How I can apply cross-disciplinary learning in PLEP
to my professional fieldMay 24 , 2017
URANCHIMEG TEGMEDRadiation Disaster Medicine Course Student,
Phoenix Leader Education Program for Renaissancefrom Radiation Disaster, Hiroshima University

Dept. of Radiation Oncology, Hiroshima University HospitalContents
I.

Main thesis (Radiation Oncology)
 Why did we do this study ?
 Methodology & Results & Conclusions
 How I can apply my PhD program to the professional field

II. Radiation Disaster Recovery Studies
 PLEP activities
 My achievements
 How I can apply cross-disciplinary learning in PLEP to myprofessional fieldDept. of Radiation Oncology, Hiroshima University Hospital

URANCHIMEG TEGMED1),
Tomoki Kimura1), Takeo Nakashima2) , Yuko Nakamura3), Toru Higaki 3), Nobuki Imano1) , Yoshiko
Doi1), Masahiro Kenjo1), Shuichi Ozawa1), Yuji Murakami1) , Kazuo Awai 3), Yasushi Nagata1)

1) Department of Radiation Oncology, Graduate School of Biomedical Sciences, Hiroshima University
2) Division of Radiation Therapy, Hiroshima University Hospital3) Department of Diagnostic Radiology, Graduate School of Biomedical Sciences, Hiroshima University

Dept. of Radiation Oncology, Hiroshima University Hospital

BackgroundHepatocellular carcinoma (liver cancer) is the 2nd leading
cause of cancer–related death worldwide by 2016.
Mongolia has the highest rate of liver cancer worldwide.
More than 80% of the patients are diagnosed at anadvanced stage and only 10% of patients are eligible forsurgery in Mongolia.
In 2013, approximately 5200 newcancer cases were diagnosed in
Mongolia and 40 % (~2000) of themwere liver cancer.
We haven’t yet started any
radiotherapy for liver cancer in
Mongolia.

Dept. of Radiation Oncology, Hiroshima University Hospital

Introduction

 Stereotactic Body Radiotherapy [SBRT]: delivers very
high dose per fraction within few fractions while limiting
the high dose area to adjacent normal tissues.
 Intensity Modulated Radiation Therapy [IMRT]: Nonuniform radiation beam intensities: based on various
computer-based optimization techniques.
IMRT

3D Conventional RTIMRTDOSE SPARING for Rectum

Rectum is not spared from high dose

Dept. of Radiation Oncology, Hiroshima University Hospital

Challenges: HCC treatment include limited liver function
 Risk of Radiation Induced Liver Disease:① Mean liver dose, ② Irradiated liver volume ③ Chronic hepatic diseases

 SBRT to liver should be planned carefully, especially for patients with poor
liver functions to avoid radiation-induced liver disease.
 An assessment of the current level of liver function using imaging modalities
are important for RT planning.
 Gadoxetate disodium enhanced hepatic MRI (EOB-MRI) during thehepatobiliary phase can detect regional and global liver function.

Purpose“To evaluate the ability of EOB-MRI guided SBRT
planning using IMRT technique for liver cancer to sparefunctional liver tissues”

Dept. of Radiation Oncology, Hiroshima University Hospital

Materials and Method
20 datasets of patients with HCC:RT planning CT & EOB-MR images
Radiotherapy Planning System: Pinnacle3 ver. 9.6 1) Planning CT
2) EOB-MRI
Deformable imaging software: Insight segmentation and registration toolkit (ITK)Statistical software: R Version 3.1.2

Dosimetric analysis
I. Target
II. Organs at risk (OARs)a)

Hepatic OARs :b) Non-hepatic OARs:

 Dose to 95% of planning target volume
 PTV mean dose

 Total and functional liver mean dose Percentages of total and functional liver volume, doses from 5 Gy to 30 Gy
 Stomach, Duodenum, Intestine :Mean dose ; dose to 0.5cc; dose to 5cc

Dept. of Radiation Oncology, Hiroshima University Hospital

SBRT planning using IMRT techniques

1. Anatomical plan: without EOB-MRI(A) Contouring targets and organs at risk

Based on planning CT(B) IMRT planning(C) Complete IMRT plans8 beams IMRT technique.
Prescription dose: 48 Gy /4 fr

Anatomical plan (Plan A)

2. Functional plan: with EOB-MRI
IMRT planningwith additional
functional liver
Information

Additionally generate functional liver map

Functional plan (Plan F)

Dept. of Radiation Oncology, Hiroshima University Hospital

Results
Compared to anatomical RT planning, functional RT planning was able
to achieve reductions in functional liver mean dose, total liver meandose, as well as total and functional liver volumes, which receive from
5 to 30 Gy, while maintaining the target dose coverage.
EOB-MRI can be good functional imaging modality for SBRT planningof liver tumor.

