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Analysis of the Imaging Dose for IGRT/Gated Treatments.

Jung Suk SHIN ; Youngyih HAN ; Sang Gyu JU ; Eunhyuk SHIN ; Chae Seon HONG ; Yong Chan AHN

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):42-48. doi:10.3857/jkstro.2009.27.1.42

PURPOSE: The introduction of image guided radiation therapy/four-dimensional radiation therapy (IGRT/4DRT) potentially increases the accumulated dose to patients from imaging and verification processes as compared to conventional practice. It is therefore essential to investigate the level of the imaging dose to patients when IGRT/4DRT devices are installed. The imaging dose level was monitored and was compared with the use of pre-IGRT practice. MATERIALS AND METHODS: A four-dimensional CT (4DCT) unit (GE, Ultra Light Speed 16), a simulator (Varian Acuity) and Varian IX unit with an on-board imager (OBI) and cone beam CT (CBCT) were installed. The surface doses to a RANDO phantom (The Phantom Laboratory, Salem, NY USA) were measured with the newly installed devices and with pre-existing devices including a single slice CT scanner (GE, Light Speed), a simulator (Varian Ximatron) and L-gram linear accelerator (Varian, 2100C Linac). The surface doses were measured using thermo luminescent dosimeters (TLDs) at eight sites-the brain, eye, thyroid, chest, abdomen, ovary, prostate and pelvis. RESULTS: Compared to imaging with the use of single slice non-gated CT, the use of 4DCT imaging increased the dose to the chest and abdomen approximately ten-fold (1.74+/-0.34 cGy versus 23.23+/-3.67 cGy ). Imaging doses with the use of the Acuity simulator were smaller than doses with the use of the Ximatron simulator, which were 0.91+/-0.89 cGy versus 6.77+/-3.56 cGy, respectively. The dose with the use of the electronic portal imaging device (EPID; Varian IX unit) was approximately 50% of the dose with the use of the L-gram linear accelerator (1.83+/-0.36 cGy versus 3.80+/-1.67 cGy). The dose from the OBI for fluoroscopy and low-dose mode CBCT were 0.97+/-0.34 cGy and 2.3+/-0.67 cGy, respectively. CONCLUSION: The use of 4DCT is the major source of an increase of the radiation (imaging) dose to patients. OBI and CBCT doses were small, but the accumulated dose associated with everyday verification need to be considered
Abdomen ; Brain ; Cone-Beam Computed Tomography ; Electronics ; Electrons ; Eye ; Female ; Fluoroscopy ; Four-Dimensional Computed Tomography ; Humans ; Light ; Ovary ; Particle Accelerators ; Pelvis ; Prostate ; Thorax ; Thyroid Gland

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A Study of the Radiotherapy Techniques for the Breast Including Internal Mammary Lymph Nodes.

Kyoungkeun JEONG ; Su Jung SHIM ; Sei Hwan YOU ; Yong Bae KIM ; Ki Chang KEUM ; Jong Dae KIM ; Chang Ok SUH

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):35-41. doi:10.3857/jkstro.2009.27.1.35

PURPOSE: This study was designed to determine the optimum radiotherapy technique for internal mammary node (IMN) irradiation after breast-conserving surgery. MATERIALS AND METHODS: We selected ten cases of early stage partial mastectomy for plan comparison. Five of the patients were treated to the right-side breast and the rest of the patients were treated to the left-side breast. For each case, four different treatment plans were made to irradiate the entire breast, IMNs and supraclavicular lymph nodes (SCLs). The four planning techniques include a standard tangential field (STF), wide tangential field (WTF), partially wide tangential field (PWT) and a photon-electron mixed field (PEM). We prescribed a dose of 50.4 Gy to the SCL field at a 3 cm depth and isocenter of the breast field. RESULTS: The dose distribution showed clear characteristics depending on the technique used. All of the techniques covered the breast tissue well. IMN coverage was also good, except for the STF, which was not intended to cover IMNs. For the cases of the left-side breasts, the volume of the heart that received more than 30 Gy was larger (in order) for the WTF, PWT, PEM and STF. For radiation pneumonitis normal tissue complication probability (NTCP), the PWT showed the best results followed by the STF. CONCLUSION: Despite the variety of patient body shapes, the PWT technique showed the best results for coverage of IMNs and for reducing the lung and heart dose.
Breast ; Breast Neoplasms ; Heart ; Humans ; Lung ; Lymph Nodes ; Mastectomy, Segmental ; Planning Techniques ; Radiation Pneumonitis

