Treatment Outcomes of Three-Dimensional Conformal Radiotherapy for Stage III N on-Small Cell Lung Cancer

여승구,Moon-June Cho,Sun-Young Kim,Seung-Pyung Lim,Ki-Hwan Kim,Jun-Sang Kim 대한암학회 2005 Cancer Research and Treatment Vol.37 No.5

Purpose: To evaluate the treatment outcomes of the three-dimensional conformal radiotherapy (3D-CRT), in conjunction with induction chemotherapy, for the treatment of stage III non-small cell lung cancer (NSCLC). Materials and Methods: Between November 1998 and March 2003, 22 patients with histologically proven, clinical stage III NSCLC, treated with induction chemotherapy,followed by 3D-CRT, were retrospectively analyzed. There were 21 males (96%) and 1 female (4%), with a median age of 68.5 (range, 42∼79). The clinical cancer stages were IIIA and IIIB in 41 and 59%, respectively. The histologies were squamous cell carcinoma, adenocarcinoma and others in 73, 18 and 9%, respectively. Twenty patients (91%) received induction chemotherapy before radiation therapy. The majority of the chemotherapy regimen consisted of cisplatin and gemcitabine. Radiation was delivered with conventional anteroposterior/ posteroanterior fields for 36 Gy, and then 3D-CRT was performed. The total radiation dose was 70.2 Gy. The median follow-up period was 17 months (range, 4∼59 months).Results: The median overall survival was 19 months. The two and four-year overall survival rates were 37.9 and 30.3%, respectively. The median progression-free survival was 21 months. The two and four-year progression-free survival rates were 42.1 and 21%, respectively. The prognostic factors for overall survival by a univariate analysis were age, histology and T stage (p〈0.05). Acute radiation toxicities, as evaluated by the RTOG toxicity criteria, included two cases of grade 3 lung toxicity and one case of grade 2 esophagus toxicity.Conclusion: The radiation dose could be increased without a significant increment in the acute toxicities when using 3D-CRT. It also seems to be a safe, welltoleratedand effective treatment modality for stage III NSCLC.

국한성병기 소세포폐암에서 하루 두 번 분할조사와동시 화학방사선치료

여승구,조문준,김선영,김기환,김준상 대한방사선종양학회 2006 Radiation Oncology Journal Vol.24 No.2

An Update on Preoperative Radiotherapy for Locally Advanced Rectal Cancer

여승구,김대용 대한대장항문학회 2012 Annals of Coloproctolgy Vol.28 No.4

Even in patients undergoing an optimal surgical technique (e.g., total mesorectal excision), radiotherapy provides a significant benefit in the local control of rectal cancer. Compared with postoperative treatment, chemoradiotherapy given preoperatively has been shown to decrease local recurrence rates and toxicity. Additionally, preoperative chemoradiotherapy permits the early identification of tumor responses to this cytotoxic treatment by surgical pathology. Pathological parameters reflecting the tumor response to chemoradiotherapy have been shown to be surrogate markers for long-term clinical outcomes. Post-chemoradiotherapy downstaging from cStage II-III to ypStage 0-I indicates a favorable prognosis, with no difference between ypStage 0 and ypStage I. Research is ongoing to develop useful tools (clinical, molecular, and radiological)for clinical determination of the pathologic chemoradiotherapeutic response before surgery, and possibly even before preoperative treatment. In the future, risk-adapted strategies, including intensification of preoperative therapy, conservative surgery, or the selective administration of postoperative chemotherapy, will be realized for locally-advanced rectal cancer patients based on their response to preoperative chemoradiotherapy.

