• Radiation Oncology Journal
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• v.22 no.3
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• pp.165-176
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• 2004

Purpose: Firstly, to analyze facto in terms of radiation treatment that might potentially cause subfrontal relapse in two patients who had been treated by craniospinal irradiation (CSI) for medulloblastoma, Secondly, to explore an effective salvage treatment for these relapses. Materials and Methods: Two patients who had high-risk disease (T3bMl, T3bM3) were treated with combined chemoradiotherapy CT-simulation based radiation-treatment planning (RTP) was peformed. One patient who experienced relapse at 16 months after CSI was treated with salvage surgery followed by a 30.6 Gy IMRT (intensity modulated radiotherapy). The other patient whose tumor relapsed at 12 months after CSI was treated by surgery alone for the recurrence. To investigate factors that might potentially cause subfrontal relapse, we evaluated thoroughly the charts and treatment planning process including portal films, and tried to find out a method to give help for placing blocks appropriately between subfrotal-cribrifrom plate region and both eyes. To salvage subfrontal relapse in a patient, re-irradiation was planned after subtotal tumor removal. We have decided to treat this patient with IMRT because of the proximity of critical normal tissues and large burden of re-irradiation. With seven beam directions, the prescribed mean dose to PTV was 30.6 Gy (1.8 Gy fraction) and the doses to the optic nerves and eyes were limited to 25 Gy and 10 Gy, respectively. Results: Review of radiotherapy Portals clearly indicated that the subfrontal-cribriform plate region was excluded from the therapy beam by eye blocks in both cases, resulting in cold spot within the target volume, When the whole brain was rendered in 3-D after organ drawing in each slice, it was easier to judge appropriateness of the blocks in port film. IMRT planning showed excellent dose distributions (Mean doses to PTV, right and left optic nerves, right and left eyes: 31.1 Gy, 14.7 Gy, 13.9 Gy, 6.9 Gy, and 5.5 Gy, respectively. Maximum dose to PTV: 36 Gy). The patient who received IMRT is still alive with no evidence of recurrence and any neurologic complications for 1 year. Conclusion: To prevent recurrence of medulloblastoma in subfrontal-cribriform plate region, we need to pay close attention to the placement of eye blocks during the treatment. Once subfrontal recurrence has happened, IMRT may be a good choice for re-irradiation as a salvage treatment to maximize the differences of dose distributions between the normal tissues and target volume.

• The Journal of Korean Society for Radiation Therapy
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• v.19 no.2
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• pp.99-106
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• 2007

Purpose: The patient's position and anatomy during the treatment course little bit varies to some extend due to setup uncertainties and organ motions. These factors could affected to not only the dose coverage of the gross tumor but over dosage of normal tissue. Setup uncertainties and organ motions can be minimized by precise patient positioning and rigid immobilization device but some anatomical site such as prostate, the internal organ motion due to physiological processes are challenge. In planning procedure, the clinical target volume is a little bit enlarged to create a planning target volume that accounts for setup uncertainties and organ motion as well. These uncertainties lead to differences between the calculated dose by treatment planning system and the actually delivered dose. The purpose of this study was to evaluate the differences of interfractional displacement of organ and GTV based on the tomoimages. Materials and Methods: Over the course of 3 months, 3 patients, those who has applied rectal balloon, treated for prostatic cancer patient's tomoimage were studied. During the treatment sessions 26 tomoimages per patient, Total 76 tomoimages were collected. Tomoimage had been taken everyday after initial setup with lead marker attached on the patient's skin center to comparing with C-T simulation images. Tomoimage was taken after rectal balloon inflated with 60 cc of air for prostate gland immobilization for daily treatment just before treatment and it was used routinely in each case. The intrarectal balloon was inserted to a depth of 6 cm from the anal verge. MVCT image was taken with 5 mm slice thickness after the intrarectal balloon in place and inflated. For this study, lead balls are used to guide the registration between the MVCT and CT simulation images. There are three image fusion methods in the tomotherapy, bone technique, bone/tissue technique, and full image technique. We used all this 3 methods to analysis the setup errors. Initially, image fusions were based on the visual alignment of lead ball, CT anatomy and CT simulation contours and then the radiation therapist registered the MVCT images with the CT simulation images based on the bone based, rectal balloon based and GTV based respectively and registered image was compared with each others. The average and standard deviation of each X, Y, Z and rotation from the initial planning center was calculated for each patient. The image fusions were based on the visual alignment of lead ball, CT anatomy and CT simulation contours. Results: There was a significant difference in the mean variations of the rectal balloon among the methods. Statistical results based on the bone fusion shows that maximum x-direction shift was 8 mm and 4.2 mm to the y-direction. It was statistically significant (P=<0.0001) in balloon based fusion, maximum X and Y shift was 6 mm, 16mm respectively. One patient's result was more than 16 mm shift and that was derived from the rectal expansions due to the bowl gas and stool. GTV based fusion results ranging from 2.7 to 6.6 mm to the x-direction and 4.3$\sim$7.8 mm to the y-direction respectively. We have checked rotational error in this study but there are no significant differences among fusion methods and the result was 0.37$\pm$0.36 in bone based fusion and 0.34$\pm$0.38 in GTV based fusion.

