The Association between Smoking Status and Influenza Vaccination Coverage Rate in Korean Adults: Analysis of the 2010–2012 Korea National Health and Nutrition Examination Survey / 가정의학회지

BACKGROUND: Globally, smoking is one of the biggest challenges in public health and is a known cause of several important diseases. Influenza is preventable via annual vaccination, which is the most effective and cost-beneficial method of prevention. However, subjects who smoke have some unhealthy behaviours such as alcohol, low physical activity, and low vaccination rate. In this study, we analyzed the relationship between smoking status and factors potentially related to the influenza vaccination coverage rate in the South Korean adult population. METHODS: The study included 13,565 participants aged >19 years, from 2010 to 2012 from the Korea National Health and Nutrition Examination Survey data. Univariate analyses were conducted to examine the association between influenza coverage rate and related factors. Multivariate analysis was obtained after adjusting for variables that were statistically significant. RESULTS: The overall vaccination rate was 27.3% (n=3,703). Older individuals (P < 0.0001), women (P < 0.0001), non-smokers (P < 0.0001), light alcohol drinkers (P < 0.0001), the unemployed (P < 0.0001), and subjects with diabetes mellitus (P < 0.0001), hypercholesterolemia (P < 0.0001), and metabolic syndrome (P < 0.0001) had higher influenza vaccination coverage than the others. In multivariate analyses, current smokers and heavy smokers showed lower vaccination rates (odds ratio, 0.734; 95% confidence interval, 0.63–0.854). CONCLUSION: In the current study, smokers and individuals with inadequate health-promoting behaviors had lower vaccination rates than the others did.

Multi-institutional Comparison of Intensity Modulated Radiation Therapy (IMRT) Planning Strategies and Planning Results for Nasopharyngeal Cancer

The intensity-modulated radiation therapy (IMRT) planning strategies for nasopharyngeal cancer among Korean radiation oncology facilities were investigated. Five institutions with IMRT planning capacity using the same planning system were invited to participate in this study. The institutions were requested to produce the best plan possible for 2 cases that would deliver 70 Gy to the planning target volume of gross tumor (PTV1), 59.4 Gy to the PTV2, and 51.5 Gy to the PTV3 in which elective irradiation was required. The advised fractionation number was 33. The planning parameters, resultant dose distributions, and biological indices were compared. We found 2-3-fold variations in the volume of treatment targets. Similar degree of variation was found in the delineation of normal tissue. The physician-related factors in IMRT planning had more influence on the plan quality. The inhomogeneity index of PTV dose ranged from 4 to 49% in Case 1, and from 5 to 46% in Case 2. Variation in tumor control probabilities for the primary lesion and involved LNs was less marked. Normal tissue complication probabilities for parotid glands and skin showed marked variation. Results from this study suggest that greater efforts in providing training and continuing education in terms of IMRT planning parameters usually set by physician are necessary for the successful implementation of IMRT.

A Study on the Availability of the On-Board Imager (OBI) and Cone-Beam CT (CBCT) in the Verification of Patient Set-up / 대한방사선종양학회지

PURPOSE: On-line image guided radiation therapy (on-line IGRT) and (kV X-ray images or cone beam CT images) were obtained by an on-board imager (OBI) and cone beam CT (CBCT), respectively. The images were then compared with simulated images to evaluate the patient's setup and correct for deviations. The setup deviations between the simulated images (kV or CBCT images), were computed from 2D/2D match or 3D/3D match programs, respectively. We then investigated the correctness of the calculated deviations. MATERIALS AND METHODS: After the simulation and treatment planning for the RANDO phantom, the phantom was positioned on the treatment table. The phantom setup process was performed with side wall lasers which standardized treatment setup of the phantom with the simulated images, after the establishment of tolerance limits for laser line thickness. After a known translation or rotation angle was applied to the phantom, the kV X-ray images and CBCT images were obtained. Next, 2D/2D match and 3D/3D match with simulation CT images were taken. Lastly, the results were analyzed for accuracy of positional correction. RESULTS: In the case of the 2D/2D match using kV X-ray and simulation images, a setup correction within 0.06degrees for rotation only, 1.8 mm for translation only, and 2.1 mm and 0.3degrees for both rotation and translation, respectively, was possible. As for the 3D/3D match using CBCT images, a correction within 0.03degrees for rotation only, 0.16 mm for translation only, and 1.5 mm for translation and 0.0degrees for rotation, respectively, was possible. CONCLUSION: The use of OBI or CBCT for the on-line IGRT provides the ability to exactly reproduce the simulated images in the setup of a patient in the treatment room. The fast detection and correction of a patient's positional error is possible in two dimensions via kV X-ray images from OBI and in three dimensions via CBCT with a higher accuracy. Consequently, the on-line IGRT represents a promising and reliable treatment procedure.

