Yn-U-Medicine#(25#2#01) 김성규(종설).hwp
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1 영남의대학술지제25권제2호 Yeungnam Univ. J. of Med. Vol.25 No.2 p85-91, Dec 종설 세기조절방사선치료의정도관리 김성규 영남대학교의과대학방사선종양학교실 Quality Assurance in Intensity Modulated Radiation Theray Sung-Kyu Kim 1) -Abstract- Department of Therapeutic Radiology & Oncology, College of Medicine, Yeungnam University, Daegu, Korea Intensity-modulated radiation therapy (IMRT) is believed to be one of the best radiation treatment techniques. IMRT is able to deliver fatal doses of radiation to the tumor region with minimal exposure of critical organs. It is essential to have a comprehensive quality assurance program to assure precision and accuracy in treatment, due to the character of IMRT. We applied quality assurance technique to the Eclipse treatment planning system and sought to determine its effectiveness in patient treatment planning. An acrylic phantom, film, and an ionization chamber were used in this study. Key Words: Intensity modulated radiation therapy, Quality assurance, Radiation treatment planning 서론세기조절방사선치료는기존의방사선치료에비해종양조직에는더많은방사선량을조사하면서, 주위정상조직과중요장기에는최소한의방사선량이조사되게하여암조직에조 사되는방사선량을증가시킴으로생존율을높이고자하는방사선치료법이다. 1-6) 그러므로치료성적의향상으로암환자의생존율을증가시키고삶의질을높이는데기여할수있는이제까지연구개발된치료법중에서가장강력한방사선치료법이다. 책임저자 : 김성규, 대구시남구대명동 317-1, 영남대학교의과대학방사선종양학교실 Tel: (053) , Fax: (053) , skkim@med.yu.ac.kr 85
2 - 김성규 - 이러한세기조절방사선치료가환자에게적용되기위해서는환자의모의치료에서부터치료계획, 환자에게방사선이조사되는과정까지 2 mm 이내의오차를유지하여야하는극도로정확성을요구하고있다. 이러한정확성의요구때문에환자에게방사선을조사하기전종양부위와근접해있는중요장기에방사선이치료계획된대로정확하게조사되는지검증하는정도관리 (Quality Assurance/Quality Control, QA/QC) 과정이무엇보다도중요하며필수적이다. 세기조절방사선치료를하기위해서필수적으로충족되어야사항은다음과같다. 6) 첫째선량분포가종양일체형이되어야하며고선량범위내에중요장기가제외되어야하며, 둘째조사면적이표시되는컴퓨터단층촬영영상의여러장을연속스캔하여이영상들을디지털화재구성을통한방사선조사방향에서해부학적구조와종양의형태가공간적으로표현되어야하며, 셋째치료부위와방사선민감장기에대한조사면의최적화영역결정이이루어져야하며, 넷째종양부위내에균등한선량이조사되어야하며, 다섯째치료계획대로치료되었는지확인할수있는시뮬레이션필름과치료필름을비교및선량측정을점검할수있는정도관리시스템이있어야한다. 세기조절방사선치료는다엽콜리메이터 (Multileaf Collimator, MLC) 를구동시켜 CTV(Clinacl target volume) 에원하는방사선량을조사하도록한다. 이때 1) MLC가먼저구동이되어방사선치료조사면적이만들어지고빔이조사되는 static 방법인 stop & shoot 방법과 2) MLC 가구동되는것과동시에빔이계속적으로조사되는 dynamic 방법인 sliding window 방법 7, 8) 이있다. Static 방법에서는빔이정지상태에서방출될때선량율이계속변화한다는단점을가지고있고, dynamic 방법에서는선량율은일정하게조사되지만 MLC 모양이계속변화하며, MLC가변화하는상태에서도빔이조사된다는단점을가지고있다. 일반적으로세기조절방사선치료시 static 방법과 dynamic 방법에서치료계획의정도관리, 치료정보의전달에관한정도관리, 치료전달과정에대한정도관리를통하여정도관리가확인되어야만환자에게방사선치료를적용할수있다. 7) 세기조절방사선치료에서정도관리절차는먼저모의치료장치의중심점과세기조절방사선치료를시행하기위한 planning CT 영상의 DRR(Digital Reconstruction Radiograph) 이일치하는지를먼저확인하여야하며, 그리고치료계획된대로방사선량이조사되는가에대한정도관리가이루어져야한다 (Fig. 1). Fig. 1. The system flowchart of quality assurance in intensity modulated radiation therapy. 재료및방법 세기조절방사선치료의정도관리를위하여사용한하드웨어구성은 Varian 120 Muti Leaf Collimator와 EPID(Electronic portal imaging 86