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Long Term Results of Radiation Therapy in Early Glottic Cancer.

Sang Jun BYUN ; Jin Hee KIM

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):29-34. doi:10.3857/jkstro.2009.27.1.29

PURPOSE: This study was designed to evaluate long-term results in terms of failure, survival and voice preservation after radiation therapy for early glottic cancer. MATERIALS AND METHODS: From February 1988 to December 2003, 70 patients with early glottic cancer were treated with radiation therapy at Keimyung University Dongsan Medical Center. Patient age distribution was from 39 to 79 years, with a median age of 62 years. All patients had squamous cell carcinoma. According to the TNM stage, 58 patients had stage I disease, 12 patients had stage II disease; 67 patients were male. The laryngeal area was irradiated with the use of bilateral opposing fields with/without a wedge filter with 6 MV photons at a total dose of 54~70.2 Gy in 1.8~2.2 Gy fractions over 6~8 weeks. We delivered a median radiation dose of 60 Gy for stage I patients and a median radiation dose of 66 Gy for stage II patients. Salvage surgery was performed in patients with local recurrence. The voice preservation rate was analyzed after all treatments including salvage surgery. Follow-up periods were from 13 to 180 months, with a median follow-up period of 77.5 months. The survival rate was analyzed by the use of the Kaplan Meier method and log rank test. A comparison of two groups was performed with the use of the chi-squared test. RESULTS: The local control rate was 98.5% (69/70). The five-year-overall survival rate was 93.9%. The five-year disease free survival rate (5YDFS) was 84.1% and the 5YDFS after radiation and salvage surgery was 92.8%. According to stage, the 5YDFS was 93.1% and 91.7% for stage I and stage II respectively. Thirteen patients (18.5%) had local failure with 24 months of median time to local failure and nine patients received salvage surgery; however, four patients were lost to follow-up after a diagnosis of recurrence. Only two patients died due to a distant metastasis at 33 months and 71 months after radiation therapy, respectively. Nine patients died due to other diseases with a median time of 73 months. There were no severe acute or chronic complications after radiation therapy. Voice preservation was ultimately achieved in 88.5% (62/70) of patients. CONCLUSION: We considered that radiation therapy was effective and we achieved excellent survival and voice preservation in early laryngeal cancer. The use of radiation therapy should be the first choice for the treatment of early glottic cancer.
Age Distribution ; Carcinoma, Squamous Cell ; Disease-Free Survival ; Follow-Up Studies ; Humans ; Laryngeal Neoplasms ; Lost to Follow-Up ; Male ; Neoplasm Metastasis ; Photons ; Recurrence ; Survival Rate ; Voice

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External Beam Radiotherapy in the Management of Low Grade Astrocytoma of the Brain.