Effectiveness of Fentanyl Transdermal Patch (Fentanyl-TTS, Durogegic(R)) for Radiotherapy Induced Pain and Cancer Pain: Multi-center Trial / 대한방사선종양학회지

PURPOSE: To evaluate the effectiveness and safety of fentanyl-TTS in the management of radiotherapy induced acute pain and cancer pain treated with radiotherapy. MATERIALS AND METHODS: Our study was open labelled prospective phase IV multi-center study. the study population included patients with more 4 numeric rating scale(NRS) score pain although managed with other analgesics or more than 6 NRS score pain without analgesics. Patients divided into two groups; patients with radiotherapy induced pain (Group A) and patients with cancer pain treated with radiotherapy (Group B). All patients received 25 ug/hr of fentanyl transdermal patch. Primary end point was pain relief; second end points were change in patient quality of life, a degree of satisfaction for patients and clinician, side effects. RESULTS: Between March 2005 and June 2005, 312 patients from 26 participating institutes were registered, but 249 patients completed this study. Total number of patients in each group was 185 in Group A, 64 in Group B. Mean age was 60 years and male to female ratio was 76:24. Severe pain NRS score at 2 weeks after the application of fentanyl was decreased from 7.03 to 4.01, p=0.003. There was a significant improvement in insomnia, social functioning, and quality of life. A degree of satisfaction for patients and clinician was very high. The most common reasons of patients' satisfactions was good pain control. Ninety six patients reported side effect. Nausea was the most common side effect. There was no serious side effect. CONCLUSION: Fentanyl-TTS was effective in both relieving pain with good tolerability and improving the quality of life for patients with radiotherapy induced acute pain and cancer pain treated with radiotherapy. The satisfaction of the patients and doctors was good. There was no major side effect.

Evaluation of Biological Characteristics of Neutron Beam Generated from MC50 Cyclotron / 대한방사선종양학회지

PURPOSE: To evaluate biological characteristics of neutron beam generated by MC50 cyclotron located in the Korea Institute of Radiological and Medical Sciences (KIRAMS). MATERIALS AND METHODS: The neutron beams generated with 15 mm Beryllium target hit by 35 MeV proton beam was used and dosimetry data was measured before in-vitro study. We irradiated 0, 1, 2, 3, 4 and 5 Gy of neutron beam to EMT-6 cell line and surviving fraction (SF) was measured. The SF curve was also examined at the same dose when applying lead shielding to avoid gamma ray component. In the X-ray experiment, SF curve was obtained after irradiation of 0, 2, 5, 10, and 15 Gy. RESULTS: The neutron beams have 84% of neutron and 16% of gamma component at the depth of 2 cm with the field size of 26 x 26 cm2, beam current 20 micro A, and dose rate of 9.25 cGy/min. The SF curve from X-ray, when fitted to linear-quadratic (LQ) model, had 0.611 as alpha/beta ratio (alpha=0.0204, beta=0.0334, R2=0.999, respectively). The SF curve from neutron beam had shoulders at low dose area and fitted well to LQ model with the value of R2 exceeding 0.99 in all experiments. The mean value of alpha and beta were -0.315 (range, -0.254 ~ -0.360) and 0.247 (0.220~0.262), respectively. The addition of lead shielding resulted in no straightening of SF curve and shoulders in low dose area still existed. The RBE of neutron beam was in range of 2.07~2.19 with SF=0.1 and 2.21~2.35 with SF=0.01, respectively. CONCLUSION: The neutron beam from MC50 cyclotron has significant amount of gamma component and this may have contributed to form the shoulder of survival curve. The RBE of neutron beam generated by MC50 was about 2.2.