3 - 세기조절방사선치료의정도관리 - device) 가장착된 21EX 선형가속장치 (Varian, 미국 ) 와물리적인인자를이용한선량분포최적화역계산 (inverse calculation) 치료계획장치인 Eclipse (Varian, Ver 6.5, 미국 ) 를사용하였다. 정도관리를실시하기위한장치로는크기가 25 cm 25 cm 25 cm인아크릴팬텀과인체모형팬텀을사용하였으며, 또한필름선량분포확인을위하여 Vidar 16 Film Sacnner (Vidar, 독 일 ) 을사용하였고, 530 Electrometer (victreen, 미국 ) 와 0.01 cc ionchamber 와 5500 TLD (Harshow, 미국 ) 로선량을측정확인하였다. 결과및토의 1. 치료계획의정도관리세기조절방사선치료를시행할환자를모의 Fig. 2. Compare simulation film image (left) to DRR image (right) (AP: upper site & Lat: lower site image). 87
4 - 김성규 - 치료장치에서치료할부위의기준점을표시한다. 치료계획컴퓨터영상촬영기영상을얻어팍스시스템에서치료계획장치의영상통합시스템인 Varis 시스템으로영상을전송한다. 전송된영상을가지고임상종양용적, 치료계획용적, 중요장기등을표시한다. 임상종양용적의총 선량을결정하고, 이에따른중요장기들에허용할수있는선량을정하여조건에부합하는최적의치료계획을얻는다. 치료전달과정에대한정도관리는선량제한인자검토, 다엽시준기 sequnce file 작성, 정도관리확인용팬텀플랜, 팬텀플랜확인측정, Fig. 3. The quality assurance of DRR (left) vs L- Gram (right) in intensity modulated radiation theray (Ap: upper site, Lat: lower site). 88
5 - 세기조절방사선치료의정도관리 - 기준점선량비교측정등을고려하여야한다. 치료계획의정도관리를시행하기위하여세기조절방사선치료계획이결정된환자에대한모의치료장치에서의영상과치료계획장치에서의컴퓨터단층촬영기영상과치료기에서의 DRR 영상을비교하여정확하게기준점이일치하는지를확인하여야한다. 그림 2에서확인한결과 1 mm의오차를보이고있다 (Fig. 2). 또한결정된치료계획에대하여그환자의모의치료영상과치료계획장치에서의디지털화재구성사진과치료장치에서의치료확인영상 (L-gram) 을비교하여두영상의기준점이일치하는지확인한다 (Fig. 3). 2. 치료정보의전달에관한정도관리치료정보의전달에관한정도관리에는모의치료영상과 sequence image 의확인, 모의치료영상과 beam pattern의비교, sequence image 와 RTP의비교, dry map과모의치료영상의비교, 모의치료영상과치료부위의기준점의비교등을고려하여야한다. 10) 정도관리를시행할수있는아크릴팬텀의평단면에대한계산치와측정치를비교하여선량분포에대한정확성을확인하며, 챔버부피 가 0.01 cc 정도되는이온챔버를사용하거나 TLD를이용하여특정점의방사선량을비교하여세기조절방사선치료의가능의유무를결정한다. 선량기울기가완만한기준점에서 lateral 로 0.1 cm, posterior로 0.02 cm, in으로 1.3 cm 이동한특정비교점에서세기조절방사선치료게획을아크릴팬텀으로옮겨정도관리에사용한계산된계산치가 1.50 Gy였으며, 같은조건으로아크릴팬텀을설치하여정도관리를시행하기위하여측정한방사선량은 Gy였으며, TLD에서의측정치는 Gy였다. 측정치의비교에서이온챔버와 TLD에서각각 1.0%, 1.2% 의차이를보였다 (Fig. 4). 또한실제로세기조절방사선치료를시행할환자에게아크릴팬텀을사용한선량분포의정도관리 11) 에서가로는 0.1 cm의오차를보이고있으며, 세로도 0.1 cm의오차를보이고있다 (Fig. 5). 3. 치료전달과정에대한정도관리치료전달과정에대한정도관리에는 localization image verification, verification image 와모의치료영상의비교, leaf sequence의 verification 12, 13) 등을고려하여야한다. 치료전달과정에대한정도관리를치료계획 Fig. 4. Dose measurement of TLD in quality assurance of intensity modulated radiation theray. 89
6 - 김성규 - Fig. 5. Film of intensity modulated radiation theray phantom planning dosimetry for coronal plane. 정도관리에서모의치료장치의영상과치료기기의디지털화재구성사진영상의비교에서매치료시마다환자의정확한 Set-Up를치료면적의중심점에서비교해본결과 1 mm의오차를보이며정확하게일치한상태에서치료가이루어졌음을확인할수있었다. 4. 환자치료시치료에대한정도관리 환자치료시치료에대한정도관리는다시한번모의치료영상과 Set-Up한환자의 DRR image 을확인하고치료를시행해야한다. 환자치료시치료에대한정도관리를위해서는치료하기전먼저팬텀에대하여 film으로모의치료를시행하고, 다음치료시팬텀의모의치료 map과치료 map를비교하여검증할수있다 (Fig. 6). Fig. 6. Comparison of the beam pattern radiation treatment planning system and that form the film dry map. 90
