Over the past decades, radiation therapy combined with imaging modalities that ensure optimal image guidance has revolutionized cancer treatment. The two major purposes of using imaging modalities in radiotherapy are to clearly delineate the target prior to treatment and set up the patient during radiation delivery. Image guidance secures target position prior to and during the treatment. High quality images provide an accurate definition of the treatment target and the possibility to reduce the treatment margin of the target volume, further lowering radiation toxicity and improving the quality of life of cancer patients. In this review, the various types of image guidance modalities used in radiation therapy are distinguished into ionized (kilovoltage and megavoltage image) and nonionized imaging (magnetic resonance image, ultrasound, surface imaging, and radiofrequency). The functional aspects, advantages, and limitation of imaging using these modalities are described as a subsection of each category. This review only focuses on the technological viewpoint of these modalities and any clinical aspects are omitted. Image guidance is essential, and its importance is rapidly increasing in modern radiotherapy. The most important aspect of using image guidance in clinical settings is to monitor the performance of image quality, which must be checked during the periodic quality assurance process.

In this study, we have investigated the shielding evaluation methodology for facilities using kV energy generators. We have collected and analysis of safety evaluation criteria and methodology for overseas facilities using radiation generators. And we investigated the current status of shielding evaluation of domestic industrial radiation generators. According to the statistical data from the Radiation Safety Information System, as of 2022, a total of 7,679 organizations are using radiation generating devices. Among them, 6,299 facilities use these devices for industrial purposes, which accounts for a considerable portion of radiation. The organizations that use these devices evaluate whether the exposure dose for workers and frequent visitors is suitable as per the limit regulated by the Nuclear Safety Act. Moreover, during this process, the safety shields are evaluated at the facilities that use the radiation generating devices. However, the facilities that use radiating devices having energy less than or equal to 6 MV for industrial purposes are still mostly evaluated and analyzed according to the National Council on Radiation Protection and Measurements 49 (NCRP 49) report published in 1976. We have investigated the technical standards of safety management, including the maximum permissible dose and parameters assessment criteria for facilities using radiation generating devices, based on the NCRP 49 and the American National Standards Institute/Health Physics Society N.43.3 reports, which are the representative reports related to radiation shielding management cases overseas.

Purpose: To clarify the relationship between the diameter of the simulated bead and the Z-resolution of the tomosynthesis image.
Methods: A simulated bead was placed on a 1,024×1,024×1,024-pixel base image. The diameters were set to 0.025, 0.05, 0.1, 0.2, 0.3, 0.7, 1.0, and 1.3 mm. A bead was placed at the center of the base image and projected at a simulated X-ray angle range of ±45° to obtain a projected image. A region of interest was placed at the center of the bead image and the slice sensitivity profile (SSP) was obtained by acquiring pixel values in the z-direction. The full width at half maximum of the SSP was defined as the Z-resolution and the frequency response was obtained by the 1-D Fourier transform of the SSP.
Results: Z-resolution increased with increasing bead diameter. However, there was no change in Z-resolution between 0.025 and 0.1 mm. The frequency response was similar to that of the Z-resolution, with a significant difference between 0.1 and 0.2 mm diameter.
Conclusions: Z-resolution is dependent on the diameter of the bead, which should be selected considering the pixel size of the tomosynthesis image.

Purpose: The proficiency test was conducted to assess the performance of the dosimetry audit service provider in the readout practice of the dose delivered to patients in medical institutions.
Methods: A certain amount of the absorbed dose to water for the high-energy X-ray from the medical linear accelerator (LINAC) installed in the Korea Research Institute of Standards and Science (KRISS) was delivered to the postal dose audit package given by the dosimetry audit service provider, in which the radio-photoluminescence (RPL) glass dosimeters were mounted. The dosimetry audit service provider read the RPL glass dosimeters and sent the readout dose value with its uncertainty to KRISS. The performance of the dosimetry audit service provider was evaluated based on the E_n number given in ISO/IEC 17043:2010.
Results: The evaluated E_n number was −0.954. Based on the ISO/IEC 17043, the performance of the dosimetry service provider is “satisfactory.”
Conclusions: As part of the conformity assessment, the KRISS performed the proficiency test over the postal dose audit practice run by the dosimetry audit service provider. The proficiency test is in line with confirming the traceability of the medical institutions to the primary standard of absorbed dose to the water of the KRISS and ensuring the confidence of the dosimetry audit service provider.