Efficient approach for determining four-dimensional computed tomography-based internal target volume in stereotactic radiotherapy of lung cancer

여승구,김은석 대한방사선종양학회 2013 Radiation Oncology Journal Vol.31 No.4

Purpose: This study aimed to investigate efficient approaches for determining internal target volume (ITV) from four-dimensional computed tomography (4D CT) images used in stereotactic body radiotherapy (SBRT) for patients with early-stage non-small cell lung cancer (NSCLC). Materials and Methods: 4D CT images were analyzed for 15 patients who received SBRT for stage I NSCLC. Three different ITVs were determined as follows: combining clinical target volume (CTV) from all 10 respiratory phases (ITV10Phases); combining CTV from four respiratory phases, including two extreme phases (0% and 50%) plus two intermediate phases (20% and 70%) (ITV4Phases); and combining CTV from two extreme phases (ITV2Phases). The matching index (MI) of ITV4Phases and ITV2Phases was defined as the ratio of ITV4Phases and ITV2Phases, respectively, to the ITV10Phases. The tumor motion index (TMI) was defined as the ratio of ITV10Phases to CTVmean, which was the mean of 10 CTVs delineated on 10 respiratory phases. Results: The ITVs were significantly different in the order of ITV10Phases, ITV4Phases, and ITV2Phases (all p < 0.05). The MI of ITV4Phases was significantly higher than that of ITV2Phases (p < 0.001). The MI of ITV4Phases was inversely related to TMI (r = –0.569, p = 0.034). In a subgroup with low TMI (n = 7), ITV4Phases was not statistically different from ITV10Phases (p = 0.192) and its MI was significantly higher than that of ITV2Phases (p = 0.016). Conclusion: The ITV4Phases may be an efficient approach alternative to optimal ITV10Phases in SBRT for early-stage NSCLC with less tumor motion.

Twice Daily Radiation Therapy Plus Concurrent Chemotherapy for Limited-Stage Small Cell Lung Cancer

Seung-Gu Yeo(여승구),Moon-June Cho(조문준),Sun-Young Kim(김선영),Ki-Whan Kim(김기환),Jun-Sang Kim(김준상) 대한방사선종양학회 2006 Radiation Oncology Journal Vol.24 No.2