7 - 세기조절방사선치료의정도관리 - 결론세기조절방사선치료를환자에게적용하기위해서는치료계획의정도관리, 치료정보의전달에관한정도관리, 치료전달과정에대한정도관리와환자치료시치료에대한정도관리를통하여방사선치료가이루어짐을알수있다. 세기조절방사선치료계획의정도관리와치료정보의전달에관한정도관리와치료전달과정에대한정도관리를직접환자를대상으로확인한결과본병원이사용하고있는역방향세기조절방사선치료계획장치인 eclipse 시스템치료계획과 21 Ex 선형가속기에서의치료에대한정도관리가잘일치함을볼수있었고, 선량전달에있어서도특정점에서의계산선량과측정선량이 1% 정도의오차를나타내어정도관리를통한시술의정확함을확인할수있어서안전하고정확한환자치료의적용을유도할수있었고, 환자치료시치료의정확성에대한검증도할수있었다. 참고문헌 1. Mohan R, Wang X, Jackson A. The potential and limitations of the inverse radiotherapy technique Sep 15;32(3): Bortfeld T, Boyer AL. Schlegel W, Kahler DL, Waldron TJ, Realization and verification of three-dimensional conformal radiotherapy with modulated fields. Int J Radiat Oncol Biol Phys 1994 Nov 15;30(4): Convey DJ, Rosenbioom ME. The generation of intensity modulated fields for conformal radiotheray by dynamic collimation. Phys Med Biol 1992 Jun 15;37(6): Brahme A, Roos J, Lax I. Solution of an integral equation encountered in radiation therapy. Phys Med Biol 1982 Oct 15;27(10): Xing L, Chen G. Iterative methods for inverse treatment planning. Phys Med Biol 1996 Oct 15;41(10): Webb S. Intensity-Modulated Radiation Therapy. 1st ed. Bristol and Philadelphia:IoP; Zhu XR, Jursinic PA, Grimm DF. Evaluation of Kodak EDR2 film for dose verification of intensity modulated radiation therapy by a static multileaf collimator. Med Phys 2002 Aug 15;29(8): Xia P, Chuang C, Verhey L. Communication and sampling rate limitations in IMRT delivery with a dynamic multileaf collimator system. Med Phys 2002 Mar 15; 29(3): Low DA, Harms WB, Mutic S. A technique for the quantitative evaluation of dose distributions. Med Phys 1998 May 15;25(5): Martens C, DeWagter C, DeNeve W. The value of the PinPoint ionchamber for characterization of small field segments used in intensity-modulated radiotheray. Phys Med Biol 2000 Sep 15;45(9): Dogan N, Leybovich LB, Sethi A. Comparative evaluation of Kodak EDR2 and XV2 films for verification of intensity modulated radiation therapy. Phys Med Biol 2002 Nov 15;47(22): Cho BC, Park SW, Oh DH, Bae HC. Quality assurance for intensity modulated radiation therapy. J Korean Soc Ther Radiol Oncol 2001 Sep 30;19(3): Kim SK, Kim MS, Yun SM. Dosimetric Evaluation of Static and Dynamic Intensity Modulated Radiation Treatment Planning and Delivery. Korean J of Med Phys 2006 Jun 30;17(2):
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