Purpose: Proton therapy has different relative biological effectiveness (RBE) compared with X-ray treatment, which is the standard in radiation therapy, and the fixed RBE value of 1.1 is widely used. However, RBE depends on a charged particle’s linear energy transfer (LET); therefore, measuring LET is important. We have developed a LET measurement method using the inefficiency characteristic of an EBT3 film on a proton beam’s Bragg peak (BP) region.
Methods: A Gafchromic EBT3 film was used to measure the proton beam LET. It measured the dose at a 10-cm pristine BP proton beam in water to determine the quenching factor of the EBT3 film as a reference beam condition. Monte Carlo (MC) calculations of dose-averaged LET (LET_d) were used to determine the quenching factor and validation. The dose-averaged LETs at the 12-, 16-, and 20-cm pristine BP proton beam in water were calculated with the quenching factor.
Results: Using the passive scattering proton beam nozzle of the National Cancer Center in Korea, the LET_d was measured for each beam range. The quenching factor was determined to be 26.15 with 0.3% uncertainty under the reference beam condition. The dose-averaged LETs were measured for each test beam condition.
Conclusions: We developed a method for measuring the proton beam LET using an EBT3 film. This study showed that the magnitude of the quenching effect can be estimated using only one beam range, and the quenching factor determined under the reference condition can be applied to any therapeutic proton beam range.

Purpose: Cerebral microbleeds are more susceptible than surrounding tissues and have been associated with a variety of neurological and neurodegenerative disorders that are indicative of an underlying vascular pathology. We investigated relaxivity changes and microvascular indices in the presence of microbleeds in an imaging voxel by evaluating those before and after contrast agent injection.
Methods: Monte Carlo simulations were run with a variety of conditions, including different magnetic field strengths (B₀), different echo times, and different contrast agents. ΔR2* and ΔR2 and microvascular indices were calculated with varying microvascular vessel sizes and microbleed loads.
Results: As B₀ and the concentration of microbleeds increased, ΔR2* and ΔR2 increased. ΔR2* increased, but ΔR2 decreased slightly as the vessel radius increased. When the vessel radius was increased, the vessel size index (VSI) and mean vessel diameter (mVD) increased, and all other microvascular indices except mean vessel density (Q) increased when the concentration of microbleeds was increased.
Conclusions: Because patients with neurodegenerative diseases often have microbleeds in their brains and VSI and mVD increase with increasing microbleeds, microbleeds can be altered microvascular signals in a voxel in the brain of a neurodegenerative disease at 3T magnetic resonance imaging.

Purpose: Radiotherapy after bladder filling protocol (BFP) is known to enhance treatment quality and reduce side effects in prostate cancer, a common male solid cancer globally. However, due to the need to hold back urine during treatment, patients frequently complain of discomfort, and treatment is frequently suspended when patients urinate during treatment and urine penetrates the treatment device, causing malfunction. Therefore, the effect of minimizing treatment time when partial-arc volumetric modulated arc therapy (VMAT) was used instead of full-arc was assessed in this study.
Methods: A total of 70 plans were created in 10 patients using 7 different arc sizes, and the treatment time for each plan was calculated.
Results: Reduced arc size by half resulted in a 54.4% decrease in mean treatment duration, with a proportional tendency observed. Furthermore, the effect of VMAT arc size reduction on target dose homogeneity was significantly limited, and the effect on surrounding organs at risk (OAR) was negligible. It should be noted, however, that when the arc size decreases by >40%, the dose increases in the area without OAR around the target.
Conclusions: The results of this study demonstrated that partial-arc VMAT for enhancing treatment convenience and efficacy of prostate cancer patients undergoing BFP can achieve a considerable reduction in treatment time while preserving treatment quality, and it is expected to be useful for partial-arc VMAT plan design and implementation in practice.