Conclusion
This simulation study demonstrates the potential of functionalimaging with EOB-MRI for SBRT planning in patients with HCC.
EOB–MRI-guided SBRT planning using the IMRT technique may
improve functional liver preservation in patients with HCC.

Dept. of Radiation Oncology, Hiroshima University Hospital

How I can apply my PhD project to my professional field My highest ambition is to start liver SBRT in Mongolia.
• New LINAC machines being installed at
the National Cancer Center ofMongolia (NCCM).
• In the last one year, the Department ofRadiation Oncology (DRO), Hiroshima
University (HU) has started a new
project with the aim to disseminate
their excellent experience to Asiancountries.

Start a collaboration

Dr. Odontuya, a head of DRO, NCCM
was invited by Prof. Nagata, achairmen of DRO, HU in Jan, 2017.

Dr. Kimura, an associate professor of HU and SBRT
specialist conducted a seminar at NCCM in Sep, 2016.

• A collaboration between DROs of HUand NCCM started in Sep, 2016.

Training Program
Clinic practical training for Mongolian staff(medical physicist and two radiotherapy
technicians ) at HU in 10-20 Jan, 2017

Radiation Disaster
Recovery Studies
ContentsII.

Radiation Disaster Recovery Studies
PLEP activitiesMy achievements



How I can apply cross-disciplinary learning in PLEP to my professional fieldPhoenix Leader Education Program (PLEP)
Radiation Disaster Medicine Course
Doctoral Dissertation

D4I will get a PhD degree on May 25, 2017.

ResearchInternational Conferences
Phoenix conference

D3Long-term Internship

ASTRO conference

Incident Emergency Center, IAEA:

Phoenix symposium

STS-Journal Clubs

Qualifying Exam

D2

Radiation Emergency Training
Short-term Field work at Fukushima and Minami Soma City

D1

Interdisciplinary
Common Subjects
Decontamination procedure in affected areaTemporary Housing at Minami Soma City, 2013

IPPNW

Coordinating STS-Journal Clubs
Dr. Rethy Chhem advised LP students to conduct a regular
Journal Club on Radiation Disaster through STS.

Phoenix advisor’s seminar:
Dr. Chhem Rethy, Cambodia
Development Resource Institute,Feb 17, 2014
Journal club with Dr. Kim Fortun,
Professor of STS at Rensselaer Politechinic
Institute, Nov 26, 2014

Journal club with Dr. Scott Knowles, Assoc.
Professor of History at Drexel University, Aug
5, 2015

Motivation to joining MPPNW was initiated through PLEP
MPPNW
wasre-activatedinSeptember 2015.
I am a board member of the MPPNW.

Learned about “International Physicians
for the Prevention of Nuclear War”
through“NaturalDisasterandInternational Cooperation” subject of
PLEP in 2013.

MPPNW/JPPNW joint Symposium
on Nuclear awareness on June 7-8, 2016 in Mongolia• A professor and a student,Nagasaki University, talked about
rescue activities after the bombingof Nagasaki, and nuclear issues inJapan today.
• I conducted a seminar on“Preventionofaccidentalexposures in medical use ofradiation”
formedicalprofessionals at NCCM.

A long-term Internship at Incident Emergency
Centre, IAEA from March 1 to June 30, 2015
Incident Emergency Centre serves as theglobal
focal
pointforinternational
preparedness and response for nuclear andradiological incidents, emergencies, threatsor events of media interest.

My tasks at IEC
1. Medical tool for assessment and follow-up ofpatients from radiological or nuclear accidents.

Inputs

Output2. Review 18 published accident reports, IAEA
3. Create a bank with medical photos of local
radiation injuries of patients.
Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

“Accidental overexposure related to newradiation therapy technologies”
Journal of Radiation Oncology, 2017, in press
U. Tsegmed1,2, N. Fahim1, A. K. Batcha1, T. Nakashima3, Y. Nagata2, M. Abdel-Wahab4
1Intern at the International Atomic Energy Agency, Vienna, Austria

2Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences,Hiroshima University, Hiroshima, Japan
4Division of Human Health, International Atomic Energy Agency, Vienna, Austria

Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

BackgroundNumber of reported cases of overexposure worldwide, 1980-2013

Enhancing safety ofcurrently available
techniques in Radiation
Oncology is essential.

