Proton Therapy Worldwide

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Proton Therapy Worldwide

• Why use Protons for cancer Tx? Clinical results
• Examples of other facilities
• Who are the vendors and what are they selling?
• Why the push for pencil beam scanning

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Dose vs. Depth in patient for various
Radiation Fields
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50 to 250 MeV is clinical range of interest

• Eye Tumors at 50 MeV Prostate Tumors at 250

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Prostate Cancer Treatmentusing Proton radiation

• 37 Daily Txs , 2 Gray per fraction, Right and
  Left Lateral beams on alternate days

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Patient in Treatment Position
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Conformal Proton Beam Dose Distribution
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Prostate CancerEffect of Initial PSA on
Disease-free Survival
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Prostate Cancer10 year Disease-free
SurvivalStage T1 - T2
Han, Partin et al. Urol Clin of N Amer, 2001
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Early Stage Lung Cancer Tx 60 Gray in 10
Fractions (46 patients)
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Breast Cancer Treatment using Proton Radiation at
LLUMC

• Partial Breast Radiation - Post Lumpectomy
• 10 Daily Txs, 4 Gray/Tx, 2 or 3 field Tx

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Breast Cancer Tx using X-rays Prone Position
for better targeting
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Patient Tx Position in Gantryusing Protons at
LLUMC

• Partial breast radiation -- post lumpectomy
• Three fields per patient to reduce skin dose

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Body Mould for Breast Tx
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CT slice with isodose curves for 3 proton beams

• Critical structures to avoid-- Skin, heart and
  lung

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Vertical CT slice through Tx Region
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Mass General Hospital Proton Facility ( 25-30
patients/day)
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Loma Linda Proton Therapy Facility 130-150
patients/day
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Fermi Lab Proton Therapy Accelerator Offered by
Optivus Technology
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Indiana Univ. Proton Therapy Facility (12-18
patients/day)
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Heidelberg Light Ion Therapy Facility ( 1st Tx in
summer 2006)
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Heidelberg Medical SynchrotronOffered by Siemans
for Proton and Carbon Therapy
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Proton Therapy Equipment

• Many vendors will provide turn key systems
  which in include
• a) Accelerator
• b) Beam lines
• c) Gantries
• d) Beam delivery systems
• e) table positioner and target alignment systems
• f) Treatment planning system integrated to
  treatment room control systems

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Lateral Beam Spreading using Pb
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Beam Spreading using Magnetic Deflection of
Pencil Beams
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Passive beam spreading vs. dynamic beam spreading
techniques
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Vendor List

• Hitachi ( 250 MeV synchrotron)
• Mitsubishi ( 250 MeV Synchrotron)
• Siemens ( 250 MeV Proton and C6 synchrotron)
• Ion Beam Applications ( 235 MeV cyclotron)
• Accel ( 250 MeV super conducting cyclotron)
• Optivus Technology (250 MeV synchrotron)

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Hitachi (Power and Industries)

• Synchronizes accelerator cycle with respiration
  cycle for chest tumors( typically 4 sec long)
• Capable of 1 x 1011 ppp with 2 sec cycle time
• Offers scanning and passive beam spreading
• Presently has delivered one complete system and
  three subsystems in Japan and one in
  commissioning phase in Houston, TX
• Patented RF driven extraction system for slow
  smooth extraction.
• Can build all components in house

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Mitsubishi

• Uses 3 MeV multi turn injection to synchrotron
• Capable of 5 x 1010 ppp with 2 sec cycle time
• Beam deliver system is passive only (no scanning)
• One working facility in Shizouka, Japan with 3
  to 4 Treatment rooms
• Built subsystems for other Japanese facilities
• They have not yet pursued non- Japanese market

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Ion Beam Applications (Belgium)

• Uses fixed energy (235 MeV) cyclotron with energy
  degrader for lower energy delivery
• Offers scanning and passive systems
• Advanced scanning system still under development
• Have built 2 complete systems
• Have 3 others under construction
• Reputation as the price leader in the field

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Accel ( Germany)

• Have worlds only super conducting cyclotron for
  proton therapy at fixed energy, approx. 250 MeV
• Worlds most compact design, 2 m diameter
• Offers only scanning beam delivery systems
• Presently commissioning first unit in Munich, GE
  with 3 gantries with scanning beams
• Teaming with CMS for Tx Planning system
• First patient treatment scheduled for this year

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Optivus Technology (San Bernardino, CA)

• Presently marketing turn key system using 250
  MeV Fermilab synchrotron with enhancements( in
  use for 15 years)
• Company was formed as a spin off from Loma
  Linda engineering group in 1995
• Offer scanning beam and passive beam delivery
  systems
• At the Loma Linda facility they have built
• a) passive beam delivery systems for clinical
  use
• b) New accelerator control systems
• c) 1st Digital imaging system for patient
  alignment
• Intensity is 2.4 x 1010 ppp with 2.2 sec
  cycle time, but have plans for upgraded
  intensity

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Siemens

• Only commercial vendor of Proton and Carbon beams
• Uses a 20 meter diameter synchrotron to
  accommodate C6 as well as Protons
• Offers proton gantries and horizontal beams for
  Carbon
• Presently building facility in Heidelberg, GE.
• Lab partner at the GSI nuclear lab ( Darmstadt,
  GE) is building massive 400 ton Carbon gantry (
  compared to Loma Lindas 90 ton gantry)
• Offers only scanned beam delivery systems

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Current Vendor Activity Score
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Conclusions

• Proton Therapy has demonstrated superior clinical
  results for tumor control in many sites
• Pencil beam scanning can achieve higher dose to
  tumor with less dose to normal tissues than
  passively scattered proton beams
• Five vendors have demonstrated their ability to
  provide turn-key systems for proton therapy
• Several vendors provide pencil beam scanning

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Prostate CancerLLUMC Results

• 1255 patients treated between 10/91 and 12/97
  with adenocarcinoma of the prostate
• Patients had no prior surgery or hormone therapy
• 74 - 75 CGE at 1.8 - 2.0 CGE per fraction
• Follow-up mean - 63 mos, median - 62 mos
  (range 1 - 132)
• Age mean - 68 years, median - 69 years,
  (range 44 90) CGE Cobalt Gray

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Treatment MorbidityRTOG Scale

Grade 2
Grade 3 4
GI
GU
Total
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• Of the 1.3 million cancer patients gt50 present
  with lung, prostate, or breast malignancy.
• All are treatable with radiation therapy
  including protons
• Prostate
• 80 Gy will give better tumor control, see JAMA
• Most of Bio Chemical failures do not die from
  prostate cancer

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Macular Degeneration (wet type)14 Gray in 1
fraction 28 patients