Purpose: Proton therapy has been used for optimal cancer treatment by adapting its Bragg-peak characteristics. Recently, a tissue-sparing effect was introduced in ultrahigh-dose-rate (FLASH) radiation; the high-energy transmission proton beam is considered in proton FLASH therapy. In measuring high-energy/ultrahigh-dose-rate proton beam, Faraday Cup is considered as a dose-rate- independent measurement device, which has been widely studied. In this paper, the feasibility of the simply designed Faraday Cup (Poor Man’s Faraday Cup, PMFC) for transmission proton FLASH therapy is investigated.
Methods: In general, Faraday cups were used in the measurement of charged particles. The simply designed Faraday Cup and Advanced Markus ion chamber were used for high-energy proton beam measurement in this study.
Results: The PMFC shows an acceptable performance, including accuracy in general dosimetric tests. The PMFC has a linear response to the dose and dose rate. The proton fluence was decreased with the increase of depth until the depth was near the proton beam range. Regarding secondary particles backscatter from PMFC, the effect was negligible.
Conclusions: In this study, we performed an experiment to investigate the feasibility of PMFC for measuring high-energy proton beams. The PMFC can be used as a beam stopper and secondary monitoring system for transmission proton beam FLASH therapy.

Purpose: Particle beam therapy is advantageous over photon therapy. However, adequately delivering therapeutic doses to tumors near critical organs is difficult. Nanoparticle-aided radiation therapy can be used to alleviate this problem, wherein nanoparticles can passively accumulate at higher concentrations in the tumor tissue compared to the surrounding normal tissue. In this study, we investigate the dose enhancement effect due to gold nanoparticle (GNP) when Carbon-12, He-4, and proton beams are irradiated on GNP.
Methods: First, monoenergetic Carbon-12 and He-4 ion beams of energy of 283.33 MeV/u and 150 MeV/u, respectively, and a proton beam of energy of 150 MeV were irradiated on a water phantom of dimensions 30 cm×30 cm×30 cm. Subsequently, the secondary-particle information generated near the Bragg peak was recorded in a phase-space (phsp) file. Second, the obtained phsp file was scaled down to a nanometer scale to irradiate GNP of diameter 50 nm located at the center of a 4 µm×4 µm×4 µm water phantom. The dose enhancement ratio (DER) was calculated in intervals of 1 nm from the GNP surface.
Results: The DER of GNP computed at 1 nm from the GNP surface was 4.70, 4.86, and 4.89 for Carbon-12, He-4, and proton beams, respectively; the DER decreased rapidly with increasing distance from the GNP surface.
Conclusions: The results indicated that GNP can be used as radiosensitizers in particle beam therapy. Furthermore, the dose enhancement effect of the GNP absorbed by tumor cells can aid in delivering higher therapeutic doses.

Purpose: T his s tudy e valuated t he q uality of plans based on magnetic resonance-guided radiotherapy (MRgRT) tri-Co-60, linac, and conventional linac-based volumetric modulated arc therapy (linac-VMAT) for prostate cancer.
Methods: Twenty patients suffering from prostate cancer with intermediate risk who were treated by MAT were selected. Additional treatment plans (primary and boost plans) were generated based on MRgRT-tri-Co-60 and MRgRT-linac. The planning target volume (PTV) of MRgRT-based plans was created by adding a 3 mm margin from the clinical target volume (CTV) due to high soft-tissue contrast and real-time motion imaging. On the other hand, the PTV of conventional linac was generated based on a 1 cm margin from CTV. The targets of primary and boost plans were prostate plus seminal vesicle and prostate only, respectively. All plans were normalized to cover 95% of the target volume by 100% of the prescribed dose. Dosimetric characteristics were evaluated for each of the primary, boost, and sum plans.
Results: For target coverage and conformity, the three plans showed similar results. In the sum plans, the average value of V_65Gy of the rectum of MRgRT-linac (2.62%±2.21%) was smaller than those of MRgRT tri-Co-60 (9.04%±3.01%) and linac-VMAT (9.73%±7.14%) (P<0.001). In the case of bladder, the average value of V_65Gy of MRgRT-linac was also smaller.
Conclusions: In terms of organs at risk sparing, MRgRT-linac shows the best value while maintaining comparable target coverage among the three plans.

