• Journal of Radiation Protection and Research
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• v.28 no.3
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• pp.225-231
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• 2003

Up-front irradiation technique as 3-dimensional conformation, or intensity modulation has kept large proportion of brain tumors from being complicated with acute radiation reactions in the normal tissue during or shortly after radiotherapy. For years, we've cannot help but counting on 2-D vertex beam technique to reduce acute reactions in the brain tumor patients because we're not equipped with 3-dimensional planning system. We analyzed its advantages and limitations in the clinical application. From 1998 to 2001, vertex or oblique vertex beams were applied to 35 patients with primary brain tumor and 25 among them were eligible for this analysis. Vertex(V) plans were optimized on the reconstructed coronal planes. As the control, we took the bilateral opposed techniques(BL) otherwise being applied. We compared the volumes included in 105% to 50% isodose lines of each plan. We also measured the radiation dose at various extracranial sites with TLD. With vertex techniques, we reduced the irradiated volumes of contralateral hemisphere and prevented middle ear effusion at contralateral side. But the low dose volume increased outside 100%; the ratio of V to BL in irradiated volume included in 100%, 80%, 50% was 0.55+/-0.10, 0.61+/-0.10, and 1.22+/-0.21, respectively. The hot area within 100% isodose line almost disappeared with vertex plan; the ratio of V to BL in irradiated volume included in 103%, 105%, 108% was 0.14+/-0.14, 0.05./-0.17, 0.00, respectively. The dose distribution within 100% isodose line became more homogeneous; the ratio of volume included in 103% and 105% to 100% was 0.62+/-0.14 and 0.26+/-0.16 in BL whereas was 0.16+/-0.16 and 0.02+/-0.04 in V. With the vertex techniques, extracranial dose increased up to $1{\sim}3%$ of maximum dose in the head and neck region except submandibular area where dose ranged 1 to 21%. From this data, vertex beam technique was quite effective in reduction of unnecessary irradiation to the contralateral hemispheres, integral dose, obtaining dose homogeneity in the clinical target. But it was associated with volume increment of low dose area in the brain and irradiation toward the head and neck region otherwise being not irradiated at all. Thus, this 2-D vertex technique can be a useful quasi-conformal method before getting 3-D apparatus.

• Progress in Medical Physics
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• v.10 no.2
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• pp.63-71
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• 1999

For the purpose of utilization in 3-D conformal radiotherapy and whole body radiosurgery, the Whole Body 3-Dimensional Topographic Radiation Therapy System has been developed. Whole body frame was constructed in order to be installed on the couch. Radiopaque catheters were engraved on it for the dedicated coordinate system and a MeV-Green immobilizer was used for the patient setup by the help of side panels and plastic rods. By designing and constructing the whole body frame in this way, geometrical limitation to the gantry rotation in 3-D conformal radiotherapy could be minimized and problem which radiation transmission may be altered in particular incident angles was solved. By analyzing CT images containing information of patient setup with respect to the whole body frame, localization and coordination of the target is performed so that patient setup error may be eliminated between simulation and treatment. For the verification of setup, the change of patient positioning is detected and adjusted in order to minimize the setup error by means of comparison of the body outlines using 3 CCTV cameras. To enhance efficiency of treatment procedure, this work can be done in real time by watching the change of patient setup through the monitor. The method of image subtraction in IDL (Interactive Data Language) was used to visualize the change of patient setup. Rotating X-ray system was constructed for detecting target movement due to internal organ motion. Landmark screws were implanted either on the bones around target or inside target, and variation of target location with respect to markers may be visualized in order to minimize internal setup error through the anterior and the lateral image information taken from rotating X-ray system. For CT simulation, simulation software was developed using IDL on GUI(Graphic User Interface) basis for PC and includes functions of graphic handling, editing and data acquisition of images of internal organs as well as target for the preparation of treatment planning.

• Radiation Oncology Journal
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• v.14 no.1
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• pp.77-85
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• 1996