목 적: 국한성병기 소세포폐암 환자에서 하루 두 번 분할조사에 의한 동시 화학방사선치료의 효율성을 치료반응률, 생존율, 실패양상, 치료부작용 등의 관점에서 평가하기 위해 후향적 연구를 수행하였다. 대상 및 방법: 1993년 2월부터 2002년 10월까지 총 76명의 환자가 조직학적으로 증명된 국한성병기 소세포폐암으로 하루 두 번 분할조사에 의한 동시 화학방사선치료를 시행 받았다. 대상환자 중 남성은 84% (64/76) 이었고, 중앙연령은 57세였다(32∼75세). 흉부방사선치료는 120 또는 150 cGy/fraction로 최소 6시간의 간격을 두고 하루 두 번, 한 주에 5일 시행하였다. 총 흉부조사선량의 중앙값은 50.4 Gy였다(45∼51 Gy). 동시 화학치료은 3주 간격으로 교대 CAV (cytoxan 1,000 mg/m2, adriamycin 40 mg/m2, vincristine 1 mg/m2)/PE (cisplatin 60 mg/m2, etoposide 100 mg/m2)이거나, 혹은 단독 PE 요법이 사용되었다. 화학치료 횟수의 중앙값은 6회였다(1∼9회). 예방적 전뇌조사는 완전관해를 보인 환자에게 25 Gy/10 fractions로 시행되었다. 중앙추적관찰기간은 18개월이었다(1∼136개월). 결 과: 치료의 반응률은 86%이었다; 완전관해가 39명(52%), 부분관해가 26명(34%)이었다. 중앙생존기간은 23개월이었다. 1년, 2년, 3년 생존율은 각각 72%, 50%, 30%이었다. 단변량분석에서 치료 반응률이 생존율의 유의한 예후인자로 밝혀졌다(p<0.001). 등급 3 이상의 급성부작용은 백혈구감소 46명(61%), 적혈구 감소 5명(6%), 혈소판 감소 10명(13%), 식도염 5명(6%), 그리고 폐독성이 2명(2%)에서 있었다. 추척관찰이 가능했던 73명의 환자 중 총 38명(52%)에서 병의 진행이 관찰되었다. 첫 번째 원격전이 장소의 빈도는 뇌가 가장 높았다.결 론: 하루 두 번 분할조사에 의한 동시 화학방사선치료는 국한성병기 소세포폐암 환자에서 나쁘지 않은 부작용과 함께 양호한 치료반응 및 생존율의 결과를 보였다. 생존율의 유의한 예후인자로 밝혀진 치료 반응률을 향상시키기 위해 방사선치료 분할방식, 화학요법제제, 화학방사선치료의 결합방식에 대한 추가적인 연 구가 필요할 것으로 생각된다. Purpose: A retrospective study was performed to evaluate the efficiency and feasibility of twice daily radiation therapy plus concurrent chemotherapy for limited-stage small cell lung cancer in terms of treatment response, survival, patterns of failure, and acute toxicities. Materials and Methods: Between February 1993 and October 2002, 76 patients of histologically proven limitedstage small cell lung cancer (LS-SCLC) were treated with twice daily radiation therapy and concurrent chemotherapy. Male was in 84% (64/76), and median age was 57 years (range, 32∼75 years). Thoracic radiation therapy consisted of 120 or 150 cGy per fraction, twice a day at least 6 hours apart, 5 days a week. Median total dose was 50.4 Gy (range, 45∼51 Gy). Concurrent chemotherapy consisted of CAV (cytoxan 1000 mg/m2, adriamycin 40 mg/m2, vincristine 1 mg/m2) alternating with PE (cisplatin 60 mg/m2, etoposide 100 mg/m2) or PE alone, every 3 weeks. The median cycle of chemotherapy was six (range, 1∼9 cycle). Prophylactic cranial irradiation (PCI) was recommended to the patients who achieved a complete response (CR). PCI scheme was 25 Gy/ 10 fractions. Median follow up was 18 months (range, 1∼136 months). Results: Overall response rate was 86%; complete response in 39 (52%) and partial response in 26 (34%) patients. The median overall survival was 23 months. One, two, and three year overall survival rate was 72%, 50% and 30%, respectively. In univariate analysis, the treatment response was revealed as a significant favorable prognostic factor for survival (p<0.001). Grade 3 or worse acute toxicities were leukopenia in 46 (61%), anemia in 5 (6%), thrombocytopenia in 10 (13%), esophagitis in 5 (6%), and pulmonary toxicity in 2 (2%) patients. Of 73 evaluable patients, 40 (55%) patients subsequently had disease progression. The most frequent first site of distant metastasis was brain. Conclusion: Twice daily radiation therapy plus concurrent chemotherapy produced favorable response and survival for LS-SCLC patients with tolerable toxicities. To improve the treatment response, which proved as a significant prognostic factor for survival, there should be further investigations about fractionation scheme, chemotherapy regimens and compatible chemoradiotherapy schedule.

비상발전기 기반 가상발전소 운용 방식 연구

박성원(Sung-Won Park),여승구(Seung-Gu Yeo),정범진(Beom-Jin Chung),손성용(Sung-Yong Son) 대한전기학회 2014 대한전기학회 학술대회 논문집 Vol.2014 No.5

Rotation Errors of Breast Cancer on 3D-CRT in TomoDirect

정재홍,조광환,문성권,배선현,민철기,김은석,여승구,최진호,정주영,최보영,서태석,Jung, Jae Hong,Cho, Kwang Hwan,Moon, Seong Kwon,Bae, Sun Hyun,Min, Chul Kee,Kim, Eun Seog,Yeo, Seung-Gu,Choi, Jin Ho,Jung, Joo-Yong,Choe, Bo Young,Suh, Tae Korean Society of Medical Physics 2015 의학물리 Vol.26 No.1