Purpose: A full-energy-peak (FEP) efficiency correction is required through a Monte Carlo simulation for accurate radioactivity measurement, considering the geometrical characteristics of the detector and the sample. However, a relative deviation (RD) occurs between the measurement and calculation efficiencies when modeling using the data provided by the manufacturers due to the randomly generated dead layer. This study aims to optimize the structure of the detector by determining the dead layer thickness based on Monte Carlo simulation.
Methods: The high-purity germanium (HPGe) detector used in this study was a coaxial p-type GC2518 model, and a certified reference material (CRM) was used to measure the FEP efficiency. Using the MC N-Particle Transport Code (MCNP) code, the FEP efficiency was calculated by increasing the thickness of the outer and inner dead layer in proportion to the thickness of the electrode.
Results: As the thickness of the outer and inner dead layer increased by 0.1 mm and 0.1 µm, the efficiency difference decreased by 2.43% on average up to 1.0 mm and 1.0 µm and increased by 1.86% thereafter. Therefore, the structure of the detector was optimized by determining 1.0 mm and 1.0 µm as thickness of the dead layer.
Conclusions: The effect of the dead layer on the FEP efficiency was evaluated, and an excellent agreement between the measured and calculated efficiencies was confirmed with RDs of less than 4%. It suggests that the optimized HPGe detector can be used to measure the accurate radioactivity using in dismantling and disposing medical linear accelerators.

Purpose: This study aimed to develop a breath control training system for breath-hold technique and respiratory-gated radiation therapy wherein the patients can learn breath-hold techniques in their convenient environment.
Methods: The breath control training system comprises a sensor device and software. The sensor device uses a loadcell sensor and an adjustable strap around the chest to acquire respiratory signals. The device connects via Bluetooth to a computer where the software is installed. The software visualizes the respiratory signal in near real-time with a graph. The developed system can signal patients through visual (software), auditory (buzzer), and tactile (vibrator) stimulation when breath-holding starts. A motion phantom was used to test the basic functions of the developed breath control training system. The relative standard deviation of the maxima of the emulated free breathing data was calculated. Moreover, a relative standard deviation of a breath-holding region was calculated for the simulated breath-holding data.
Results: The average force of the maxima was 487.71 N, and the relative standard deviation was 4.8%, while the average force of the breath hold region was 398.5 N, and the relative standard deviation was 1.8%. The data acquired through the sensor was consistent with the motion created by the motion phantom.
Conclusions: We have developed a breath control training system comprising a sensor device and software that allow patients to learn breath-hold techniques in their convenient environment.

Purpose: This study seeks to compare the dosimetric parameters of the bulk electron density (ED) approach and synthetic computed tomography (CT) image in terms of position variation of the air cavity in magnetic resonance-guided radiotherapy (MRgRT) for patients with pancreatic cancer.
Methods: This study included nine patients that previously received MRgRT and their simulation CT and magnetic resonance (MR) images were collected. Air cavities were manually delineated on simulation CT and MR images in the treatment planning system for each patient. The synthetic CT images were generated using the deep learning model trained in a prior study. Two more plans with identical beam parameters were recalculated with ED maps that were either manually overridden by the cavities or derived from the synthetic CT. Dose calculation accuracy was explored in terms of dose-volume histogram parameters and gamma analysis.
Results: The D_95% averages were 48.80 Gy, 48.50 Gy, and 48.23 Gy for the original, manually assigned, and synthetic CT-based dose distributions, respectively. The greatest deviation was observed for one patient, whose D_95% to synthetic CT was 1.84 Gy higher than the original plan.
Conclusions: The variation of the air cavity position in the gastrointestinal area affects the treatment dose calculation. Synthetic CT-based ED modification would be a significant option for shortening the time-consuming process and improving MRgRT treatment accuracy.

