• Proceedings of the Korean Society of Medical Physics Conference
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• 2002.09a
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• pp.436-438
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• 2002

As the use of virtual simulation expands, digitally reconstructed radiographs (DRRs), which mimic conventional simulation films, play an increasingly important role as reference images in the verification of treatment fields. The purpose of our study is to develop an algorithm for computation of digitally reconstructed radiographs based on Monte Carlo simulation that take into account almost all possible physical processes by which photons interact with matter. The Monte Carlo simulation based DRRs have the following features. 1) Account has been taken of almost all possible physical processes of interaction of photons with matter, including a detector (film) response. In principle, this is equivalent to X-ray radiography. 2) Arbitrary photon energies (from diagnostic to therapeutic) can be used to produce DRRs. One can even use electrons as the source. 3) It is easy to produce a double exposure, which mimics the double exposure portal image and may have superior visual appeal for treatment field verification, with weighting within the treatment field.

• Progress in Medical Physics
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• v.17 no.2
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• pp.67-76
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• 2006

We evaluated the accuracy of a patient setup error correction due to reference image quality for a 2D-2D matching process. Digitally reconstructed radiographs (DRRs) generated by use of the Pinnacle3 and the Eclipse for various regions of a humanoid phantom and a patient for different CT slice thickness were employed as a reference images and kV X-ray Images from the On-Board Imager were registered to the reference DRRs. In comparison of the DRRs and profiles, DRR image quality was getting worse with an increase of CT image slice thickness. However there were only slight differences of setup errors evaluation between matching results for good and poor reference DRRs. Although DRR image quality did not strongly affect to the 2D-2D matching accuracy, there are still potential errors for matching procedure, therefore we recommend that DRR images are needed to be generated with less than 3mm slice thickness for 2D-2D matching.

• Progress in Medical Physics
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• v.14 no.3
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• pp.196-202
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• 2003

In 3-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT), many studies on reducing setup error have been conducted in order to focus the irradiation on the tumors while sparing normal tissues as much as possible. As one of these efforts, we developed an image enhancement and registration tool for simulators and portal images that analyze setup errors in a quantitative manner. For setup verification, we used simulator (films and EC-L films (Kodak, USA) as portal images. In addition, digital-captured images during simulation, and digitally-reconstructed radiographs (DRR) can be used as reference images in the software, which is coded using IDL5.4 (Research Systems Inc., USA). To improve the poor contrast of portal images, histogram-equalization, and adaptive histogram equalization, CLAHE (contrast limited adaptive histogram equalization) was implemented in the software. For image registration between simulator and portal images, contours drawn on the simulator image were transferred into the portal image, and then aligned onto the same anatomical structures on the portal image. In conclusion, applying CLAHE considerably improved the contrast of portal images and also enabled the analysis of setup errors in a quantitative manner.

• The Journal of Korean Society for Radiation Therapy
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• v.11 no.1
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• pp.100-105
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• 1999

Purpose : When the value of X,Y,Z coordination of the isocenter are reallocated from an arbitrary point using DRR (Digitally Reconstructed Radiographs) image in CT Simulation, conventional simulation is normally performed to verify the accuracy of this reallocation of the isocenter through the fluroscopy. The purpose of our experiment is to determine whether repeated test of the verification is necessary or not, and to analyze errors of reallocation with respect to the body region and the beam projection, if necessary, Material and Method : For 200 simulation patient, an arbitrary point is marked on each body and axial scaning is performed using CT, and treatment planing is done by drawing tumor and target volume on each slice. Using the planing data and the reallocated point of the isocenter, DRR image can be obtained and the final isocenter are marked on the patient's skin. In order to verify this reallocation of X,Y.Z coordination from CT simulation, We measure and evaluate the errors of these value on the fluoroscopy monitor and systematize them by classifying according to each body region (Brain, Neck and SCL, Lung, Esophagus, abdomen, Breast and Pelvis) and each beam projection {AP(PA), Supine, Prone and conformal : etc. } Conclusion : Isocenters are shifted by 3-5 mm in the case of Neck & SCL, Breast. at Abdomen, while noticeable differences are not found in other regions. Also, there are not correlations between the errors and the body regions or beam projections. However, our experiment intends to decide whether the procedure of verification is necessary on the vase of time and economy. It is regretful that we could not fully analyze the geometrical errors of DRR image and visual errors from the divergence. In conclusion, according to how much doctor consider tumor margin in drawing tumor and target volume, the meaning of analysis on the reallocation of isocenter should be reinterpreted, (which depends on the experience and capability of doctors)