Purpose : Multileaf collimator(MLC) is very suitable tool for conformal radio-therapy and commissioning measurements for a multileaf collimator installed on a dual energy accelerator with 6 and 10MV photons are required, For modeling the collimator with treament planning software, detailed dosimetric characterization of the multileaf collimator including the penumbra width, leaf transmission between leaf leakage and localization of the leaf ends and sides is an essential requirement. materials and Methods : Measurement of characteristic data of the MLC with 26 pair block leaves installed on CLINAC 2100C linear accelerator was performed. Low sensitive radiographic film(X-omatV) was used for the penumbra measurement and separate experiments using radiographic film and thermoluminescent dosimeters were performed to verify the dose distribution, Measured films were analized with a photodensitometer of WP700i scanner. Results : For 6 & 10 MV x-ray energies, approximately $2.0\%$ of photons incident on the multileaf collimator were transmitted and an additional $0.5\%$ leakage occurs between the leaves. Localizing the physical end of the leaves showed less than 1mm deviation from the $50\%$ decrement line and this difference is attributed to the curved shaped end on the leaves One side of a sin히e leaf corresponded to the $50\%$ decrement line, but the opposite face was aligned with a lower value. This difference is due to the tongue and groove used to decrease between leaf leakage. Alignment of the leaves to form a straight edge resulted larger penumbra at far position from isocenter as compare with divergent alloy blocks. When the MLC edge is stepped by sloping field, the isodose lines follow the leaf pattern and Produce scalloping isodose curves in tissue. The effective penumbra by 45 degree stepped MLC is about 10mm at 10cm depth for 6MV x-ray. The difference of effective penumbra in deep tissue between MLC and divergent alloy blocks is small (5mm). Conclusion : Using the characteristic data of MLC, the MLC has the clinlical acceptability and suitability for 3-D conformal radiotherapy except small field size.

• Progress in Medical Physics
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• v.14 no.3
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• pp.151-160
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• 2003

The application of more complex radiotherapy techniques using multileaf collimation (MLC), such as 3D conformal radiation therapy and intensity-modulated radiation therapy (IMRT), has increased the significance of verifying leaf position and motion. Due to thier reliability and empirical robustness, quality assurance (QA) of MLC. However easy use and the ability to provide digital data of electronic portal imaging devices (EPIDs) have attracted attention to portal films as an alternatives to films for routine qualify assurance, despite concerns about their clinical feasibility, efficacy, and the cost to benefit ratio. In this study, we developed method for daily QA of MLC using electronic portal images (EPIs). EPID availability for routine QA was verified by comparing of the portal films, which were simultaneously obtained when radiation was delivered and known prescription input to MLC controller. Specially designed two-test patterns of dynamic MLC were applied for image acquisition. Quantitative off-line analysis using an edge detection algorithm enhanced the verification procedure as well as on-line qualitative visual assessment. In conclusion, the availability of EPI was enough for daily QA of MLC leaf position with the accuracy of portal films.

• Progress in Medical Physics
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• v.23 no.2
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• pp.81-90
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• 2012

The effect of setup uncertainties on CTV dose and the correlation between setup uncertainties and setup margin were evaluated by Monte Carlo based numerical simulation. Patient specific information of IMRT treatment plan for rectal cancer designed on the VARIAN Eclipse planning system was utilized for the Monte Carlo simulation program including the planned dose distribution and tumor volume information of a rectal cancer patient. The simulation program was developed for the purpose of the study on Linux environment using open source packages, GNU C++ and ROOT data analysis framework. All misalignments of patient setup were assumed to follow the central limit theorem. Thus systematic and random errors were generated according to the gaussian statistics with a given standard deviation as simulation input parameter. After the setup error simulations, the change of dose in CTV volume was analyzed with the simulation result. In order to verify the conventional margin recipe, the correlation between setup error and setup margin was compared with the margin formula developed on three dimensional conformal radiation therapy. The simulation was performed total 2,000 times for each simulation input of systematic and random errors independently. The size of standard deviation for generating patient setup errors was changed from 1 mm to 10 mm with 1 mm step. In case for the systematic error the minimum dose on CTV $D_{min}^{stat{\cdot}}$ was decreased from 100.4 to 72.50% and the mean dose $\bar{D}_{syst{\cdot}}$ was decreased from 100.45% to 97.88%. However the standard deviation of dose distribution in CTV volume was increased from 0.02% to 3.33%. The effect of random error gave the same result of a reduction of mean and minimum dose to CTV volume. It was found that the minimum dose on CTV volume $D_{min}^{rand{\cdot}}$ was reduced from 100.45% to 94.80% and the mean dose to CTV $\bar{D}_{rand{\cdot}}$ was decreased from 100.46% to 97.87%. Like systematic error, the standard deviation of CTV dose ${\Delta}D_{rand}$ was increased from 0.01% to 0.63%. After calculating a size of margin for each systematic and random error the "population ratio" was introduced and applied to verify margin recipe. It was found that the conventional margin formula satisfy margin object on IMRT treatment for rectal cancer. It is considered that the developed Monte-carlo based simulation program might be useful to study for patient setup error and dose coverage in CTV volume due to variations of margin size and setup error.