On-line Image Guided Radiation Therapy using Cone-Beam CT (CBCT) / 대한방사선종양학회지

PURPOSE: Using cone beam CT, we can compare the position of the patients at the simulation and the treatment. In on-line image guided radiation therapy, one can utilize this compared data and correct the patient position before treatments. Using cone beam CT, we investigated the errors induced by setting up the patients when use only the markings on the patients' skin. MATERIALS AND METHODS: We obtained the data of three patients that received radiation therapy at the Department of Radiation Oncology in Chung-Ang University during August 2006 and October 2006. Just as normal radiation therapy, patients were aligned on the treatment couch after the simulation and treatment planning. Patients were aligned with lasers according to the marking on the skin that were marked at the simulation time and then cone beam CTs were obtained. Cone beam CTs were fused and compared with simulation CTs and the displacement vectors were calculated. Treatment couches were adjusted according to the displacement vector before treatments. After the treatment, positions were verified with kV X-ray (OBI system). RESULTS: In the case of head and neck patients, the average sizes of the setup error vectors, given by the cone beam CT, were 0.19 cm for the patient A and 0.18 cm for the patient B. The standard deviations were 0.15 cm and 0.21 cm, each. On the other hand, in the case of the pelvis patient, the average and the standard deviation were 0.37 cm and 0.1 cm. CONCLUSION: Through the on-line IGRT using cone beam CT, we could correct the setup errors that could occur in the conventional radiotherapy. The importance of the on-line IGRT should be emphasized in the case of 3D conformal therapy and intensity-modulated radiotherapy, which have complex target shapes and steep dose gradients.

Patient Setup Aid with Wireless CCTV System in Radiation Therapy / 대한방사선종양학회지

PURPOSE: To develop a wireless CCTV system in semi-beam's eye view (BEV) to monitor daily patient setup in radiation therapy. MATERIALS AND METHODS: In order to get patient images in semi-BEV, CCTV cameras are installed in a custom-made acrylic applicator below the treatment head of a linear accelerator. The images from the cameras are transmitted via radio frequency signal (~2.4 GHz and 10 mW RF output). An expected problem with this system is radio frequency interference, which is solved utilizing RF shielding with Cu foils and median filtering software. The images are analyzed by our custom-made software. In the software, three anatomical landmarks in the patient surface are indicated by a user, then automatically the 3 dimensional structures are obtained and registered by utilizing a localization procedure consisting mainly of stereo matching algorithm and Gauss-Newton optimization. This algorithm is applied to phantom images to investigate the setup accuracy. Respiratory gating system is also researched with real-time image processing. A line-laser marker projected on a patient's surface is extracted by binary image processing and the breath pattern is calculated and displayed in real-time. RESULTS: More than 80% of the camera noises from the linear accelerator are eliminated by wrapping the camera with copper foils. The accuracy of the localization procedure is found to be on the order of 1.5+/-0.7 mm with a point phantom and sub-millimeters and degrees with a custom-made head/neck phantom. With line-laser marker, real-time respiratory monitoring is possible in the delay time of ~0.17 sec. CONCLUSION: The wireless CCTV camera system is the novel tool which can monitor daily patient setups. The feasibility of respiratory gating system with the wireless CCTV is hopeful.

Characteristics of Detectors for Measurements of Photon Depth Doses in Build-Up Region / 의학물리

To determine the appropriate method out of various available methods to measure build-up doses, the measurements and comparisons of depth doses of build-up region including the surface dose were executed using the Attix parallel-plate ionization chamber, the Markus chamber, a cylindrical ionization chamber, and a diode detector. Based on the measurements using the Attix chamber, discrepancies of the Markus chamber were within 2% for the open field and increased up to 3.9% in the case of photon beam containing the contaminant electrons. The measurements of an cylindrical ionization chamber and a diode detector accord with those of the Attix chamber within 1.5% and 1.0% after those detectors were completely immersed in the water phantom. The results suggest that the parallel-plate chamber is the best choice to measure depth doses in the build-up region containing the surface, however, using cylindrical ionization chamber or diode detector would be a reasonable choice if no special care is necessary for the exact surface dose.