• Radiation Oncology Journal
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• v.35 no.1
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• pp.65-70
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• 2017

Purpose: To evaluate the utility of implanted surgical clips for detecting interfractional errors in the treatment of hepatobiliary and pancreatic cancer with postoperative radiotherapy (PORT). Methods and Materials: Twenty patients had been treated with PORT for locally advanced hepatobiliary or pancreatic cancer, from November 2014 to April 2016. Patients underwent computed tomography simulation and were treated in expiratory breathing phase. During treatment, orthogonal kilovoltage (kV) imaging was taken twice a week, and isocenter shifts were made to match bony anatomy. The difference in position of clips between kV images and digitally reconstructed radiographs was determined. Clips were consist of 3 proximal clips (clip_p, ${\leq}2cm$) and 3 distal clips (clip_d, >2 cm), which were classified according to distance from treatment center. The interfractional displacements of clips were measured in the superior-inferior (SI), anterior-posterior (AP), and right-left (RL) directions. Results: The translocation of clip was well correlated with diaphragm movement in 90.4% (190/210) of all images. The clip position errors greater than 5 mm were observed in 26.0% in SI, 1.8% in AP, and 5.4% in RL directions, respectively. Moreover, the clip position errors greater than 10 mm were observed in 1.9% in SI, 0.2% in AP, and 0.2% in RL directions, despite respiratory control. Conclusion: Quantitative analysis of surgical clip displacement reflect respiratory motion, setup errors and postoperative change of intraabdominal organ position. Furthermore, position of clips is distinguished easily in verification images. The identification of the surgical clip position may lead to a significant improvement in the accuracy of upper abdominal radiation therapy.

• Radiation Oncology Journal
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• v.25 no.2
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• pp.134-144
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• 2007

[ $\underline{Purpose}$ ]: Immobilization devices that improve the setup reproducibility of pelvic cancer patients and that provide comfort to patients during radiotherapy were designed and the feasibility of the devices was evaluated. $\underline{Materials\;and\;Methods}$: A customized device was designed to immobilize a knee, thigh, and foot of a patient. Sixty-one patients with prostate cancer were selected and were divided into two groups-with or without devices. The setup errors were measured with respect to bony landmarks. The difference between digitally reconstructed radiographs (DRR) and simulation films, and the differences between DRR and portal films were measured. $\underline{Results}$: The left-right (LR), anterior-posterior (AP) and craniocaudal (CC) errors between the DRR and simulation films were $1.5{\pm}0.9\;mm$, $3.0{\pm}3.6\;mm$, and $1.6{\pm}0.9\;mm$, respectively without devices. The errors were reduced to $1.3{\pm}1.9\;mm$, $1.8{\pm}1.5\;mm$ and $1.1{\pm}1.1\;mm$, respectively with the devices. The errors between DRR and portal films were $1.6{\pm}1.2\;mm$, $4.0{\pm}4.1\;mm$, and $4.2{\pm}5.5\;mm$, respectively without the devices and were reduced to $1.0{\pm}1.8\;mm$, $1.2{\pm}0.9\;mm$, and $1.2{\pm}0.8\;mm$, respectively, with the devices. The standard deviations among the portal films were 1.1 mm, 2.1 mm, and 1.0 mm at each axis without the devices and 0.9 mm, 1.6 mm and 0.8 mm with the devices. The percentage of setup errors larger than 3 mm and 5 mm were significantly reduced by use of the immobilization devices. $\underline{Conclusion}$: The designed devices improved the setup reproducibility for all three directions and significantly reduced critical setup errors.