• Radiation Oncology Journal
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• v.16 no.4
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• pp.409-423
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• 1998

Purpose : This retrospective study was tried to evaluate the clinical characteristics of patients, patterns of failure, survival rates, prognostic factors affecting survival, and treatment related toxicities when non-small cell lung cancer patients was treated by definitive radiotherapy alone or combined with chemotherapy. Materials and Methods : We evaluated the treatment results of 70 patients who were treated by definitive radiation therapy for non-small cell lung cancer at the Department of Radiation Oncology, Ewha Womans University Hospital, between March 1982 and April 1996. The number of patients of each stage was 2 in stage I, 6 in stage II, 30 in stage III-A, 29 in stage III-B, 3 in stage IV. Radiation therapy was administered by 6 MV linear accelerator and daily dose was 1.8-2.0 Gy and total radiation dose was ranged from 50.4 Gy to 72.0 Gy with median dose 59.4 Gy. Thirty four patients was treated with combined therapy with neoadjuvant or concurrent chemotherapy and radiotherapy, and most of them were administered with the multi-drug combined chemotherapy including etoposide and cisplatin. The survival rate was calculated with the Kaplan-Meier methods. Results : The overall 1-year, 2-year, and 3-year survival rates were 63$\%$, 29$\%$, and 26$\%$, respectively. The median survival time of all patients was 17 months. The disease-free survival rate for 1-year and 2-year were 23$\%$ and 16$\%$, respectively. The overall 1-year survival rates according to the stage was 100$\%$ for stage I, 80$\%$ for stage II, 61$\%$ for stage III, and 50$\%$ for stage IV. The overall 1-year 2-year, and 3-year survival rates for stage III patients only were 61$\%$, 23$\%$, and 20$\%$, respectively. The median survival time of stage III patients only was 15 months. The complete response rates by radiation therapy was 10$\%$ and partial response rate was 50$\%$. Thirty patients (43$\%$) among 70 patients assessed local control at initial 3 months follow-up duration. Twenty four (80$\%$) of these 30 Patients was possible to evaluate the pattern of failure after achievement of local control. And then, treatment failure occured in 14 patients (58$\%$): local relapse in 6 patients (43$\%$), distant metastasis in 6 patients (43$\%$) and local relapse with distant metastasis in 2 patients (14$\%$). Therefore, 10 patients (23$\%$) were controlled of disease of primary site with or without distant metastases. Twenty three patients (46$\%$) among 50 patients who were possible to follow-up had distant metastasis. The overall 1-year survival rate according to the treatment modalities was 59$\%$ in radiotherapy alone and 66$\%$ in chemoirradiation group. The overall 1-year survival rates for stage III patients only was 51$\%$ in radiotherapy alone and 68$\%$ in chemoirradiation group which was significant different. The significant prognostic factors affecting survival rate were the stage and the achievement of local control for all patients at univariate- analysis. Use of neoadjuvant or concurrent chemotherapy, use of chemotherapy and the achievement of local control for stage III patients only were also prognostic factors. The stage, pretreatment performance status, use of neoadjuvant or concurrent chemotherapy, total radiation dose and the achievement of local control were significant at multivariate analysis. The treatment-related toxicities were esophagitis, radiation pneunonitis, hematologic toxicity and dermatitis, which were spontaneously improved, but 2 patients were died with radiation pneumonitis. Conclusion : The conventional radiation therapy was not sufficient therapy for achievement of long-term survival in locally advanced non-small cell lung cancer. Therefore, aggressive treatment including the addition of appropriate chemotherapeutic drug to decrease distant metastasis and preoperative radiotherapy combined with surgery, hyperfractionation radiotherapy or 3-D conformal radiation therapy for increase local control are needed.

• Progress in Medical Physics
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• v.20 no.4
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• pp.269-276
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• 2009

Radiation treatment techniques using photon beam such as three-dimensional conformal radiation therapy (3D-CRT) as well as intensity modulated radiotherapy treatment (IMRT) demand accurate dose calculation in order to increase target coverage and spare healthy tissue. Both jaw collimator and multi-leaf collimators (MLCs) for photon beams have been used to achieve such goals. In the Pinnacle3 treatment planning system (TPS), which we are using in our clinics, a set of model parameters like jaw collimator transmission factor (JTF) and MLC transmission factor (MLCTF) are determined from the measured data because it is using a model-based photon dose algorithm. However, model parameters obtained by this auto-modeling process can be different from those by direct measurement, which can have a dosimetric effect on the dose distribution. In this paper we estimated JTF and MLCTF obtained by the auto-modeling process in the Pinnacle3 TPS. At first, we obtained JTF and MLCTF by direct measurement, which were the ratio of the output at the reference depth under the closed jaw collimator (MLCs for MLCTF) to that at the same depth with the field size $10{\times}10\;cm^2$ in the water phantom. And then JTF and MLCTF were also obtained by auto-modeling process. And we evaluated the dose difference through phantom and patient study in the 3D-CRT plan. For direct measurement, JTF was 0.001966 for 6 MV and 0.002971 for 10 MV, and MLCTF was 0.01657 for 6 MV and 0.01925 for 10 MV. On the other hand, for auto-modeling process, JTF was 0.001983 for 6 MV and 0.010431 for 10 MV, and MLCTF was 0.00188 for 6 MV and 0.00453 for 10 MV. JTF and MLCTF by direct measurement were very different from those by auto-modeling process and even more reasonable considering each beam quality of 6 MV and 10 MV. These different parameters affect the dose in the low-dose region. Since the wrong estimation of JTF and MLCTF can lead some dosimetric error, comparison of direct measurement and auto-modeling of JTF and MLCTF would be helpful during the beam commissioning.