Definitive High Dose Thoracic Irradiation by 3 Gy Fraction Size in Stage III Non-small Cell Lung Cancer

PURPOSE: Definitive high dose thoracic radiation therapy (TRT) alone in stage III non-small cell lung cancer (NSCLC) has resulted in only modest survival gains that are far from satisfaction. When using conventional fractionation schedules, which usually last for about 7 weeks, issues relating to the cost versus the benefit ratio are raised, including the treatment costs, protracted side effects and inconvenience to patients and family, especially if they reside in a remote district from the hospital. A retrospective analyses on the stage III NSCLC patients who received definitive high dose TRT alone, in 3 Gy per fractions lasting less than 4 weeks, were performed. MATERIALS AND METHODS: Between October 1994 and June 2001, 82 NSCLC patients were given definitive high dose TRT alone, in 3 Gy fractions, at Samsung Medical Center. Of these patients 37 (45.1%) had a stage IIIA and 45 (54.9%) had a IIIB disease. Squamous cell carcinomas were the most common (65.9%) pathology followed by adenocarcinomas (23.2%). External beam radiation therapy (ERT) alone was employed in 61 patients (74.4%), with additional high dose rate endobronchial brachytherapy (EBB) in 21 patients (25.6%). The TRT was typically started with the AP/PA technique using 10 MV X-rays for 30 Gy, and then a computerized CT plan was performed to keep the total spinal cord dose below 40 Gy. The median total TRT dose was 54 Gy/18 fractions (range: 39-60 Gy). RESULTS: The median age was 68 years (43-84), with a male to female ratio of 4.9/1. After a median follow-up of 10 months (1~72), 31 (37.8%) and 24 (29.3%) developed local in-field failures and distant metastases, respectively, with the lung being the most common site (12, 38.7%). The median and overall survivals at 1-, 2-, 3- and 4-year were 10 months and 45.9, 19.4, 12.9 and 9.7%, respectively. The median relapse-free survival was 13.0 months, and relapse-free survival rates at 1-, 2-, 3-, and 4-year were 51.9, 23.3, 11.6 and 7.3%, respectively. From a univariate analysis, the performance status (p= 0.0366) and radiotherapy response (p=0.0323) were significant on the overall survival, gender (p=0.0329) and response (p=0.0107) on the relapse free survival, and histology (p=0.0466) on the local relapse. From a multivariate analysis, the nodal status, radiotherapy response and mediastinal radiation dose were significant prognostic factors on both the relapse free survival and local control. Treatment related morbidities were observed in 75 patients (91.5%), 10 of whom had grade 3 or 4 complications (12.2%), with esophagitis being the most common (73 patients). Symptomatic radiation pneumonitis occurred in 20 patients (24.4%), with 17 requiring steroid medication and a further 1 each required mechanical dilatation for an esophageal stricture and tracheal stenosis. CONCLUSION: Based on the above results, definitive high dose TRT in 3.0 Gy per fractions was adjudged to be comparable to TRT using the conventional fractionation schedules reported in the literature, with the advantages of shorter treatment duration and less overall cost

Expression of Cyclooxygenase (COX)-2 as a Prognostic Factor in Nasopharyngeal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: To evaluate the relationship between treatment failure and COX-2 expression in nasopharyngeal cancer patients treated with chemotherapy and radiotherapy. MATERIALS AND METHODS: The subjects of this study were 22 nasopharyngeal cancer patients. The patients were treated with neoadjuvant chemotherapy, followed by radiotherapy, or with radiotherapy alone. The formalin- fixed, paraffin- embedded tissues of 11 patients who developed a locoregional recurrence (n=7) or distant metastasis (n=4) were compared with those of 11 disease free patients. Prognostic factors, including histological type, stage, radiation dose and chemotherapy, were well balanced between the two groups. The COX-2 expression was determined immunohistochemically. RESULTS: COX-2 expression was stronger in the patients with a locoregional recurrence or distant metastasis than in those free of disease. The COX-2 distribution scores of the control group were as follows: 0 in 7, 1 in 2 and 2 in 2 patients. In the recurrence group, the scores were as follows; 0 in 3, 1 in 1, 2 in 2 and 3 in 5 patients. COX-2 expression was shown to have a statistically significant influence on the treatment failure by the Mann-Whitney U test (p=0.024) and Mantel-Haenszel Chi-Square test (p=0.018). It also significantly influenced the treatment failure when an analysis was performed within patients with a undifferentiated histology (p=0.039 by the Mann- Whitney U test, p=0.037 by the Mantel-Haenszel Chi- Square test). CONCLUSION: COX-2 expression is believed to be one of the important factors associated with a locoregional recurrence or distant metastasis.