Ha Chung CHUN

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):23-28. doi:10.3857/jkstro.2009.27.1.23

PURPOSE: This study was designed to evaluate the effectiveness of postoperative radiotherapy for patients with low-grade astrocytomas and to define an optimal radiotherapeutic regimen and prognostic factors. MATERIALS AND METHODS: A total of 69 patients with low-grade astrocytomas underwent surgery and postoperative radiotherapy immediately following surgery at our institution between October 1989 and September 2006. The median patient age was 36 years. Forty-one patients were 40 years or younger and 28 patients were 41 years or older. Fourteen patients underwent a biopsy alone and the remaining 55 patients underwent a subtotal resection. Thirty-nine patients had a Karnofsky performance status of less than 80% and 30 patients had a Karnofsky performance status greater than 80%. Two patients were treated with whole brain irradiation followed by a coned down boost field to the localized area. The remaining 67 patients were treated with a localized field with an appropriate margin. Most of the patients received a dose of 50~55 Gy and majority of the patients were treated with a dose of 54 Gy. RESULTS: The overall 5-year and 7-year survival rates for all of the 69 patients were 49% and 44%, respectively. Corresponding disease free survival rates were 45% and 40%, respectively. Patients who underwent a subtotal resection showed better survival than patients who underwent a biopsy alone. The overall 5-year survival rates for patients who underwent a subtotal resection and patients who underwent a biopsy alone were 57% and 38%, respectively (p<0.05). Forty-one patients who were 40 years or younger showed a better overall 5-year survival rate as compared with 28 patients who were 41 years or older (56% versus 40%, p<0.05). The overall 5-year survival rates for 30 patients with a Karnofsky performance status greater than 80% and 39 patients with a Karnofsky performance status less than 80% were 51% and 47%, respectively. This finding was not statistically significant. Although one patient was not able to complete the treatment because of neurological deterioration, there were no significant treatment related toxicities. CONCLUSION: Postoperative radiotherapy following surgery is a safe and effective treatment for patients with low-grade astrocytomas. The extent of surgery and age were noted as significant prognostic factors in this study. However, further effective treatment might be necessary in the future to improve long-term survival rates.
Astrocytoma ; Biopsy ; Brain ; Disease-Free Survival ; Humans ; Karnofsky Performance Status ; Survival Rate

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Analysis of Bone Mineral Density and Related Factors after Pelvic Radiotherapy in Patients with Cervical Cancer.

Sun Shin YI ; Tae Sig JEUNG

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):15-22. doi:10.3857/jkstro.2009.27.1.15

PURPOSE: This study was designed to evaluate the effects on bone mineral density (BMD) and related factors according to the distance from the radiation field at different sites. This study was conducted on patients with uterine cervical cancer who received pelvic radiotherapy. MATERIALS AND METHODS: We selected 96 patients with cervical cancer who underwent determination of BMD from November 2002 to December 2006 after pelvic radiotherapy at Kosin University Gospel Hospital. The T-score and Z-score for the first lumbar spine (L1), fourth lumbar spine (L4) and femur neck (F) were analyzed to determine the difference in BMD among the sites by the use of ANOVA and the post-hoc test. The study subjects were evaluated for age, body weight, body mass index (BMI), post-radiotherapy follow-up duration, intracavitary radiotherapy (ICR) and hormonal replacement therapy (HRT). Association between the characteristics of the study subjects and T-score for each site was evaluated by the use of Pearson's correlation and multiple regression analysis. RESULTS: The average T-score for all ages was -1.94 for the L1, -0.42 for the L4 and -0.53 for the F. The average Z-score for all ages was -1.11 for the L1, -0.40 for the L4 and -0.48 for the F. The T-score and Z-score for the L4 and F were significantly different from the scores for the L1 (p<0.05). There was no significant difference between the L4 and F. Results for patients younger than 60 years were the same as for all ages. Age and ICR were negatively correlated and body weight and HRT were positively correlated with the T-score for all sites (p<0.05). BMI was positively correlated with the T-score for the L4 and F (p<0.05). Based on the use of multiple regression analysis, age was negatively associated with the T-score for the L1 and F and was positively correlated for the L4 (p<0.05). Body weight was positively associated with the T-score for all sites (p<0.05). ICR was negatively associated with the T-score for the L1 (p<0.05). HRT was positively associated with the T-score for the L4 and F (p<0.05). CONCLUSION: The T-score and Z-score for the L4 and F were significantly higher than the scores for the L1, a finding in contrast to some previous studies on normal women. It was thought that radiation could partly influence BMD because of a higher T-score and Z-score for sites around the radiotherapy field. We suggest that a further long-term study is necessary to determine the clinical significance of these findings, which will influence the diagnosis of osteoporosis based on BMD in patients with cervical cancer who have received radiotherapy.
Body Mass Index ; Body Weight ; Bone Density ; Female ; Femur Neck ; Follow-Up Studies ; Humans ; Osteoporosis ; Spine ; Uterine Cervical Neoplasms