The purpose of this study was to analyze the rotational errors of roll, pitch, and yaw in the whole breast cancer treated by the three-dimensional radiation therapy (3D-CRT) using TomoDirect (TD). Twenty-patient previously treated with TD 3D-CRT was selected. We performed a retrospective clinical analysis based on 80 images of megavoltage computed tomography (MVCT) including the systematic and random variation with patient setup errors and treatment setup margin (mm). In addition, a rotational error (degree) for each patient was analyzed using the automatic image registration. The treatment margin of X, Y, and Z directions were 4.2 mm, 6.2 mm, and 6.4 mm, respectively. The mean value of the rotational error for roll, pitch, and yaw were $0.3^{\circ}$, $0.5^{\circ}$, $0.1^{\circ}$, and all of systematic and random error was within $1.0^{\circ}$. The errors of patient positioning with the Y and Z directions have generally been mainly higher than the X direction. The percentage in treatment fractions in less than $2^{\circ}$ at roll, pitch, and yaw are 95.1%, 98.8%, and 97.5%, respectively. However, the edge of upper and lower (i.e., bottom) based on the center of therapy region (point) will quite a possibility that it is expected to twist even longer as the length of treatment region. The patient-specific characters should be considered for the accuracy and reproducibility of treatment and it is necessary to confirm periodically the rotational errors, including patient repositioning and repeating MVCT scan. 본 연구의 목적은 토모다이렉트 3D-CRT (TD 3D-CRT)을 이용한 유방암 방사선치료에서 회전축(roll, pitch, and yaw) 오차를 분석하고 자 하였다. TD-3DCRT로 치료가 종료된 유방암 환자 총 20명을 선정하였고, 총 80회의 MVCT 영상을 바탕으로 시스템(systematic), 임의(random) 오류를 포함한 환자위치잡이 오차(patient setup errors)와 치료 여백(treatment margin, mm)을 후향적으로 분석하였다. 또한, 각 환자에 대한 회전축 오차 분석은 자동영상정합(automatic image registration)을 이용하였다. X, Y, Z 방향에 대한 치료여백은 각각 4.2 mm, 6.2 mm, 6.4 mm였다. 회전축 오차에 대한 평균 각도(degree)는 roll, pitch, yaw가 각각 0.3도, 0.5도, 0.1도였고, 시스템과 임의 오류는 모두 1도 이내였다. 전반적으로 환자 위치잡이 오차는 Y와 Z방향에서 X에 비하여 높게 나타났다. 본 연구에서 회전축 오차 각도가 2도 이내는 roll, pitch, yaw에서 각각 95.1%, 98.8%, 97.5% 분포였다. 그러나, 치료영역의 길이가 길어짐에 따라 치료 중심지점을 기준으로 상부와 하부의 가장자리(Edge)가 틀어지게(Twisted)될 가능성이 높아질 수 있다. 따라서 치료의 정확성과 재현성을 위하여 각 환자의 특성을 고려하고, 회전축 오차를 주기적으로 확인할 필요가 있다.

성문암 세기조절 방사선치료에서 변형영상정합을 이용한 선량변화 평가

김우철,민철기,이석,최상현,조광환,정재홍,김은석,여승구,권수일,이길동,Kim, Woo Chul,Min, Chul Kee,Lee, Suk,Choi, Sang Hyoun,Cho, Kwang Hwan,Jung, Jae Hong,Kim, Eun Seog,Yeo, Seung-Gu,Kwon, Soo-Il,Lee, Kil-Dong 한국의학물리학회 2014 의학물리 Vol.25 No.3

본 연구는 IMRT가 적용된 성문암 환자에 대하여 CBCT영상과 변형영상 정합기법을 이용하여 치료기간 동안 실제 환자에게 전달되는 선량 변화를 평가하고자 하였다. B-spline 알고리즘을 사용한 변형영상정합 시스템을 통해 치료 중 1주 간격으로 얻은 CBCT를 재구성하고 치료계획을 재계산하여 종양과 결정장기의 선량 분포를 비교하였다. 체중에 따른 체적변화는 3~5 주부터 평균 1.38~2.04 kg로 증가하였으며 체표면의 변화는 평균 2.1 mm로 감소하였다. 또한, 3주 이후의 경동맥에 전달된 선량은 계획되었던 값보다 최대 8.76%로 증가하였고, 갑상선샘은 26.4%로 감소하였다. 종양의 물리적의 평가인자인 PITV, TCI, rDHI, mDHI 그리고, CN은 치료 계획된 값보다 각각 평균 4.32%, 5.78%, 44.54%, 12.32% 그리고, 7.11%로 감소하였다. PTV에 대한 $D_{max}$는 평균 2.99% 증가하였고, $D_{mean}$, $V_{67.50}$, $D_{95}$는 각각 평균 1.52%, 5.78%, 11.94%로 감소하였다. 체중변화에 따른 체적의 변화가 없더라도 체형변화는 발생하였고, 좁은 여유마진을 가지는 IMRT는 이러한 변화에 민감하게 반응하였다. 성문암에 대한 IMRT 적용 시 환자의 체중변화를 관찰과 함께 변화를 기록하고 치료 중 변형영상정합 시스템을 이용하여 선량분포를 평가할 필요가 있다. 최종적으로 치료 중 실제 전달되는 선량평가는 적응형치료계획을 통하여 확인하고 정확한 선량전달이 필요하다고 사료된다. 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.