Karen Coeytaux et al, “Reported Radiation overexposure accidents worldwide, 1980-2013: A systematic Review”,
J. Plos One, 2015
Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

Purpose
To analyze the main causes of RT accidental overexposure
related to expansion of new technologies in order toenhance safety in the field of modern radiation oncology.

• Publications & reports:

Materials- ICRP, IAEA, UNSCEAR, Japanese Intersociety Council of Medical Physics (JRS,JASTRO, JSMP, JSRT).

• Official websites:‒ Radiation Protection of Patients, IAEA – www.rpop.iaea.org/SAFRON/‒ United State Nuclear Regulatory Commission: www.nrc.gov; Radiation Oncology
Safety Information System‒ ROSIS [ESTRO]: www.rosis-info.org;

Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

Results
Pattern oferrors
Calibration

Root cause of errors

Affectedpatients

Death379

04127

Human error System related Equipment relatedTotal

Treatmentplanning
Treatmentsetup
Treatmentdelivery

5576028400

1310410702035Total

941

8152724 Of the 24 RT accidents, a total of 941 patients were overexposed and 8 patientsdied as a result of their overexposure.
Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

Conclusion
The proper preparation and availability of resources,
including adequate staff training, risk estimation
before the installation of new technology, enhanced
safety culture and quality-assurance, can reduce thenumber of accidental events related to the use of newradiation therapy technologies.

Dept. of Radiation Oncology, Hiroshima University HospitalInternational Atomic Energy Agency

My achievements from PLEP
i. I obtained comprehensive interdisciplinary
knowledge and practice in Radiation Disaster
Recovery Studies, as well as Radiation Oncology.
ii. Research protects: 2 publications

Medicine Radiation
Radiation Oncology
Disaster
Environment Society1) U. Tsegmed, T. Kimura, et al., Functional image-guided stereotactic body radiation
therapy planning for patients with hepatocellular carcinoma. Medical Dosimetry,
2017,42(2):p. 97-103.
2) U. Tsegmed, N. Fahim, et al., Accidental overexposure related to new radiation therapy
technologies. Journal of Radiation Oncology, 2017iii. I improved my presentation and communication skills : 8 oral and 7
poster presentations at international conferences
iv. I gained working experience at international organization
v. Building international network

How I can apply cross-disciplinary learningin PLEP to my professional fieldApplications of nuclear technology and preparedness
and response for radiation emergencies in Mongolia
 Nowadays, applications of nuclear technology in different areas have been largely
expanded in Mongolia.
 Radiation accidents are always a possibility.

An adequate medical system for radiation emergencies is not established!

Main reasons to establish Radiation
Emergency Medicine program in Mongolia•

In the health sector, modern RT and nuclear technologies are newly introduced.
Thus, significant challenges are posed in quality assurance of the advanced nuclear
technologies, as well as in radiation safety and protection issues.

•Recently, the uranium mining sector has rapidly expanded in Mongolia. However,the field of radiation protection and safety has not been developed well.

•In addition, public perception of radiation and radiation protection are very weak.

•Mongolia is sandwiched between Russia and China, and both these countries havenuclear power plants and nuclear weapons.

•There is a lack of specialists in radiation disaster medicine in Mongolia.

I am keen to play a leadership role in developing a radiation emergency
medicine program and enhancing the field of radiation protection in mycountry.

Steps towards the establishment of a Radiation
Emergency Medicine program in Mongolia Establishment of the system for radiation emergency medicine• To prepare specialists and other human resources in the field of radiation
emergency medicine• To establish a 24//7 national and local radiation emergency response
capability at NCCM.
 Education and training of Radiation Disaster Medicine:• Medical professionals• Medical students
 Radiation education for the public Building international cooperation

STS will be included as a tool for establishing the radiation emergency
medicine program.

Acknowledgements
I wish to thank to:• PLEP for giving me great opportunities to obtain broad, interdisciplinary
knowledge and skills for a specialist in radiation disaster recovery.
• My PhD supervisor Prof. Nagata and team members from DRO.
• The IAEA for providing me with the opportunity to gain international
experience through a long-term internship.
• Phoenix advisors for their support and mentoring.

Thank you very much for your kind attention!