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Results of Radiation Therapy for Squamous Cell Carcinoma of the Esophagus.

Ha Chung CHUN ; Myung Za LEE

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):10-14. doi:10.3857/jkstro.2009.27.1.10

PURPOSE: This study was designed to evaluate the effectiveness and prognostic factors for patients treated with postoperative radiation therapy following surgery or with radiation therapy alone for squamous cell carcinoma of the esophagus. MATERIALS AND METHODS: We retrospectively analyzed 132 esophageal cancer patients treated with postoperative radiation therapy following surgery or patients who were treated with radiation therapy alone at our institution from 1989 to 2006. Thirty-five patients had stage II disease, 88 patients had stage III disease and nine patients had stage IV disease. Tumors were located at the upper esophagus in 18 patients, the mid esophagus in 81 patients and the distal esophagus in 33 patients. Sixty patients were treated with radiation therapy alone and 72 patients were treated with postoperative radiation therapy following surgery. Eight patients received a dose less than 40 Gy and 78 patients received a dose of 40 to 50 Gy. The remaining 46 patients received a dose of 50 to 60 Gy. The majority of patients who underwent postoperative radiation therapy received a dose of 45 Gy. RESULTS: Actuarial survival rates for all of the patients at two years and five years were 24% and 5%, respectively. The median survival time was 11 months. Survival rates for patients who underwent postoperative RT at two years and five years were 29% and 8%, respectively. The corresponding survival rates for patients who received radiation alone were 18% and 2%, respectively. Survival rates at two years and five years were 43% and 15% for stage II disease, 22% and 2% for stage III disease and 0% and 0% for stage IV disease, respectively; these findings were statistically significant. Two-year survival rates for patients with upper, middle and distal esophageal cancer were 19, 29% and 22%, respectively. Although there was a trend of slightly better survival for middle esophageal tumors, this finding was not statistically significant. Complete response to radiation was achieved in 13 patients (22%) and partial response to radiation was achieved in 40 patients (67%) who received radiation alone. No response to radiation was noted in seven patients (12%). A statistically significant difference in survival rates was seen between patients that had a complete response and patients that had a partial response. Two-year survival rates for patients that had a complete response versus patients that had a partial response were 31% and 17%, respectively. There were no survivors for patients with no response as determined at two-year follow-up. CONCLUSION: We conclude that radiation therapy is an effective treatment for esophageal cancer. Stage and response to radiation therapy were noted to be prognostic factors. A more effective treatment modality is needed to improve long term survival because of the relatively dismal prognosis for this tumor.
Carcinoma, Squamous Cell ; Esophageal Neoplasms ; Esophagus ; Follow-Up Studies ; Humans ; Prognosis ; Retrospective Studies ; Survival Rate ; Survivors

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Post Pelvic Radiotherapy Bony Changes.