GafChromic Film Dosimetry for Stereotactic Radiosurgery with a Linear Accelerator / 대한방사선종양학회지

PURPOSE: The purpose of this study was to evaluate whether a GafChromic film applied to stereotactic radiosurgery with a linear accelerator could provide information on the value for acceptance testing and quality control on the absolute dose and relative dose measurements and/or calculation of treatment planning system. MATERIALS AND METHODS: A spherical acrylic phantom, simulating a patient's head, was constructed from three points. The absolute and relative dose distributions could be measured by inserting a GafChromic film into the phantom. We tested the use of a calibrated GafChromic film (MD-55-2, Nuclear Associate, USA) for measuring the optical density. These measurements were achieved by irradiating the films with a dose of 0-112 Gy employing 6 MV photon. To verify the accuracy of the prescribed dose delivery to a target isocenter using a five arc beams (irradiated in 3 Gy per one beam) setup, calculated by the Linapel planning system the absolute dose and relative dose distribution using a GafChromic film were measured. All the irradiated films were digitized with a Lumiscan 75 laser digitizer and processed with the RIT113 film dosimetry system. RESULTS: We verified the linearity of the Optical Density of a MD-55-2 GafChromic film, and measured the depth dose profile of the beam. The absolute dose delivered to the target was close to the prescribed dose of Linapel within an accuracy for the GafChromic film dosimetry (of +/- 3%), with a measurement uncertainty of +/- 1 mm for the 50~90% isodose lines. CONCLUSION: Our results have shown that the absolute dose and relative dose distribution curves obtained from a GafChromic film can provide information on the value for acceptance. To conclude the GafChromic film is a convenient and useful dosimetry tool for linac based radiosurgery.

Outcome of LINAC Radiosurgery for a Cavernous Angioma / 대한방사선종양학회지

PURPOSE: To establish the role of stereotactic radiosurgery using a linear accelerator for the treatment of patients with cavernous angioma. MATERIALS AND METHODS: Between February 1995 and May 1997, 11 patients with cavernous angioma were treated with stereotactic radiosurgery using a linear accelerator. Diagnoses were based on the magnetic resonance imaging in 8 patients, and the histological in 3. The vascular lesions were located in the brainstem (5 cases), cerebellum (2 cases) thalamus (1 case) and cerebrum (3 cases). The clinical presentation at onset included previous intracerebral hemorrhages (9 cases) and seizures (2 cases). All patients were treated with a a linac-based radiosurgery. The median dose of radiation delivered was 16 Gy ranging from 14 to 24 Gy, which was typically prescribed to the 80% isodose surface (range 50~80%), corresponding to the periphery of the lesion with a single isocenter. Ten patients were followed-up. RESULTS: The median follow-up was 49 months ranging from 8 to 73 months, during which time two patients developed an intracerebral hemorrhage, 1 at 8 months, with the other at 64 months post radiosurgery. One patient developed neurological deficit after radiosurgery, and two developed an edema on the T2 weighted images of the MRI surrounding the radiosurgical target. CONCLUSION: The use of stereotactic radiosurgery in the treatment of a cavernous angioma may be effective in the prevention of rebleeding, and can be safely delivered. However, a longer follow-up period will be required.