• Progress in Medical Physics
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• v.15 no.2
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• pp.63-69
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• 2004

HDR brachytherapy administers a large dose of radiation in a short time compare with LDR, and its optimization for treatment is related to several complex factors, such as physical, radiation and optimization algorithms, so there is a need for these to be verified for accurate dose delivery. In our approach, a previous study concerning the phantom for dose verification has been modified, and a new pelvic phantom fabricated for the purpose of localization, including a structure enabling the use of a CT or MRI system. In addition, a comparison study was performed to verify an orthogonal method that is commonly used for brachytherapy localization by comparing target coordinates from a CT system. Since the developed phantom was designed to simulate the clinical setups of cervix cancer, it included an air-filled bladder and a rectum structure shaped sphere and cylinder An N-shaped localizer was used to obtain precision coordinates from both CT and films. Moreover, the IDL 5.5 software program for Windows was used to perform coordinates analysis based on an orthogonal algorithm. The film results showed differences within 1.0 mm of the selected target points compare with the CT coordinates. For these results, a Plato planning system (Nucletron, Netherlands) could be independently verified using this phantom and software. Furthermore, the new phantom and software will be efficient and powerful qualify assurance (QA) tools in the field of brachytherapy QA.

• Proceedings of the Korean Society of Medical Physics Conference
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• 2004.11a
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• pp.126-129
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• 2004

We compared intensity-modulated radiotherapy (IMRT) treatment plans with commercially available multileaf collimators (MLCs) of different leaf width for intracranial lesions. Twelve cases previously treated with micro-MLCs(mMLCs) were replanned using the Varian 120 and 80 MLCs. These collimators have minimum leaf width of 3mm, 5 mm and 10 mm at isocenter, respectively. These three plans were compared with respect to the uniformity and the conformity indices, doses to normal tissue. For the uniformity index of planning target volume (PTV),there was no statistically significant difference between mMLCs with 120 MLCs (p = 0.06). However, there was a little difference between mMLCs with 80 MLCs (p = 0.001). Maximum target dose to the PTV showedno dependency with respect to the leaf width. On the contrary, there were statistically significant differences in the conformity indices between mMLCs and 120 MLCs (p = 0.003) and between mMLCs and 80 MLCs (p = 0.003).The volumetric increments for MLCs with leaf widths of 5 mm and 10 mm were 6.3% and 23.2% for the normal tissue Irradiated to = 50% dose, and 8.7% and 32.7% for the normal tissue Irradiated to = 70% dose, respectively, compared to the volume for MLCs with leaf width of 3 mm. This shows that for the sparing of normal tissue, MLCs with leaf width of 3 mm are more effective, compared to MLCs with leaf widths of 5 mm and 10 mm.

• Progress in Medical Physics
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• v.20 no.1
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• pp.43-50
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• 2009

The 4 bank mico-MLC (mMLC; Acculeaf, Direx, Isral) has been commissioned for clinical use of linac based stereotactic radiosurgery. The geometrical parameters to control the leaves were determined and comparisons between measured and calculated by the calculation model were performed in terms of absolute dose (cGy/100 MU). As a result of evaluating calculated dose for various field sizes and depths of 5 and 10 cm in water in the geometric condition of fixed SSD (source to surface distance) and fixed SCD (source to chamber distance), most of differences were within 1% for 6 MV and 15 MV x-rays. The penumbral widths at the isocenter were approximately evaluated to 0.29~0.43 cm depending on the field size for 6 MV and 0.36~0.51 cm for 15 MV x-rays. The average transmission and leakage for 6 MV and 15 MV x-rays were 6.6% and 7.4% respectively in single level of leaves fully closed. In case of dual level of leaves fully closed the measured transmission is approximately 0.5% for both 6 MV and 15 MV x-rays. Through the commissiong procedure we could verify the dose characteristics of mMLC and approximately evaluate the error ranges for treatment planning system.