Seung Jae HUH

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2009;27(1):1-9. doi:10.3857/jkstro.2009.27.1.1

There has been recent interest in radiation-induced bone injury in clinical conditions, especially for pelvic insufficiency fracture (PIF). A PIF is caused by the effect of normal or physiological stress on bone with demineralization and decreased elastic resistance. Pelvic radiotherapy (RT) can also contribute to the development of a PIF. A PIF has been regarded as a rare complication with the use of megavoltage equipment. However, recent studies have reported the incidence of PIFs as 8.2~20% after pelvic RT in gynecological patients, an incidence that was higher than previously believed. The importance of understanding a PIF lies in the potential for misdiagnosis as a bony metastasis. If patients complain of pelvic pain after whole-pelvis radiation therapy, the presence of a PIF must be considered in the differential diagnosis. The use of multibeam arrangements and conformal RT to reduce the volume and dose of irradiated pelvic bone can be helpful to minimize the risk of fracture. In addition to a PIF, osteonecrosis and avascular necrosis of the femoral head can develop after radiation therapy. Osteoradionecrosis of the pelvic bone is a clinical diagnostic challenge that must be differentiated from an osseous metastasis. A post-radiation bone sarcoma can result as a long-term sequela of pelvic irradiation for uterine cervical cancer.
Diagnosis, Differential ; Diagnostic Errors ; Fractures, Stress ; Head ; Humans ; Incidence ; Necrosis ; Neoplasm Metastasis ; Osteonecrosis ; Osteoradionecrosis ; Pelvic Bones ; Pelvic Pain ; Sarcoma ; Stress, Physiological ; Uterine Cervical Neoplasms

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Tissue Inhomogeneity Correction in Clinical Application of Transmission Dosimetry to Head and Neck Cancer Radiation Treatment.

Suzy KIM ; Sung Whan HA ; Hong Gyun WU ; Soon Nyung HUH

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2004;22(2):155-163.

PURPOSE: To confirm the reproducibility of in vivo transmission dosimetry system and the accuracy of the algorithms for the estimation of transmission dose in head and neck radiation therapy patients. MATERIALS AND MEHTODS: From September 5 to 18, 2001, transmission dose measurements were performed when radiotherapy was given to brain or head and neck cancer patients. The data of 35 patients who were treated more than three times and whose central axis of the beam was not blocked were analyzed in this study. To confirm the reproducibility of this system, transmission dose was measured before daily treatment and then repetitively every hour during the treatment time, with a field size of 10x10 cm2 and a delivery of 100 MU. The accuracy of the transmission dose calculation algorithms was confirmed by comparing estimated dose with measured dose. To accurately estimate transmission dose, tissue inhomogeneity correction was done. RESULTS: The measurement variations during a day were within +/-0.5% and the daily variations in the checked period were within +/-1.0%, which were acceptable for system reproducibility. The mean errors between estimated and measured doses were within +/-5.0% in patients treated to the brain, +/-2.5% in head, and +/-5.0% in neck. CONCLUSION: The results of this study confirmed the reproducibility of our system and its usefulness and accuracy for daily treatment. We also found that tissue inhomogeneity correction was necessary for the accurate estimation of transmission dose in patients treated to the head and neck.
Axis, Cervical Vertebra ; Brain ; Brain Neoplasms ; Head and Neck Neoplasms* ; Head* ; Humans ; Neck ; Radiotherapy

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A Novel Chenodeoxycholic Derivative HS-1200 Enhances Radiation-induced Apoptosis in Human MCF-7 Breast Cancer Cells.

Hyung Sik LEE ; Young Min CHOI ; Hyuk Chan KWON ; Yeon Suk SONG

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2004;22(2):145-154.

