• Radiation Oncology Journal
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• v.20 no.2
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• pp.165-171
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• 2002

Purpose : In order to perform craniospinal irradiation (CSI) in the supine position on patients who are unable to lie in the prone position, a new simulation technique using a CT simulator was developed and its availability was evaluated. Materials and Method : A CT simulator and a 3-D conformal treatment planning system were used to develop CSI in the supine position. The head and neck were immobilized with a thermoplastic mask in the supine position and the entire body was immobilized with a Vac-Loc. A volumetrie image was then obtained using the CT simulator. In order to improve the reproducibility of the patients' setup, datum lines and points were marked on the head and the body. Virtual fluoroscopy was peformed with the removal of visual obstacles such as the treatment table or the immobilization devices. After the virtual simulation, the treatment isocenters of each field were marked on the body and the immobilization devices at the conventional simulation room. Each treatment field was confirmed by comparing the fluoroscopy images with the digitally reconstructed radiography (DRR)/digitally composite radiography (DCR) images from the virtual simulation. The port verification films from the first treatment were also compared with the DRR/DCR images for a geometrical verification. Results : CSI in the supine position was successfully peformed in 9 patients. It required less than 20 minutes to construct the immobilization device and to obtain the whole body volumetric images. This made it possible to not only reduce the patients' inconvenience, but also to eliminate the position change variables during the long conventional simulation process. In addition, by obtaining the CT volumetric image, critical organs, such as the eyeballs and spinal cord, were better defined, and the accuracy of the port designs and shielding was improved. The differences between the DRRs and the portal films were less than 3 mm in the vertebral contour. Conclusion : CSI in the supine position is feasible in patients who cannot lie on prone position, such as pediatric patienta under the age of 4 years, patients with a poor general condition, or patients with a tracheostomy.

• Radiation Oncology Journal
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• v.25 no.1
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• pp.26-33
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• 2007

[ $\underline{Purpose}$ ]: The aim of this study is to evaluate and compare the incidence and aspects of myocardial perfusion defects in patients who were subjected to either two-dimensional or three-dimensional simulation techniques for early left-sided breast cancer. The myocardial perfusion defects were determined from using single photon emitted computerized tomography (SPECT) myocardial perfusion images. $\underline{Materials\;and\;Methods}$: Between January 2002 and August 2003, 32 patients were enrolled in this study. The patients were diagnosed as having early (AJCC stage T1-T2N0M0) left-sided breast cancer and were treated with tangential irradiation after breast-conserving surgery and systemic chemotherapy. The patients were divided into two groups according to the type of simulation received: two-dimensional simulation using an X-ray fluoroscope simulator or three-dimensional simulation with a CT simulator. All patients underwent technetium-99m-sestamibi gated perfusion SPECT at least 3 years after radiotherapy. The incidence and area of myocardial perfusion defects were evaluated and were compared in the two groups, and at the same time left ventricular ejection fraction and cardiac wall motion were also analyzed. The cardiac volume included in the radiation fields was calculated and evaluated to check for a correlation between the amount of irradiated cardiac volume and aspects of myocardial perfusion defects. $\underline{Results}$: A myocardial perfusion defect was detected in 11 of 32 patients (34.4%). There were 7 (46.7%) perfusion defect cases in 15 patients who underwent the two-dimensional simulation technique and 4 (23.5%) patients with perfusion defects in the three-dimensional simulation group (p=0.0312). In 10 of 11 patients who had myocardial perfusion changes, the perfusion defects were observed in the cardiac apex. The left ventricular ejection fraction was within the normal range and cardiac wall motion was normal in all patients. The irradiated cardiac volume of patients in the three-dimensional simulation group was less than that of patients who received the two-dimensional simulation technique, but there was no statistical significance as compared to the incidence of perfusion defects. $\underline{Conclusion}$: Radiotherapy with a CT simulator (three-dimensional simulation technique) for early left-sided breast cancer may reduce the size of the irradiated cardiac volume and the incidence of myocardial perfusion defects. Further investigation and a longer follow-up duration are needed to analyze the relationship between myocardial perfusion defects and clinical ischemic heart disease.