Thiamine-responsive Megaloblastic Anemia Syndrome in a Mother and Five Daughters / 대한소아혈액종양학회지

Thiamine-responsive megaloblastic anemia (TRMA) syndrome is an early-onset autosomal recessive disorder characterized by megaloblastic anemia with ringed sideroblasts, diabetes mellitus and progressive sensorineural deafness, all of which respond in varying degrees to the administration of thiamine, in pharmacologic doses. TRMA syndrome has been reported in less than 30 families, but has never been reported in Korea. It has been demonstrated recently that TRMA is consistently associated with a defect in thiamine transport across cellular membranes and with impaired intracellular pyrophosphorylation. The TRMA syndrome gene, SCL19A2, locates on chromosome 1q23.2-23.3, and encodes a high-affinity thiamine transporter protein. We recently experienced 6 cases of thiamine-responsive megaloblastic anemia syndrome in a family, including a mother and five daughters. All the six cases revealed megaloblastic anemia refractory to vitamin B12 and folic acid therapy but responded to thiamine. We report the cases with a brief review of the literature.

Application of Intensity Modulated Radiation Therapy (IMRT) in Prostate Cancer / 대한방사선종양학회지

This study was done to implement intensity-modulated radiation therapy (IMRT) for the treatment of primary prostate cancer and to compare this technique with conventional treatment methods. A 72-year- old male patient with prostate cancer stage T2a was treated with IMRT delivered with dynamic multi-leaf collimation. Treatment was designed using an inverse planning algorithm, which accepts dose and dose- volume constraints for targets and normal structures. The IMRT plan was compared with a three-dimensional (3D) plan using the same 6 fields technique. Lower normal tissue doses and improved target coverage were achieved using IMRT at current dose levels, and facilitate dose escalation to further enhance locoregional control and organ movement during radiotherapy is an important issue of IMRT in prostate cancer.

Quality As surance for Intensity Modulated Radiation Therapy / 대한방사선종양학회지

PURPOSE: To setup procedures of quality assurance (QA) for implementing intensity modulated radiation therapy (IMRT) clinically, report QA procedures performed for one patient with prostate cancer. MATERIALS AND METHODS: P3IMRT (ADAC) and linear accelerator (Siemens) with multileaf collimator are used to implement IMRT. At first, the pos itional accuracy, reproducibility of MLC, and leaf transmission factor were evaluated. RTP commissioning was performed again to considers mall field effect. After RTP recommissioning, a test plan of a C-s haped PTV was made using 9 intensity modulated beams, and the calculated isocenter dose was compared with the measured one insolid water phantom. As a patient-specific IMRT QA, one patient with prostate cancer was planned us ing 6 beams of total 74 segmented fields. The same beams were used to recalculate dose in a solid water phantom. Dose of these beams were meas ured with a 0.015cc microionization chamber, a diode detector, films, and a narray detector and compared with calculated one. RESULTS: The pos itioning accuracy of MLC was about 1 mm, and the reproducibility was around 0.5 mm. For leaf transmission factor for 10 MV photon beams, interleaf leakage was measured 1.9% and midleaf leakage 0.9% relative to 10x10 cm2 open filed. Penumbra meas ured with film, diode detector, microionization chamber, and conventional 0.125 cc chambers howed that 80~20% penumbra width meas ured with a 0.125cc chamber was 2 mm larger than that of film, which means a 0.125 ccionization chamber was unacceptable for meas urings mall fields uch like 0.5 cm beamlet. After RTP recommissioning, the discrepancy between the meas ured and calculated dose profile for a small field of 1x1 cm2 size was less than 2%. The isocenter dose of the test plan of C-s haped PTV was meas ured two times with microionization chamber in solid phantom showed that the errors upto 12% for individual beam, but total dose delivered were agreed with the calculated within 2%. The transverse dose distribution meas ured with EC-L film was agreed with the calculated one ingeneral. The isocenter dose for the patient meas ured in solid phantom was agreed within 1.5%. Off-axis dose profiles of each individual beam at the position of the central leaf measured with film and array detector were found that at out-of-the-field region, the calculated dose underestimates about 2%, at inside-the-field the meas ured one was agreed within 3%, except some position. CONCLUSION: It is necessary more tight quality control of MLC for IMRT relative to conventional large field treatment and to develop QA procedures to check intensity pattern more efficiently. At the conclusion, we did setup an appropriate QA procedures for IMRT by a series of verifications including the measurement of absolute dose at the isocenter with a microionization chamber, film dosimetry for verifying intensity pattern, and another meas urement with an array detector for comparing off-axis dose profile.