• Progress in Medical Physics
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• v.13 no.4
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• pp.202-208
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• 2002

The purpose of this study is to evaluate the monitor unit obtained from various methods for the treatment of superficial cancers using electron beams. Thirty-three breast cancer patients who were treated in our institution with 6, 9, and 12 MeV electron beams, were selected for this study. For each patient, irregularly shaped treatment blocks were drawn on simulation film and constructed. Using the irregular blocks, monitor units to deliver 100 cGy to the dose maximum (dmax) were calculated from measurement and three-dimensional radiation treatment planning (3D RTP) system (PINNACLE 6.0, ADAC Laboratories, Milpitas CA) Measurements were made in solid water phantom with plane parallel (PP) chamber (Roos, OTW Germany) at 100 cm source-to surface distances. CT data was used to investigate the effect of heterogeneity. Monitor units were calculated by overriding CT values with 1 g/㎤ and in the presence of heterogeneity. The monitor unit values obtained by the above methods were compared. The dose, obtained from measurement in solid water phantom was higher than that of RTP values for irregularly shaped blocks. The maximum differences between monitor unit calculated in flat water phantom at gantry zero position were 4% for 6 MeV and 2% for 9 and 12 MeV electrons. When CT data was used at a various gantry angle the agreement between the TPS data with and without density correction was within 3% for all energies. These results indicate that there are no significant difference in terms of monitor unit when density is corrected for the treatment of breast cancer patients with electrons.

• Progress in Medical Physics
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• v.19 no.4
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• pp.231-240
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• 2008

We developed a user-friendly program to independently verify monitor units (MUs) calculated by radiation treatment planning systems (RTPS), as well as to manage beam database in clinic. The off-axis factor, beam hardening effect, inhomogeneity correction, and the different depth correction were incorporated into the program algorithm to improve the accuracy in calculated MUs. A beam database in the program was supposed to use measured data from routine quality assurance (QA) processes for timely update. To enhance user's convenience, a graphic user interface (GUI) was developed by using Visual Basic for Application. In order to evaluate the accuracy of the program for various treatment conditions, the MU comparisons were made for 213 cases of phantom and for 108 cases of 17 patients treated by 3D conformal radiation therapy. The MUs calculated by the program and calculated by the RTPS showed a fair agreement within ${\pm}3%$ for the phantom and ${\pm}5%$ for the patient, except for the cases of extreme inhomogeneity. By using Visual Basic for Application and Microsoft Excel worksheet interface, the program can automatically generate beam data book for clinical reference and the comparison template for the beam data management. The program developed in this study can be used to verify the accuracy of RTPS for various treatment conditions and thus can be used as a tool of routine RTPS QA, as well as independent MU checks. In addition, its beam database management interface can update beam data periodically and thus can be used to monitor multiple beam databases efficiently.

• Progress in Medical Physics
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• v.24 no.4
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• pp.237-242
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• 2013

In the intracranial regions, an accurate delineation of the target volume has been difficult with only the CT data due to poor soft tissue contrast of CT images. Therefore, the magnetic resonance images (MRI) for the delineation of the target volumes were widely used. To calculate dose distributions with MRI-based RTP, the electron density (ED) mapping concept from the diagnostic CT images and the pseudo CT concept from the MRI were introduced. In this study, the look up table (LUT) from the fifteen patients' diagnostic brain MRI images was created to verify the feasibility of MRI-based RTP. The dose distributions from the MRI-based calculations were compared to the original CT-based calculation. One MRI set has ED information from LUT (lMRI). Another set was generated with voxel values assigned with a homogeneous density of water (wMRI). A simple plan with a single anterior 6MV one portal was applied to the CT, lMRI, and wMRI. Depending on the patient's target geometry for the 3D conformal plan, 6MV photon beams and from two to five gantry portals were used. The differences of the dose distribution and DVH between the lMRI based and CT-based plan were smaller than the wMRI-based plan. The dose difference of wMRI vs. lMRI was measured as 91 cGy vs. 57 cGy at maximum dose, 74 cGt vs. 42 cGy at mean dose, and 94 cGy vs. 53 at minimum dose. The differences of maximum dose, minimum dose, and mean dose of the wMRI-based plan were lower than the lMRI-based plan, because the air cavity was not calculated in the wMRI-based plan. These results prove the feasibility of the lMRI-based planning for brain tumor radiation therapy.