• Progress in Medical Physics
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• v.19 no.4
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• pp.263-268
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• 2008

The application of a respiratory gated radiotherpy method to the lung radiation surgery was evaluated compared with the conventional method in which the whole tumor motion range is considered in the delineation of PTV (Planning target volume). The four dimensional CT simulation images were acquired for the five NSCLC (Non-small cell lung cancer) patients for radiation surgery. The respiratory gated plan was prepared with the 50% phase CT images and the conventional method was planned based on the ITV (Internal target volume) which include all the target volumes created in each phase CT images within a whole respiratory period. The DVH (Dose volume histogram) of OAR (Organ at risk) which calculated in each method was compared for the evaluation of the plan properness. The relative decrease of OARs' DVH were verified in the application of respiratory gated method. The average decrease rate were $16.88{\pm}9.97%$ in the bronchus, $34.13{\pm}19.15%$ in the spinal cord, $28.42{\pm}18.49%$ in the chest wall and $32.48{\pm}16.66%$ in the lung. Based on these results, we can verified the applicability and the effectiveness of the respiratory gated method in the lung radiation surgery.

• Progress in Medical Physics
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• v.19 no.4
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• pp.241-246
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• 2008

Patient's respiration can have an effect on movement of tumor range and peripheral organs. Therefore, the respiratory signal was acquired by relation between external markers and movement of patient's abdomen during radiational therapy in order to minimize the effect of respiration. Based on this technique, many studies of rational therapy to irradiate at particular part of stable respiratory signals have executed and they have been clinically applied. Nevertheless, the phase-based method is preferred to the amplitude-based method for the rational therapy related to respiration. Because stabilization of the respiratory signal are limited. In this study, a in-house respiratory signal analysis program was developed for the phase reassignment and the analysis of the irregular respiratory signals. Various irregular respiratory patterns was obtained from clinical experimental volunteers. After then, the in-house program analyzed the factors affecting to phase assignment which is directly related to irradiated sector. Subsequently, accuracy of phase assignment was improved with removement of irregular signals by self-developed algorithm. This study is considered to be useful for not only image reconstruction and elevation of irradiating accuracy through phase assignment of RPM system but also analysis of respiratory signals. Moreover, development of 4D CT image is planed with phantom researches or clinical experiments based on this program.

• The Journal of Korean Society for Radiation Therapy
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• v.21 no.2
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• pp.83-88
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• 2009

Purpose: Cone beam computed tomography (CBCT) using an on board imager (OBI) can check the movement and setup error in patient position and target volume by comparing with the image of computer simulation treatment in real.time during patient treatment. Thus, this study purposed to check the change and movement of patient position and target volume using CBCT in IMRT and calculate difference from the treatment plan, and then to correct the position using an automated match system and to test the accuracy of position correction using an electronic portal imaging device (EPID) and examine the usefulness of CBCT in IMRT and the accuracy of the automatic match system. Materials and Methods: The subjects of this study were 3 head and neck patients and 1 pelvis patient sampled from IMRT patients treated in our hospital. In order to investigate the movement of treatment position and resultant displacement of irradiated volume, we took CBCT using OBI mounted on the linear accelerator. Before each IMRT treatment, we took CBCT and checked difference from the treatment plan by coordinate by comparing it with the image of CT simulation. Then, we made correction through the automatic match system of 3D/3D match to match the treatment plan, and verified and evaluated using electronic portal imaging device. Results: When CBCT was compared with the image of CT simulation before treatment, the average difference by coordinate in the head and neck was 0.99 mm vertically, 1.14 mm longitudinally, 4.91 mm laterally, and 1.07o in the rotational direction, showing somewhat insignificant differences by part. In testing after correction, when the image from the electronic portal imaging device was compared with DRR image, it was found that correction had been made accurately with error less than 0.5 mm. Conclusion: By comparing a CBCT image before treatment with a 3D image reconstructed into a volume instead of a 2D image for the patient's setup error and change in the position of the organs and the target, we could measure and correct the change of position and target volume and treat more accurately, and could calculate and compare the errors. The results of this study show that CBCT was useful to deliver accurate treatment according to the treatment plan and to increase the reproducibility of repeated treatment, and satisfactory results were obtained. Accuracy enhanced through CBCT is highly required in IMRT, in which the shape of the target volume is complex and the change of dose distribution is radical. In addition, further research is required on the criteria for match focus by treatment site and treatment purpose.