• Radiation Oncology Journal
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• v.18 no.4
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• pp.345-354
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• 2000

Purpose : Conventional radiation therapy Portal images gives low contrast images. The purpose of this study was to enhance image contrast of a linacgram by developing a low-cost image processing method. Materials and Methods : Chest linacgram was obtained by irradiating humanoid Phantom and scanned using Diagnostic-Pro scanner for image processing. Several types of scan method were used in scanning. These include optical density scan, histogram equalized scan, linear histogram based scan, linear histogram independent scan, linear optical density scan, logarithmic scan, and power square root scan. The histogram distribution of the scanned images were plotted and the ranges of the gray scale were compared among various scan types. The scanned images were then transformed to the gray window by pallette fitting method and the contrast of the reprocessed portal images were evaluated for image improvement. Portal images of patients were also taken at various anatomic sites and the images were processed by Gray Scale Expansion (GSE) method. The patient images were analyzed to examine the feasibility of using the GSE technique in clinic. Results :The histogram distribution showed that minimum and maximum gray scale ranges of 3192 and 21940 were obtained when the image was scanned using logarithmic method and square root method, respectively. Out of 256 gray scale, only 7 to 30$\%$ of the steps were used. After expanding the gray scale to full range, contrast of the portal images were improved. Experiment peformed with patient image showed that improved identification of organs were achieved by GSE in portal images of knee joint, head and neck, lung, and pelvis. Conclusion :Phantom study demonstrated that the GSE technique improved image contrast of a linacgram. This indicates that the decrease in image quality resulting from the dual exposure, could be improved by expanding the gray scale. As a result, the improved technique will make it possible to compare the digitally reconstructed radiographs (DRR) and simulation image for evaluating the patient positioning error.

• Radiation Oncology Journal
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• v.29 no.2
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• pp.91-98
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• 2011

Purpose: To assess the usefulness of implanted fiducial markers in the setup of hypofractionated radiotherapy for prostate cancer patients by comparing a fiducial marker matched setup with a pelvic bone match. Materials and Methods: Four prostate cancer patients treated with definitive hypofractionated radiotherapy between September 2009 and August 2010 were enrolled in this study. Three gold fiducial markers were implanted into the prostate and through the rectum under ultrasound guidance around a week before radiotherapy. Glycerin enemas were given prior to each radiotherapy planning CT and every radiotherapy session. Hypofractionated radiotherapy was planned for a total dose of 59.5 Gy in daily 3.5 Gy with using the Novalis system. Orthogonal kV X-rays were taken before radiotherapy. Treatment positions were adjusted according to the results from the fusion of the fiducial markers on digitally reconstructed radiographs of a radiotherapy plan with those on orthogonal kV X-rays. When the difference in the coordinates from the fiducial marker fusion was less than 1 mm, the patient position was approved for radiotherapy. A virtual bone matching was carried out at the fiducial marker matched position, and then a setup difference between the fiducial marker matching and bone matching was evaluated. Results: Three patients received a planned 17-fractionated radiotherapy and the rest underwent 16 fractionations. The setup error of the fiducial marker matching was $0.94{\pm}0.62$ mm (range, 0.09 to 3.01 mm; median, 0.81 mm), and the means of the lateral, craniocaudal, and anteroposterior errors were $0.39{\pm}0.34$ mm, $0.46{\pm}0.34$ mm, and $0.57{\pm}0.59$ mm, respectively. The setup error of the pelvic bony matching was $3.15{\pm}2.03$ mm (range, 0.25 to 8.23 mm; median, 2.95 mm), and the error of craniocaudal direction ($2.29{\pm}1.95$ mm) was significantly larger than those of anteroposterior ($1.73{\pm}1.31$ mm) and lateral directions ($0.45{\pm}0.37$ mm), respectively (p<0.05). Incidences of over 3 mm and 5 mm in setup difference among the fractionations were 1.5% and 0% in the fiducial marker matching, respectively, and 49.3% and 17.9% in the pelvic bone matching, respectively. Conclusion: The more precise setup of hypofractionated radiotherapy for prostate cancer patients is feasible with the implanted fiducial marker matching compared with the pelvic bony matching. Therefore, a less marginal expansion of planning target volume produces less radiation exposure to adjacent normal tissues, which could ultimately make hypofractionated radiotherapy safer.