[논문]간종양 방사선치료 시 토모테라피 메가볼트 CT를 이용한 치료 여백 평가

유세환; 성진실; 이익재; 금웅섭; 전병철

doi:10.3857/jkstro.2008.26.4.280

간종양 방사선치료 시 토모테라피 메가볼트 CT를 이용한 치료 여백 평가
Treatment Margin Assessment using Mega-Voltage Computed Tomography of a Tomotherapy Unit in the Radiotherapy of a Liver Tumor 원문보기

대한방사선종양학회지 = The Journal of the Korean soceity for therapeutic radiology and oncology, v.26 no.4, 2008년, pp.280 - 288

유세환 (연세대학교 의과대학 연세암센터 방사선종양학교실) , 성진실 (연세대학교 의과대학 연세암센터 방사선종양학교실) , 이익재 (연세대학교 의과대학 연세암센터 방사선종양학교실) , 금웅섭 (연세대학교 의과대학 연세암센터 방사선종양학교실) , 전병철 (연세대학교 의과대학 연세암센터 방사선종양학교실)

초록
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목 적: 토모테라피 영상유도장치인 MVCT (mega-voltage computed tomography) 영상을 이용하여 자유 호흡시 분할 치료 간 간조직의 위치변화 양상을 알아보고자 하였다. 대상 및 방법: 2006년 4월부터 2007년 8월까지 간종양에 토모테라피를 받은 환자 26 명을 대상으로 치료 시작 후 10회까지 매회 치료시의 MVCT 영상을 분석하였다. 1차적으로 골격 구조에 따라 셋업오차보정을 한 상태에서 2차원 직교좌표계 상에서 간조직 경계부위의 위치 변화를 치료계획 KVCT (Kilo-Voltage Computed Tomography)와 MVCT의 영상융합을 통해 비교하여 오차 정도를 파악하였다. 간종양의 위치 별 변화 양상을 보기 위하여 종양 위치를 Couinaud's proposal을 기준으로 1군(Segment 1), 2군(Segment 2, 3, 4), 3군(Segment 5, 6), 4군(Segment 7, 8)으로 나누어 각 군별 위치 변화 양상을 비교하였다. 결 과: MVCT를 통해 알아본 평균 셋업오차는 각각 $0.45{\pm}2.04\;mm$ (좌-우), $0.97{\pm}4.06\;mm$ (상-하), $8.38{\pm}4.67\;mm$ (전-후) 이었다. 2군에서 전방 바깥쪽으로 $2.80{\pm}1.73\;mm$, 좌방 안쪽으로 $2.23{\pm}1.37\;mm$ 이동하였고 4군에서는 전, 후, 좌, 우 각 방향으로 $-0.15{\pm}3.93\;mm$, $-3.15{\pm}6.58\;mm$, $-0.60{\pm}3.58\;mm$, $-4.50{\pm}5.35\;mm$ 이동하였다. 1, 2, 3군에서 후방으로의 위치 변화는 평균 1 mm 이내였다(각각 $0.07{\pm}0.9 \;mm$, $-0.07{\pm}1.38\;mm$, $0.50{\pm}0.47\;mm$). MVCT 값들의 적용 시 보이는 2군에서의 종양체적 감소는 위 독성을 증가시킬 것으로 생각되었다. 결 론: 분할치료 간 간조직의 위치 변화 양상은 각 군마다 편차가 있는 가운데 어느 정도 규칙적이었다. 호흡에 의한 간조직의 기하학적 변형은 segment 2, 3, 4에서 좌방 표적 체적의 감소를 가져오는 반면 segment 5, 6에서는 호흡에도 불구하고 안정적인 양상을 나타내었다. 따라서 자유 호흡 상태에서 간 좌엽에 대한 방사선치료 시 위에 대한 독성을 줄이기 위해 보다 세심한 접근이 필요하다.

Abstract ▼ AI-Helper

Purpose: To identify the inter-fractional shift pattern and to assess an adequate treatment margin in the radiotherapy of a liver tumor using mega-voltage computed tomography (MVCT) of a tomotherapy unit. Materials and Methods: Twenty-six patients were treated for liver tumors by tomotherapy from April 2006 to August 2007. The MVCT images of each patient were analyzed from the $1^{st}$ to the $10^{th}$ fraction for the assessment of the daily liver shift by four groups based on Couinard's proposal. Daily setup errors were corrected by bony landmarks as a prerequisite. Subsequently, the anterior-, posterior-, right-, and left shifts of the liver edges were measured by maximum linear discrepancies between the kilo-voltage computed tomography (KVCT) image and MVCT image. All data were set in the 2-dimensional right angle coordinate system of the transverse section of each patient's body. Results: The liver boundary shift had different patterns for each group. In group II (segment 2, 3, and 4), the anterior mean shift was $2.80{\pm}1.73\;mm$ outwards, while the left mean shift was $2.23{\pm}1.37\;mm$ inwards. In group IV (segment 7 and 8), the anterior-, posterior-, right-, and left mean shifts were $0.15{\pm}3.93\;mm$ inwards, $3.15{\pm}6.58\;mm$ inwards, $0.60{\pm}3.58\;mm$ inwards, and $4.50{\pm}5.35\;mm$ inwards, respectively. The reduced volume in group II after MVCT reassessment might be a consequence of stomach toxicity. Conclusion: Inter-fractional liver shifts of each group based on Couinard's proposal were somewhat systematic despite certain variations observed in each patient. The geometrical deformation of the liver by respiratory movement can cause shrinkage in the left margins of liver. We recommend a more sophisticated approach in free-breathing mode when irradiating the left lobe of liver in order to avoid stomach toxicity.

주제어

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문제 정의

The purpose of this study is to identify the interfractional liver shift pattern in free-breathing mode and to assess adequate treatment margin in radiotherapy of liver tumor using MVCT image.

제안 방법

For cranio-caudal direction, we used the routinely measured diaphrag matic movement range in free breathing obtained from a x-ray fluoroscopy because of poor resolution of reconstructed coronal and sagittal MVCT images. All patients were classified into 4 groups according to Couinaud's proposal on the basis of the tumor location in order to assess the shift pattern of each group. Group I was composed of the patients who have liver tumor in seg ment 1.
Three patients were excluded because of poor performance and long period of rest. Thus, 26 patients were enrolled and for these patients daily liver shift pattern were analyzed with MVCT image from 1st to 10th fraction in order to assess interfractional change. The number of measurement for shift was restricted up to 10th fraction to minimize body contour factors such as weight loss or breathing pattern change during radiotherapy.
Therefore, the best realistic alternative to breathinghold method might be more accurate delineation of internal target volume and planning target volume in the state of natural breathing with proper treatment margin. With this concept, we assessed interfractional liver boundary shift deviation for proper establishment of treatment margin using MVCT, a volumetric image-guidance system of helical tomotherapy.

성능/효과

In conclusion, MVCT image might be useful for verification of interfractional liver boundary displacement in tomotherapy to liver tumors and appropriate PTV margin based on MVCT image will be able to provide useful information for precision radiation therapy in liver tumors. Interfractional liver shift patterns are somewhat systematic according to tumor locations despite certain variations in each patient.

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