Purpose: Elekta synergy^® was commissioned in the Seoul National University Veterinary Medical Teaching Hospital. Recently, Chung-Ang University Gwang Myeong Hospital commissioned Elekta Versa HD^TM. The beam characteristics of both machines are similar because of the same Agility^TM MLC Model. We compared measured beam data calculated using the Elekta treatment planning system, Monaco^®, for each institute.
Methods: Beam of the commissioning Elekta linear accelerator were measured in two independent institutes. After installing the beam model based on the measured beam data into the Monaco^®, Monte Carlo (MC) simulation data were generated, mimicking the beam data in a virtual water phantom. Measured beam data were compared with the calculated data, and their similarity was quantitatively evaluated by the gamma analysis.
Results: We compared the percent depth dose (PDD) and off-axis profiles of 6 MV photon and 6 MeV electron beams with MC calculation. With a 3%/3 mm gamma criterion, the photon PDD and profiles showed 100% gamma passing rates except for one inplane profile at 10 cm depth from VMTH. Gamma analysis of the measured photon beam off-axis profiles between the two institutes showed 100% agreement. The electron beams also indicated 100% agreement in PDD distributions. However, the gamma passing rates of the off-axis profiles were 91%–100% with a 3%/3 mm gamma criterion.
Conclusions: The beam and their comparison with MC calculation for each institute showed good performance. Although the measuring tools were orthogonal, no significant difference was found.

Purpose: We subjected scanning electron microscopic (SEM) images of the active layer of EBT3 film to texture analysis to determine the dose-response curve.
Methods: Uncoated Gafchromic EBT3 films were prepared for direct surface SEM scanning. Absorbed doses of 0–20 Gy were delivered to the film’s surface using a 6 MV TrueBeam STx photon beam. The film’s surface was scanned using a SEM under 100× and 3,000× magnification. Four textural features (Homogeneity, Correlation, Contrast, and Energy) were calculated based on the gray level co-occurrence matrix (GLCM) using the SEM images corresponding to each dose. We used R-square to evaluate the linear relationship between delivered doses and textural features of the film’s surface.
Results: C orrelation r esulted i n h igher l inearity a nd d ose-response c urve s ensitivity t han Homogeneity, Contrast, or Energy. The R-square value was 0.964 for correlation using 3,000× magnified SEM images with 9-pixel offsets. Dose verification was used to determine the difference between the prescribed and measured doses for 0, 5, 10, 15, and 20 Gy as 0.09, 1.96, −2.29, 0.17, and 0.08 Gy, respectively.
Conclusions: Texture analysis can be used to accurately convert microscopic structural changes to the EBT3 film’s surface into absorbed doses. Our proposed method is feasible and may improve the accuracy of film dosimetry used to protect patients from excess radiation exposure.

The number of facilities using radiation generators increases and related regulations are strengthened, the establishment of a shielding management and evaluation technology has become important. The characteristics of the radiation generator used in previous report differ from those of currently available high-frequency radiation generators. This study aimed to manufacture lead, iron, and concrete shielding materials for the re-verification of half-value layers, tenth-value layers, and attenuation curve. For a comparison of attenuation ratio, iron, lead, and concrete shields were manufactured in this study. The initial dose was measured without shielding materials, and doses measured under different types and thicknesses of shielding material were compared with the initial dose to calculate the transmission rate on 50–300 kVp X-ray. All the three shielding materials showed a tendency to require greater shielding thickness for higher energy. The attenuation graph showed an exponential shape as the thickness decreased and a straight line as the thickness increased. The difference between the measurement results and the previous study, except in extrapolated parts, may be due to the differences in the radiation generation characteristics between the generators used in the two studies. The attenuated graph measured in this study better reflects the characteristics of current radiation generators, which would be more effective for shield designing.

Recently, tetrahedral phantoms have been newly adopted as international standard mesh-type reference computational phantoms (MRCPs) by the International Commission on Radiological Protection, and a program has been developed to convert them to computational tomography images and DICOM-RT structure files for application of radiotherapy. Through this program, the use of the tetrahedral standard phantom has become available in clinical practice, but utilization has been difficult due to various library dependencies requiring a lot of time and effort for installation. To overcome this limitation, in this study a newly developed TET2DICOM-GUI, a TET2DICOM program based on a graphical user interface (GUI), was programmed using only the MATLAB language so that it can be used without additional library installation and configuration. The program runs in the same order as TET2DICOM and has been optimized to run on a personal computer in a GUI environment. A tetrahedron-based male international standard human phantom, MRCP-AM, was used to evaluate TET2DICOM-GUI. Conversion into a DICOM-RT dataset applicable in clinical practice in about one hour with a personal computer as a basis was confirmed. Also, the generated DICOM-RT dataset was confirmed to be effectively implemented in the radiotherapy planning system. The program developed in this study is expected to replace actual patient data in future studies.