• Progress in Medical Physics
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• v.18 no.2
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• pp.93-97
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• 2007

This study was designed to evaluate radiosurgery technique using multiple noncoplanar arc therapy with intensity modulated fine MLC shaped photon beam. The stereotactic radiosurgery was performed with 6-MV X-ray beams from a Clinac 21EX LINAC (Varian, Palo Alto, CA, USA) with a MLC-120, which features a full $40{\times}40cm$ field and is the first MLC for general use that offers 0.5 cm resolution for high precision treatment of small and irregular fields. We used a single isocenter and five gantry-couch combinations with a set of intensity modulated arc therapy. We investigated dosimetric characteristics of 2 cm sized spherical target volume with film (X-OMAT V2 film, Kodak Inc, Rochester NY, USA) dosimetry within $25{\times}25cm$ acrylic phantom. A simulated single isocentric treatment using inversely Planned 3D radiotherapy planning system demonstrated the ability to conform the dose distribution to an spherical target volume. The 80% dose level was adequate to encompass the target volume in frontal, sagittal, and transverse planes, and the region between the 40% and 80% isodose lines was $4.0{\sim}4.5mm$ and comparable to the dose distribution of the Boston Arcs. We expect that our radiosurgery technique could be a treatment option for irregular-shaped large intracranial target.

• Journal of the Korean Society of Radiology
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• v.15 no.3
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• pp.273-279
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• 2021

Metal material inserted into the body have a large difference in density from human tissues or bones around the Metal during CT scans.. Therefore, the Metal material inserted into the body produces Artifact. Metal Artifact, which occurs around Metals, can degrade the quality of CT images, causing confusion when medical team diagnose lesions. Through this experiment, we confirm that the occurrence of Artifacts decrease by using Dual energy CT and MAR algorithm in Single source Dual energy CT. We also want to present basic data on clinical application methods by comparing and analyzing the characteristics of images obtained by each method. Using GE 750HD CT, artificial implants were scanned using general method and Dual energy. Then we apply the MAR algorithm to each image obtained. And all previously acquired images were compared and analyzed the characteristics of the examination, such as image quality evaluation and dose evaluation. Images with MAR algorithm and Dual Energy confirmed a decrease in Metal Artifact. Images with MAR algorithm have reduced Metal Artifact, but have the disadvantage of distorting the details of artificial joint implants. On the other hand images teseted with Dual Energy have the advantage of being able to implement details than those applied with MAR algorithms, it takes longer to reconstruct the image and the exposure dose was about four times higher than those applied with MAR algorithm. In order to locate Metals, such as the post-operative follow-up period, it is useful to apply MAR algorithm to obtain images. And it is more useful to examine with Dual Energy when micro lesion identification, such as cardiac examination, and surgical planning or when tests are performed in diagnostic way.

• Journal of the Korean Physical Society
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• v.80
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• pp.516-525
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• 2022

This study is to assess the clinical use of commercial PerFRACTION^TM for patient-specific quality assurance of volumetric-modulated arc therapy. Forty-six pretreatment verification plans for patients treated using a TrueBeam STx linear accelerator for lesions in various treatment sites such as brain, head and neck (H&N), prostate, and lung were included in this study. All pretreatment verification plans were generated using the Eclipse treatment planning system (TPS). Dose distributions obtained from electronic portal imaging device (EPID), ArcCHECK^TM, and two-dimensional (2D)/three-dimensional (3D) PerFRACTION^TM were then compared with the dose distribution calculated from the Eclipse TPS. In addition, the correlation between the plan complexity (the modulation complexity score and the leaf travel modulation complexity score) and the gamma passing rates (GPRs) of each quality assurance (QA) system was evaluated by calculating Spearman's rank correlation coefficient (r_s) with the corresponding p-values. The gamma passing rates of 46 patients analyzed with the 2D/3D PerFRACTION^TM using the 2%/2 mm and 3%/3 mm criteria showed almost similar trends to those analyzed with the Portal dose imaging prediction (PDIP) and ArcCHECK^TM except for those analyzed with ArcCHECK^TM using the 2%/2 mm criterion. Most of weak or moderate correlations between GPRs and plan complexity were observed for all QA systems. The trend of mean rs between GPRs using PDIP and 2D/3D PerFRACTION^TM for both criteria and plan complexity indices as in the GPRs analysis was significantly similar for brain, prostate, and lung cases with lower complexity compared to H&N case. Furthermore, the trend of mean rs for 2D/3D PerFRACTION^TM for H&N case with high complexity was similar to that of ArcCHECK^TM and slightly lower correlation was observed than that of PDIP. This work showed that the performance of 2D/3D PerFRACTION^TM for pretreatment patient-specific QA was almost comparable to that of PDIP, although there was small difference from ArcCHECK^TM for some cases. Thus, we found that the PerFRACTION^TM is a suitable QA system for pretreatment patient-specific QA in a variety of treatment sites.