• The Journal of Korean Society for Radiation Therapy
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• v.25 no.1
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• pp.15-24
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• 2013

Purpose: In Asan Medical Center, Two parallel opposite beams are employed for total body irradiation. Patients are required to be in supine position where two arms are attached to mid axillary line. Normally, physical compensators are required to compensate the large dose difference for different parts of body due to the different thicknesses compared to the umbilicus separation. There was the maximum dose difference up to 30% in lung and chest wall compared to the prescription dose. In order to resolve the dose discrepancy occurring on different body regions, the feasibility of using Fieid-in-Field Technique is investigated in this study. Materials and Methods: CT scan was performed to The RANDO Phantom with fabricated two arms and sent to Eclipse treatment planning system (version 10.0, Varian, USA). Conventional plan with physical lead compensator and new plan using Field-in-Field Technique were established on TPS. AAA (Anisotropic Analytical Algorithm) dose calculation algorithm was employed for two parallel opposite beams attenuation. Results: The dose difference between two methods was compared with the prescription dose. The dose distribution of chest and anterior chest wall uncovered by patient arms was 114~124% for physical lead compensator while Field-in-Field Technique gave 106~107% of the dose distribution. In-vivo dosimetry result using TLD showed that the dose distribution to the same region was 110~117% for conventional physical compensator and 104~107% for Field-in-Field Technique. Conclusion: In this study, the feasibility of using FIF technique has been investigated with fabricated arms attached Rando phantom. The dose difference was up to 17% due to the attached arms. It is shown that the dose homogeneity is within ${\pm}10%$ with the CT based 3-dimensional 4 step FIF technique. The in-vivo dosimetry result using TLD was showed that 95~107% dose distribution compared to prescription dose. It is considered that CT based 3-dimensional Field-in-Field Technique for the total body irradiation gives much homogeneous dose distribution for different body parts than the conventional physical compensator method and might be useful to evaluate the dose on each part of patient body.

• The Journal of Korean Society for Radiation Therapy
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• v.26 no.1
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• pp.127-135
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• 2014