Dose-Response Relationship of Radiotherapy for Locally Advanced Hepatocellular Carcinoma / 대한암학회지

PURPOSE: Recently radiotherapy is applied alone or in conjunction with transcatheter arterial chemoembolizaion (TACE) or percutaneous ethanol injection therapy (PEIT) for locally advanced hepatocellular carcinoma (HCC). The purpose of this study was to evaluate dose-response relationship of radiotherapy for local control and toxicity in inoperable HCC. MATERIALS AND METHODS: Twenty-eight patients who were not eligible for TACE and PEIT or had showed no response to these treatment were treated with a total dose of 40 Gy with 2 Gy per fraction or 30 Gy with 3 Gy per fraction (low dose group, 18 patients) or 45 Gy with 3 Gy per fraction (high dose group, 10 patients). RESULTS: The median survival duration was 8 months and 1-year survival rate was 37%. The treatment results were as follows; partial response in 11% and 70% (p=0.001), stable disease in 56% and 30%, and progressive disease in 33% and 0% in low dose group and high dose group, respectively. The incidence of gastrointestinal (G-I) toxicity by the criteria of Southwest Oncology Group was as follows; grade 1 in 22% and 40%, grade 2 in 17% and 10%, respectively (p=0.56). There was no patient with severe G-I toxicity above grade 3. The incidence of G-I toxicity by site was as follows; grade 1 in 24% and 29%, and grade 2 in 0% and 57% in patients with right lobe and left lobe lesion, respectively (p=0.001). CONCLUSION: This study indicates that there is clear dose-response relationship in local control. The G-I toxicity does not increase significantly with increment of radiation dose within the dose range tested in this study. And careful attention should be paid for G-I toxicity when the tumor is located in left lobe.

Radiation Oncology Digital Image Chart and Digital Radiotherapy Record System at Samsung Medical Center / 대한방사선종양학회지

BACKGROUND: The authors have developed a Digital image chart(DIC) and digital Radiotherapy Record System (DRRS). We have evaluated the DIC and DRRS for reliability, usefulness, ease of use, and efficiency. METHOD AND MATERIALS: The basic design o f the DIC and DRRS was to build an digital image database of radiation therapy patient records for a more efficient and timely flow of critical image in formation throughout the department. This system is a subunit of comprehensive radiation oncology managemert system (C-ROMS) and composed of a picture archiving and communication system (PACS), radiotherapy information database, and a radiotherapy imaging database. The DIC and DRRS were programmed using Delphi under a Windows 95 environment and is capable of displaying the digital images of patients identification photos, simulation films, radiotherapy setup, diagnostic radiology image... Gross lesion photos, and radiotherapy planning isodose charts with beam arrangements. Twenty-three clients in the department are connected by Ethernet (10 Mbps) to the central image server (Sun Ultra-sparc 1 workstation). RESULTS: From the introduction of this system in February 1998 through December 1999, we have accumulated a total of 15,732 individual images for 2,556 patients. We can organize radiation therapy in; paperless environment in 120 patients with breast cancer. Using this system, we have succeeded in the prompt, accurate, and simultaneous access to patient care information from multiple locations throughout the department. This coordination has resulted in improved operational efficiency within the department. CONCLUSION: The authors believe that the DIC and DRRS has contributed to the improvement of radiation oncology department efficacy as well as to time and resource savings by providing necessary visual information throughout the department conveniently and simultaneously. As a result, we can also achieve the paperless and filmless practice of radiation oncology with this system.

Individualized Determination of Lower Margin in Pelvic Radiation Field after Low Anterior Resection for Rectal Cancer Resulted in Equivalent Local Control and Radiation Volume Reduction Compared with Traditional Method / 대한방사선종양학회지