Chronic Expanding Hematoma of the Adrenal Gland Mimicking a Hemangioma: A Case Report

이현정,김민정,하홍일,이인재,이관섭,서진원,여승구 대한영상의학회 2013 대한영상의학회지 Vol.68 No.4

We report a rare case of unilateral chronic expanding hematoma in the left adrenal gland, mimicking a hemangioma on multiphase computed tomography (CT). On CT, the mass showed several enhancing foci of irregular and frond-like shape in the periphery at the hepatic arterial phase and gradual fill-in pattern at the portal venous phase, which was similar with the enhancement pattern of hemangioma.

Analysis of Automatic Rigid Image-Registration on Tomotherapy

김영록,조광환,정재홍,정주영,임광채,김용호,문성권,배선현,민철기,김은석,여승구,서태석,최보영,민정환,안재억 대한방사선과학회 2014 방사선기술과학 Vol.37 No.1

본 연구는 토모테라피(Accuray Inc, Sunnyvale, CA, USA)의 자동영상정합 과정에서 조정인자에 따른 종축과 회전축의 오치를 분석하였다. 다섯그룹(두부, 경부, 흉부, 복부, 골반부)으로 구분된 총 50명의 치료가 종료된 환자를 대상으로 하였고, 총 500개의 megavoltage computed tomography (MVCT) 영상을 분석하였다. 모의치료에서 kilovoltage computed tomography (kVCT)영상을 얻었고, 치료계획을 위하여 토모테라피 Hi-Art II 치료계획시스템(Accuray Inc, Sunnyvale, CA, USA)을 사용하였다. 매 회 치료 전 자동영상정합 과정을 시행하였고, 종축과 회전축의 오차를 기록하였다. 종축과 회전축의 일치도(adjustments)에서 자동영상정합을 분석하기 위하여 총 아홉 가지 조정인자를 적용하였고, 각 그룹의 계통적(systematic, ∑)과 통계적(random, RMS) 오차에 대하여 종합적 평균오차(overall mean value , M)를 구했다. 각 그룹 간 회전축 일치도의 종합적 평균오차에서 밀도와 해상도에 따른 다양한 조정인자에 의한 차이를 보였다. 밀도와 해상도가 높아짐에 띠라 회전축 일치도에서 편차가 작았다. 그러므로, 토모테라피에서 “full-image”모드와 “standard” 해상도를 이용한 자동영상정합은 정확한 오차 확인이 가능하고, 환자 재위치잡이(repositionning) 및 보정(correcting)에 도움이 될 것으로 사료된다. The purpose of this study was to analyze translational and rotational adjustments during automatic rigid image-registration by using different control parameters for a total of five groups on TomoTherapy (Accuray Inc, Sunnyvale, CA, USA). We selected a total of 50 patients and classified them in five groups (brain, head-and-neck, lung, abdomen and pelvic) and used a total of 500 megavoltage computed tomography (MVCT) image sets for the analysis. From this we calculated the overall mean value(M) for systematic and random errors after applying the different control parameters. After randomization of the patients into the five groups, we found that the overall mean value varied according to three techniques and resolutions. The deviation for the lung, abdomen and pelvic groups was approximately greater than the deviation for the brain and head-and-neck groups in all adjustments. Overall, using a "full-image" produces smaller deviations in the rotational adjustments. We found that rotational adjustment has deviations with distinctly different control parameters. We concluded that using a combination of the "full-image" technique and "standard' resolution will be helpful in assisting with patients' repositioning and in correcting for set-up errors prior to radiotherapy on TomoTherapy.