• 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.

• Progress in Medical Physics
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• v.24 no.2
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• pp.127-132
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• 2013

The position of the internal organs can change continually and periodically inside the body due to the respiration. To reduce the respiration induced uncertainty of dose localization, one can use a respiratory gated radiotherapy where a radiation beam is exposed during the specific time of period. The main disadvantage of this method is that it usually requests a long treatment time, the massive effort during the treatment and the limitation of the patient selection. In this sense, the combination of the real-time position management (RPM) system and the volumetric intensity modulated radiotherapy (RapidArc) is promising since it provides a short treatment time compared with the conventional respiratory gated treatments. In this study, we evaluated the accuracy of the respiratory gated RapidArc treatment. Total sic patient cases were used for this study and each case was planned by RapidArc technique using varian ECLIPSE v8.6 planning machine. For the Quality Assurance (QA), a MatriXX detector and I'mRT software were used. The results show that more than 97% of area gives the gamma value less than one with 3% dose and 3 mm distance to agreement condition, which indicates the measured dose is well matched with the treatment plan's dose distribution for the gated RapidArc treatment cases.

• Journal of radiological science and technology
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• v.38 no.4
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• pp.463-475
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• 2015

The standard treatment of locally advanced type of mid-esophageal cancer is concurrent chemoradiation therapy (CRT). We evaluated the feasibility of chemotherapy with adding docetaxel to the classical basic regimens of cisplatin plus 5-fluorouracil (5-FU) and radiotherapy up to 70.2 Gy using dose escalations for esophageal cancer. It was possible to escalate radiation treatment dose up to 70.2 Gy by the respiratory-gated intensity-modulated radiotherapy (gated-IMRT) based on the 4DCT-simulation, with improving target coverage and normal tissue (ex., lung, heart, and spinal cord) sparing. This study suggested that the definitive chemo-radiotherapy with docetaxel, cisplatin, and 5-fluorouracil (i.e., DCF-R) and gating IMRT is tolerable and active in patients with locally advanced mid-esophageal cancer (AEC).

• BMB Reports
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• v.42 no.8
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• pp.535-539
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• 2009

Voltage-gated $K^+$ (Kv) channels are widely expressed in the plasma membranes of numerous cells such as epithelial cells. Recently, it has been demonstrated that Kv channels are associated with the proliferation of several types of cancer cells. Specifically, Kv1.3 seems to be involved in cancer cell proliferation and apoptosis. In the present study, we examined the expression of Kv1.3 in immortalized and tumorigenic human mammary epithelial cells. We also evaluated the expression level of Kv1.3 in each stage of breast cancer using mRNA isolated from breast cancer patients. In addition, treatment with tetraethylammonium, a Kv channel blocker, suppressed tumorigenic human mammary epithelial cell proliferation. Therefore, Kv1.3 may serve as a novel molecular target for breast cancer therapy while its stage-specific expression pattern may provide a potential diagnostic marker for breast cancer development.

• The Journal of the Korea Contents Association
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• v.15 no.8
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• pp.416-423
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• 2015

The study was conducted targeting 25 patients who underwent the respiratory gated radiation therapy in the abdominal region at Radiation Oncology of a University Hospital from December 2013 to June 2014 and types of cancer included liver(64%), CBD(8%), gastric(8%), GB(8%), pancreas(8%), SMA(4%). The means of ITV and PTV volume are 471.44 cm3 and 425.48 cm3, showing an increase in volume. Normal tissue volume was also found to have increased due to the increase of the section selected from PTV section to ITV section. Right kidney showed a significant increase in differences between increase in normal tissue volume, increase in target volume and increase in therapy irradiation area and difference between the means of dose applied to normal tissue. There was no significant difference in the mean dose applied to normal tissue according to the respiratory average. Both kidneys showed a significant difference in the difference between mean doses of target moving and normal tissue. In this study, both therapy methods through PTV section and ITV section volume setting were appropriate for protection doses of normal tissue and distributed over 95% of the prescribed dose and therefore, it is considered to be okay to be optionally used depending on the patient's therapeutic purpose. But in order to minimize the unexpected side effect, the plan of PTV section and ITV section should be established and used by evaluating normal tissue protection dose.