Purpose : By taking advantage of each imaging modality, the use of fused CT/MRI image has increased in prostate cancer radiation therapy. However, fusion uncertainty may cause partial target miss or normal organ overdose. In order to complement such limitation, our hospital acquired MRI image (Planning MRI) by setting up patients with the same fixing tool and posture as CT simulation. This study aims to evaluate the usefulness of the Planning MRI through comparing and analyzing the diagnostic MRI image and Planning MRI image. Materials and Methods : This study targeted 10 patients who had been diagnosed with prostate cancer and prescribed nonhormone and definitive RT 70 Gy/28 fx from August 2011 to July 2013. Each patient had both CT and MRI simulations. The MRI images were acquired within one half hour after the CT simulation. The acquired CT/MRI images were fused primarily based on bony structure matching. This study measured the volume of prostate in the images of Planning MRI and diagnostic MRI. The diameters at the craniocaudal, anteroposterior and left-to-right directions from the center of prostate were measured in order to compare changes in the shape of prostate. Results : As a result of comparing the volume of prostate in the images of Planning MRI and diagnostic MRI, they were found to be $25.01cm^3$(range $15.84-34.75cm^3$) and $25.05cm^3$(range $15.28-35.88cm^3$) on average respectively. The diagnostic MRI had an increase of 0.12 % as compared with the Planning MRI. On the planning MRI, there was an increase in the volume by $7.46cm^3$(29 %) at the transition zone directions, and there was a decrease in the volume by $8.52cm^3$(34 %) in the peripheral zone direction. As a result of measuring the diameters at the craniocaudal, anteroposterior and left-to-right directions in the prostate, the Planning MRI was found to have on average 3.82cm, 2.38cm and 4.59cm respectively and the diagnostic MRI was found to have on average 3.37cm, 2.76cm and 4.51cm respectively. All three prostate diameters changed and the change was significant in the Planning MRI. On average, the anteroposterior prostate diameter decrease by 0.38cm(13 %). The mean right-to-left and craniocaudal diameter increased by 0.08cm(1.6 %) and 0.45cm(13 %), respectively. Conclusion : Based on the results of this study, it was found that the total volumes of prostate in the Planning MRI and the diagnostic MRI were not significantly different. However, there was a change in the shape and partial volume of prostate due to the insertion of prostate balloon tube to the rectum. Thus, if the Planning MRI images were used when conducting the fusion of CT/MRI images, it would be possible to include the target in the CTV without a loss as much as the increased volume in the transition zone. Also, it would be possible to reduce the radiation dose delivered to the rectum through separating more clearly the reduction of peripheral zone volume. Therefore, the author of this study believes that acquisition of Planning MRI image should be made to ensure target delineation and localization accuracy.

• The Journal of Korean Society for Radiation Therapy
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• v.24 no.2
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• pp.123-135
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• 2012

Purpose: It is essential to minimize the movement of tumor due to respiratory movement at the time of respiration controlled radiotherapy of non-small cell lung cancer patient. Accordingly, this Study aims to evaluate the usefulness of restricted respiratory period by comparing and analyzing the treatment plans that apply free and restricted respiration period respectively. Materials and Methods: After having conducted training on 9 non-small cell lung cancer patients (tumor n=10) from April to December 2011 by using 'signal monitored-breathing (guided- breathing)' method for the 'free respiratory period' measured on the basis of the regular respiratory period of the patents and 'restricted respiratory period' that was intentionally reduced, total of 10 CT images for each of the respiration phases were acquired by carrying out 4D CT for treatment planning purpose by using RPM and 4-dimensional computed tomography simulator. Visual gross tumor volume (GTV) and internal target volume (ITV) that each of the observer 1 and observer 2 has set were measured and compared on the CT image of each respiratory interval. Moreover, the amplitude of movement of tumor was measured by measuring the center of mass (COM) at the phase of 0% which is the end-inspiration (EI) and at the phase of 50% which is the end-exhalation (EE). In addition, both observers established treatment plan that applied the 2 respiratory periods, and mean dose to normal lung (MDTNL) was compared and analyzed through dose-volume histogram (DVH). Moreover, normal tissue complication probability (NTCP) of the normal lung volume was compared by using dose-volume histogram analysis program (DVH analyzer v.1) and statistical analysis was performed in order to carry out quantitative evaluation of the measured data. Results: As the result of the analysis of the treatment plan that applied the 'restricted respiratory period' of the observer 1 and observer 2, there was reduction rate of 38.75% in the 3-dimensional direction movement of the tumor in comparison to the 'free respiratory period' in the case of the observer 1, while there reduction rate was 41.10% in the case of the observer 2. The results of measurement and comparison of the volumes, GTV and ITV, there was reduction rate of $14.96{\pm}9.44%$ for observer 1 and $19.86{\pm}10.62%$ for observer 2 in the case of GTV, while there was reduction rate of $8.91{\pm}5.91%$ for observer 1 and $15.52{\pm}9.01%$ for observer 2 in the case of ITV. The results of analysis and comparison of MDTNL and NTCP illustrated the reduction rate of MDTNL $3.98{\pm}5.62%$ for observer 1 and $7.62{\pm}10.29%$ for observer 2 in the case of MDTNL, while there was reduction rate of $21.70{\pm}28.27%$ for observer 1 and $37.83{\pm}49.93%$ for observer 2 in the case of NTCP. In addition, the results of analysis of correlation between the resultant values of the 2 observers, while there was significant difference between the observers for the 'free respiratory period', there was no significantly different reduction rates between the observers for 'restricted respiratory period. Conclusion: It was possible to verify the usefulness and appropriateness of 'restricted respiratory period' at the time of respiration controlled radiotherapy on non-small cell lung cancer patient as the treatment plan that applied 'restricted respiratory period' illustrated relative reduction in the evaluation factors in comparison to the 'free respiratory period.