PURPOSE: When determining the lower margin of post-operative pelvic radiation therapy field according to the traditional method (recommended by Gunderson), the organs located in the low pelvic cavity and the perineum are vulnerable to unnecessary radiation. This study evaluated the effect of individualized determination of the lower margin at 2 cm to 3 cm below the anastomotic site on the failure patterns. MATERIALS AND METHODS: Authors included 88 patients with modified Astler-Coller (MAC) stages from B2 through C3, who received low anterior resection and post-operative pelvic radiation therapy from Sept. 1994 to May 1998 at Samsung Medical Center, Sungkyunkwan University. The numbers of male and female patients were 44 and 44, and the median age was 57 years (range: 32-81 years). Three field technique (posterior-anterior and bilateral portals) by 6, 10, 15 MV X-rays was used to deliver 4,500 cGy to the whole pelvis followed by 600 cGy's small field boost to the tumor bed over 5.5 weeks. Sixteen patients received radiation therapy by traditional field margin determination, and the lower margin was set either at the low margin of the obturator foramen or at 2 cm to 3 cm below the anastomotic site, whichever is lower. In 72 patients, the lower margin was set at 2 cm to 3 cm below the anastomotic site, irrespectively of the obturator foramen, by which the reduction of radiation volume was possible in 55 patients (76%). Authors evaluated and compared survival, local control, and disease-free survival rates of these two groups. RESULTS: The median follow-up period was 27 months (range : 7-58 months). MAC stages were B2 in 32 (36%), B3 in 2 (2%), C1 in 2 (2%), C2 in 50 (57%), and C3 in 2 (2%) patients, respectively. The entire patients' overall survival rates at 2 and 4 years were 94% and 68%, respectively, and disease-free survival rates at 2 and 4 years were 86% and 58%, respectively. The first failure sites were local only in 4, distant only in 14, and combined local and distant in 1 patient, respectively. There was no significant difference with respect to local control and disease-free survival rates ( p=0.42, p=0.68) between two groups of different lower margin determination policies. CONCLUSION: The new concept in the individualized determination of the lower margin depending on the anastomotic site has led to the equivalent local control and disease-free survival rates, and is expected to contribute to the reduction of unnecessary radiation-related morbidity by reduction of radiation volume, compared with the traditional method of lower margin determination.

Preliminary Results of Postoperative Radiotherapy after Breast Conserving Surgery in Early Breast Cancer / 대한암학회지

PURPOSE: To evaluate treatment results of breast conserving surgery and radiation therapy including survival rates, patterns of failure, and complication and to analyze prognostic factors. MATERIALS AND METHODS: Retrospective analysis was carried out for 111 (112 cases) consecutive patients with breast cancer treated by radiation therapy after breast conserving surgery from October 1994 to April 1997. The median follow up was 45 months (range 10~66). AJCC staging was as follows: 16 cases (14%) for ductal carcinoma in situ, 46 cases (41%) for stage I, 33 cases (30%) for stage IIa, and 17 cases (15%) for stage IIb. Radiation therapy after breast conserving surgery was delivered to whole breast with 50.4 Gy and additional 10 Gy electron beam boost to tumor bed. Adjuvant CMF or CAF chemotherapy was performed in 61 patients. RESULTS: Overall three- and five-year survivals were 99% and 95%, and progression-free survival were 93%, 87%, respectively. Treatment failure occurred in 11 cases (10%); loco-regional recur rence in six; distant metastasis in five. Univariate analysis showed prognostic factor affecting survival was only T-stage. Acute radiation dermatitis were found in five cases (4%), and chronic complications were found in five (4%); one case with amputation of nipple, two cases with lymphedema requiring rehabilitation therapy and two cases with symptomatic radiation pneu monitis requiring steroid therapy. CONCLUSION: Breast conserving therapy of early breast cancer including ductal carcinoma in situ showed high survival rates and low complications, and T stage was prognostic factor for survival. But further follow-up should be needed.

Clear cell carcinoma arising in a Cesarean section scar endometriosis: a case report

Endometriosis of a surgical scar is rare and occurs mainly when a hysterectomy or Cesarean section was performed. We describe a 54-year-old woman with a large suprapubic mass as a definite case of a endomerioid carcinoma developing within the scar endometriosis following Cesarean section. Scar endometriosis, as well as endometriosis at other sites, can turn malignant. Endometrioid carcinoma is the most common histological pattern of malignant tumor arising in endometriosis. But clear cell carcinoma is very unusual. A case of primary clear cell carcinoma in endometriosis of a Cesarean section scar is described. To the best of our knowledge, this is the first documented case of endomerioid carcinoma developing within the scar endometriosis in Korea.