• Progress in Medical Physics
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• v.25 no.2
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• pp.100-109
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• 2014

In stereotactic body radiotherapy (SBRT), the accurate location of treatment sites should be guaranteed from the respiratory motions of patients. Lots of studies on this topic have been conducted. In this letter, a new verification method simulating the real respiratory motion of heterogenous treatment regions was proposed to investigate the accuracy of lung SBRT for Volumetric Modulated Arc Therapy. Based on the CT images of lung cancer patients, lung phantoms were fabricated to equip in $QUASAR^{TM}$ respiratory moving phantom using 3D printer. The phantom was bisected in order to measure 2D dose distributions by the insertion of EBT3 film. To ensure the dose calculation accuracy in heterogeneous condition, The homogeneous plastic phantom were also utilized. Two dose algorithms; Analytical Anisotropic Algorithm (AAA) and AcurosXB (AXB) were applied in plan dose calculation processes. In order to evaluate the accuracy of treatments under respiratory motion, we analyzed the gamma index between the plan dose and film dose measured under various moving conditions; static and moving target with or without gating. The CT number of GTV region was 78 HU for real patient and 92 HU for the homemade lung phantom. The gamma pass rates with 3%/3 mm criteria between the plan dose calculated by AAA algorithm and the film doses measured in heterogeneous lung phantom under gated and no gated beam delivery with respiratory motion were 88% and 78%. In static case, 95% of gamma pass rate was presented. In the all cases of homogeneous phantom, the gamma pass rates were more than 99%. Applied AcurosXB algorithm, for heterogeneous phantom, more than 98% and for homogeneous phantom, more than 99% of gamma pass rates were achieved. Since the respiratory amplitude was relatively small and the breath pattern had the longer exhale phase than inhale, the gamma pass rates in 3%/3 mm criteria didn't make any significant difference for various motion conditions. In this study, the new phantom model of 4D dose distribution verification using patient-specific lung phantoms moving in real breathing patterns was successfully implemented. It was also evaluated that the model provides the capability to verify dose distributions delivered in the more realistic condition and also the accuracy of dose calculation.

• Progress in Medical Physics
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• v.25 no.3
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• pp.128-138
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• 2014

In gated radiation therapy (gRT), due to residual motion, beam delivery is intended to irradiate not only the true extent of disease, but also neighboring normal tissues. It is desired that the delivery covers the true extent (i.e. clinical target volume or CTV) as a minimum, although target moves under dose delivery. The objectives of our study are to validate if the intended dose is surely delivered to the true target in gRT and to quantitatively understand the trend of dose delivery on it and neighboring normal tissues when gating window (GW), motion amplitude (MA), and CTV size changes. To fulfill the objectives, experimental and computational studies have been designed and performed. A custom-made phantom with rectangle- and pyramid-shaped targets (CTVs) on a moving platform was scanned for four-dimensional imaging. Various GWs were selected and image integration was performed to generate targets (internal target volume or ITV) for planning that included the CTVs and internal margins (IM). The planning was done conventionally for the rectangle target and IMRT optimization was done for the pyramid target. Dose evaluation was then performed on a diode array aligned perpendicularly to the gated beams through measurements and computational modeling of dose delivery under motion. This study has quantitatively demonstrated and analytically interpreted the impact of residual motion including penumbral broadening for both targets, perturbed but secured dose coverage on the CTV, and significant doses delivered in the neighboring normal tissues. Dose volume histogram analyses also demonstrated and interpreted the trend of dose coverage: for ITV, it increased as GW or MA decreased or CTV size increased; for IM, it increased as GW or MA decreased; for the neighboring normal tissue, opposite trend to that of IM was observed. This study has provided a clear understanding on the impact of the residual motion and proved that if breathing is reproducible gRT is secure despite discontinuous delivery and target motion. The procedures and computational model can be used for commissioning, routine quality assurance, and patient-specific validation of gRT. More work needs to be done for patient-specific dose reconstruction on CT images.