• Radiation Oncology Journal
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• v.28 no.3
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• pp.155-165
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• 2010

Purpose: In order to evaluate the positional uncertainty of internal organs during radiation therapy for treatment of liver cancer, we measured differences in inter- and intra-fractional variation of the tumor position and tidal amplitude using 4-dimentional computed radiograph (DCT) images and gated orthogonal setup kilovolt (KV) images taken on every treatment using the on board imaging (OBI) and real time position management (RPM) system. Materials and Methods: Twenty consecutive patients who underwent 3-dimensional (3D) conformal radiation therapy for treatment of liver cancer participated in this study. All patients received a 4DCT simulation with an RT16 scanner and an RPM system. Lipiodol, which was updated near the target volume after transarterial chemoembolization or diaphragm was chosen as a surrogate for the evaluation of the position difference of internal organs. Two reference orthogonal (anterior and lateral) digital reconstructed radiograph (DRR) images were generated using CT image sets of 0% and 50% into the respiratory phases. The maximum tidal amplitude of the surrogate was measured from 3D conformal treatment planning. After setting the patient up with laser markings on the skin, orthogonal gated setup images at 50% into the respiratory phase were acquired at each treatment session with OBI and registered on reference DRR images by setting each beam center. Online inter-fractional variation was determined with the surrogate. After adjusting the patient setup error, orthogonal setup images at 0% and 50% into the respiratory phases were obtained and tidal amplitude of the surrogate was measured. Measured tidal amplitude was compared with data from 4DCT. For evaluation of intra-fractional variation, an orthogonal gated setup image at 50% into the respiratory phase was promptly acquired after treatment and compared with the same image taken just before treatment. In addition, a statistical analysis for the quantitative evaluation was performed. Results: Medians of inter-fractional variation for twenty patients were 0.00 cm (range, -0.50 to 0.90 cm), 0.00 cm (range, -2.40 to 1.60 cm), and 0.00 cm (range, -1.10 to 0.50 cm) in the X (transaxial), Y (superior-inferior), and Z (anterior-posterior) directions, respectively. Significant inter-fractional variations over 0.5 cm were observed in four patients. Min addition, the median tidal amplitude differences between 4DCTs and the gated orthogonal setup images were -0.05 cm (range, -0.83 to 0.60 cm), -0.15 cm (range, -2.58 to 1.18 cm), and -0.02 cm (range, -1.37 to 0.59 cm) in the X, Y, and Z directions, respectively. Large differences of over 1 cm were detected in 3 patients in the Y direction, while differences of more than 0.5 but less than 1 cm were observed in 5 patients in Y and Z directions. Median intra-fractional variation was 0.00 cm (range, -0.30 to 0.40 cm), -0.03 cm (range, -1.14 to 0.50 cm), 0.05 cm (range, -0.30 to 0.50 cm) in the X, Y, and Z directions, respectively. Significant intra-fractional variation of over 1 cm was observed in 2 patients in Y direction. Conclusion: Gated setup images provided a clear image quality for the detection of organ motion without a motion artifact. Significant intra- and inter-fractional variation and tidal amplitude differences between 4DCT and gated setup images were detected in some patients during the radiation treatment period, and therefore, should be considered when setting up the target margin. Monitoring of positional uncertainty and its adaptive feedback system can enhance the accuracy of treatments.