• Progress in Medical Physics
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• v.25 no.3
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• pp.167-175
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• 2014

The purpose of this study is to evaluate the variation of the dose which is delivered to the patients with glottis cancer under IMRT (intensity modulated radiation therapy) by using the 3D registration with CBCT (cone beam CT) images and the DIR (deformable image registration) techniques. The CBCT images which were obtained at a one-week interval were reconstructed by using B-spline algorithm in DIR system, and doses were recalculated based on the newly obtained CBCT images. The dose distributions to the tumor and the critical organs were compared with reference. For the change of volume depending on weight at 3 to 5 weeks, there was increased of 1.38~2.04 kg on average. For the body surface depending on weight, there was decreased of 2.1 mm. The dose with transmitted to the carotid since three weeks was increased compared be more than 8.76% planned, and the thyroid gland was decreased to 26.4%. For the physical evaluation factors of the tumor, PITV, TCI, rDHI, mDHI, and CN were decreased to 4.32%, 5.78%, 44.54%, 12.32%, and 7.11%, respectively. Moreover, $D_{max}$, $D_{mean}$, $V_{67.50}$, and $D_{95}$ for PTV were increased or decreased to 2.99%, 1.52%, 5.78%, and 11.94%, respectively. Although there was no change of volume depending on weight, the change of body types occurred, and IMRT with the narrow composure margin sensitively responded to such a changing. For the glottis IMRT, the patient's weight changes should be observed and recorded to evaluate the actual dose distribution by using the DIR techniques, and more the adaptive treatment planning during the treatment course is needed to deliver the accurate dose to the patients.

• Journal of radiological science and technology
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• v.37 no.4
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• pp.331-339
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• 2014

To test feasibility of proton arc therapy (PAT) in the treatment of para-aortic lymph node tumor and compare its dosimetric properties with advanced radiotherapy techniques such as intensity modulated radiation therapy (IMRT) and conventional 3D conformal proton beam therapy (PBT). The treatment plans for para-aortic lymph node tumor were planned for 9 patients treated at our institution using IMRT, PBT, and PAT. Feasibility test and dosimetric evaluation were based on comparisons of dose volume histograms (DVHs) which reveal mean dose, $D_{30%}$, $D_{60%}$, $D_{90%}$, $V_{30%}$, $V_{60%}$, $V_{90%}$, organ equivalent doses (OEDs), normal tissue complication probability (NTCP), homogeneity index (HI) and conformity index (CI). The average doses delivered by PAT to the liver, kidney, small bowel, duodenum, stomach were 7.6%, 3%, 17.3%, 26.7%, and 14.4%, of the prescription dose (PD), respectively, which is higher than the doses delivered by IMRT (0.4%, 7.2%, 14.2%, 15.9%, and 12.8%, respectively) and PBT (4.9%, 0.5%, 14.12%, 16.1% 9.9%, respectively). The average homogeneity index and conformity index of tumor using PAT were 12.1 and 1.21, respectively which were much better than IMRT (21.5 and 1.47, respectively) and comparable to PBT (13.1 and 1.23, respectively). The result shows that both NTCP and OED of PAT are generally lower than IMRT and PBT. This study demonstrates that PAT is better in target conformity and homogeneity than IMRT and PBT but worse than IMRT and PBT for most of dosimetric factor which indicate that PAT is not recommended for the treatment of para-aortic lymph node tumor.