that utilized unit tissue density for dose calculations.