PURPOSE: To examine whether a synthetic bile acid derivatives (HS-1200) sensitizes the radiation-induced apoptosis in human breast cancer cells (MCF-7) and to investigate the underlying mechanism. MATERIALS AND MEHTODS: Human breast cancer cells (MCF-7) in exponential growth phase were treated with HS-1200 for 24 hours at 37degrees C with 5% CO2 in air atmosphere. After removal of HS-1200, cells were irradiated with 2~8 Gy X-ray, and then cultured in drug-free media for 24-96 hours. The effect of radiation on the clonogenicity of MCF-7 cells was determined with clonogenic cell survival assay with 16muM of HS-1200. The induction of apoptosis was determined using agarose gel electrophoresis and Hoechst staining. The expression level of apoptosis-related molecules, such as PARP, Bax, Bcl-2, Bak and AIF, were assayed by Western blotting analysis with 40muM of HS-1200 combined with 8 Gy irradiation. To examine the cellular location of cytochrome c, bax and AIF immunofluorescent stainings were undertaken RESULTS: Treatment of MCF-7 cells with 40muM of HS-1200 combined with 8 Gy irradiation showed several changes associated with enhanced apoptosis by agarose gel electrophoresis and Hoechst staining. HS-1200 combined with 8 Gy irradiation treatment also enhanced production of PARP cleavage products and increased Bax/Bcl-2 ratio by Western blotting. Loss of mitochondrial membrane potential (delta psi m) and increased cytochrome c staining indicated that cytochrome c had been released from the mitochondria in HS-1200 treated cells. CONCLUSION: We demonstrated that combination treatment with a synthetic chenodeoxycholic acid derivative HS-1200 and irradiation enhanced radiation-induced apoptosis of human breast cancer cells (MCF-7). We suggest that the increased Bax/Bcl-2 ratio in HS-1200 co-treatment group underlies the increased radiosensitivity of MCF-7 cells. Further futures studies are remained elusive.
Apoptosis* ; Atmosphere ; Bile ; Blotting, Western ; Breast Neoplasms* ; Breast* ; Cell Survival ; Chenodeoxycholic Acid ; Cytochromes c ; Electrophoresis, Agar Gel ; Humans* ; MCF-7 Cells ; Membrane Potential, Mitochondrial ; Mitochondria ; Radiation Tolerance

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Trichostatin A, a Histone Deacetylase Inhibitor, Potentiated Cytotoxic Effect of Ionizing Radiation in Human Head and Neck Cancer Cell Lines.

Jin Ho KIM ; Jin Hee SHIN ; Eui Kyu CHIE ; Hong Gyun WU ; Jae Sung KIM ; Il Han KIM ; Sung Whan HA ; Charn Il PARK ; Wee Saing KANG

The Journal of the Korean Society for Therapeutic Radiology and Oncology.2004;22(2):138-144.

PURPOSE: We have previously reported that human glioblastoma cells are sensitized to radiation-induced death after their exposure to trichostatin A (TSA), a histone deacetylase inhibitor (HDAC-I), prior to the irradiation. We aimed to measure the magnitude of the radiosensitizing effect of TSA in human head and neck cancer cell lines. MATERIALS AND MEHTODS: Human head and neck cancer cell lines, HN-3 and HN-9, were exposed to 0, 50, 100, and 200 nM TSA for 18 hr prior to irradiation. Then, the TSA-treated cells were irradiated with 0, 2, 4, 6, and 8 Gy, and cell survival was measured by clonogenic assay. RESULTS: Pre-irradiation exposure to TSA was found to radiosensitize HN-3 and HN-9 cell lines. In HN-9 cells, the fraction surviving after 2 Gy (SF2) was significantly reduced by treatment of TSA at concentration as low as 50 nM. However, a treatment with 200 nM TSA was required to significantly decrease SF2 in the HN-3 cell line. SER of pre-irradiation treatment with 200 nM TSA was 1.84 in HN-3 and 7.24 in HN-9, respectively. CONCLUSIONS: Our results clearly showed that human head and neck cancer cell lines can be sensitized to ionizing radiation by pre-irradiation inhibition of histone deacetylase (HDAC) using TSA, and that this potentiation might well be a general phenomenon.
Cell Line* ; Cell Survival ; Glioblastoma ; Head and Neck Neoplasms* ; Head* ; Histone Deacetylase Inhibitors* ; Histone Deacetylases* ; Histones* ; Humans* ; Radiation, Ionizing* ; Radiation-Sensitizing Agents

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