• The Journal of Korean Society for Radiation Therapy
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• v.28 no.2
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• pp.149-159
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• 2016

Purpose : To evaluate the usefulness of the breathing exercise,we analyzed the change in the RPM signal and the diaphragm imagebefore 4D respiratory gated radiation therapy planning of lung cancer patients. Materials and Methods : The breathing training was enforced on 11 patients getting the 4D respiratory gated radiation therapy from April, 2016 until August. At the same time, RPM signal and diaphragm image was obtained respiration training total three steps in step 1 signal acquisition of free-breathing state, 2 steps respiratory signal acquisition through the guide of the respiratory signal, 3 steps, won the regular respiration signal to the description and repeat training. And then, acquired the minimum value, maximum value, average value, and a standard deviation of the inspiration and expiration in RPM signal and diaphragm image in each steps. Were normalized by the value of the step 1, to convert the 2,3 steps to the other distribution ratio (%), by evaluating the change in the interior of the respiratory motion of the patient, it was evaluated breathing exercise usefulness of each patient. Results : The mean value and the standard deviation of each step were obtained with the procedure 1 of the RPM signal and the diaphragm amplitude as a 100% reference. In the RPM signal, the amplitudes and standard deviations of four patients (36.4%, eleven) decreased by 18.1%, 27.6% on average in 3 steps, and 2 patients (18.2%, 11 people) had standard deviation, It decreased by an average of 36.5%. Meanwhile, the other four patients (36.4%, eleven) decreased by an average of only amplitude 13.1%. In Step 3, the amplitude of the diaphragm image decreased by 30% on average of 9 patients (81.8%, 11 people), and the average of 2 patients (18.2%, 11 people) increased by 7.3%. However, the amplitudes of RPM signals and diaphragm image in 3steps were reduced by 52.6% and 42.1% on average from all patients, respectively, compared to the 2 steps. Relationship between RPM signal and diaphragm image amplitude difference was consistent with patterns of movement 1, 2 and 3steps, respectively, except for No. 2 No. 10 patients. Conclusion : It is possible to induce an optimized respiratory cycle when respiratory training is done. By conducting respiratory training before treatment, it was possible to expect the effect of predicting the movement of the lung which could control the patient's respiration. Ultimately, it can be said that breathing exercises are useful because it is possible to minimize the systematic error of radiotherapy, expect more accurate treatment. In this study, it is limited to research analyzed based on data on respiratory training before treatment, and it will be necessary to verify with the actual CT plan and the data acquired during treatment in the future.

• Progress in Medical Physics
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• v.21 no.2
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• pp.127-136
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• 2010

Emerging technologies such as four-dimensional computed tomography (4D CT) is expected to allow clinicians to accurately model interfractional motion and to quantitatively estimate internal target volumes (ITVs) for radiation therapy involving moving targets. A need exists for a 4D radiation therapy quality assurance (QA) device that can incorporate and analyze the patient specific intrafractional motion as it relate to dose delivery and respiratory gating. We built a 4D RT prototype device and analyzed the patient-specific 4D radiation therapy QA for 2D dose distributions successfully. With more improvements, the 4D RT QA prototype device could be an integral part of a 4D RT decision process to confirm the dose delivery.

• Journal of radiological science and technology
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• v.39 no.4
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• pp.601-606
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• 2016

Because of non-coplanar therapy with couch rotation in respiratory gated radiation therapy, the recognition of marker movement due to the change in the distance between the infrared camera and the marker due to the rotation of the couch is called RPM (Real-time The purpose of this paper is to evaluate the accuracy of motion reflections (baseline changes) of 2D gating configuration (two dot marker block) and 3D gating configuration (six dot marker block). The motion was measured by varying the couch angle in the clockwise and counterclockwise directions by $10^{\circ}$ in the 2D gating configuration. In the 3D gating configuration, the couch angle was changed by $10^{\circ}$ in the clockwise direction and compared with the baseline at the reference $0^{\circ}$. The reference amplitude was 1.173 to 1.165, the couch angle at $20^{\circ}$ was 1.132, and the couch angle at $1.0^{\circ}$ was 1.083. At $350^{\circ}$ counterclockwise, the reference amplitude was 1.168 to 1.157, the couch angle at $340^{\circ}$ was 1.124, and the couch angle at $330^{\circ}$ was 1.079. In this study, the phantom is used to quantitatively evaluate the value of the amplitude according to couch change.