Vienna The Gantry 1 of PSI Eros Pedroniinfo.tuwien.ac.at/.../Pedroni_HadronTherapyWorld_compr.pdf · 2014-11-15 · E. Pedroni Center for Proton Radiation Therapy - Paul Scherrer

E. Pedroni Center for Proton Radiation Therapy - Paul Scherrer Institute Wien 15-03-2011 1

Vienna15.03.2011

Status of Hadrontherapy facilities worldwide

Eros Pedroni

Center for Proton Radiation TherapyPaul Scherrer Institute

SWITZERLAND

Author’s competence: Gantry with proton pencil beam scanningHigh LET radiation - with pion therapy

The Gantry 1 of PSI

2E. Pedroni Center for Proton Radiation Therapy - Paul Scherrer Institute Wien 15-03-2011

Outline of the presentation

1. Motivation for HadrontherapyPhysical selectivityRadiobiology of High LET radiation

2. Scanning beams vs. passive scattering3. Tour of the world of the hadrontherapy facilities4. The point of view of PSI: past experience and future plans5. New accelerator concepts6. Conclusions


1. Hadrontherapy: the context


Hadrontherapy

• HT = Radiotherapy (RT) using protons and ion beams

• The term of comparison for hadron-therapy:Conventional radiotherapy (RT) with photons– With new dynamic beam delivery techniques

– Intensity Modulated RT (IMRT)– Tomotherapy

– Treatment of moving tumors– Respiration gated irradiations– Use of time resolved images

• 4d-CT and 4d-MRI– Image-guided radiotherapy

– Beam delivery adaptation on line


1A. Physical selectivity goal

Protons

Proton beams: the best external radiation therapy with low-LET


The rationale for using protonsPhysical selectivity Finite range Bragg peak

SOBPPhotons Protons (and ions)

depth (cm) depth (cm)

dose

– No significant radiobiological difference between protons and photons• Main advantage of protons compared to photons – the distribution of the dose

– Dose burden on the healthy tissues outside of the target volume reduced by a factor 2 to 5


1B. Different radiobiology

heavier (light) ions

Carbon ion: the best external radiation therapy with high-LET


• LET (LET - Linear energy transfer – “ionization density”– Relevant at the size of the DNA structure– Low LET at low doses -> single damage to the DNA chain -> Repair– High LET -> multiple damages to the DNA chain -> NO repair

• High LET: means – For the tumor cells

• Increased efficiency of killing– For the healthy tissues

• Increased “collateral damage” ??– Acute effects– Late effects– Secondary cancer induction

• Sensitive tissues within or outside of the target?

What is high-LET radiation ?

(a wikipedia image)

vs.

“CANNON BALL”

“BULLET”

X-raysProtons

Ions

DNA


• Improved ballistic precision– Low multiple Coulomb scattering

• Improved lateral precision– Sharper Bragg peak

• But loss of primary beam– Fractionation tails

• Interesting: for the future– The use of helium ions – a low enough “low-LET radiation”

for the highest precision?

The strength of carbon ions: High LET with very good physical selectivity


2. Technical options

Gantry vs. Horizontal beam Scanning beams vs. passive scattering


The price to pay for the ions : the increased size of the facility

70m

37m

Carbon ions

Protons

• The magnetic rigidity of the beam– Carbon ions 3 times higher than protons

• Size increased by a factor of 2 in all dimensions

• Costs doubled• No gantry or a huge gantry

– Or a dedicated proton gantry …


The established traditional method (of the 60s)

range-shifter wheel

scatter foils

collimator

compensator

entrance dose

100% dose

target volumepatient

Passive scattering

• Not truly 3d-conformal (fixed modulation of the range)• Field specific hardware needed for each field• IMRT difficult (if not unfeasible)

• Less sensitive to organ motion errors than scanning


DEPTH

~ 20 cm

Lateralposition

Pencil beam scanning

• Fully 3d conformal (variable range modulation) • Better dose precision - less material in the nozzle• Fully automated (no specific hardware needed)• Clean beam: less activation, less neutron background


• Flexibility to shape the dose distribution within the field• Simultaneous optimization of fields

– Intensity modulated therapy IMPT (40% of the PSI treatments) • Attract large interest due to competition with photon IMRT

• Biological targeting (non-uniform dose distribution)

Advantage of using a scanning gantry: IMPT

• Disadvantage of scanning– Sensitivity to

organ motion• Need to develop

– Faster scanning– Repainting– Gating– Tracking


3.Tour of the world of

hadrontherapy facilities


EYE treatments - dedicated - at low energy

EUROPE• PSI, Villigen Switzerland p 72 1984 5458

– OPTIS2 since Nov 2010)• Clatterbridge England p 62 1989 2021• Nice France p 65 1991 4209 • HZB (HMI), Berlin Germany p 72 1998 1660• INFN-LNS, Catania Italy p 60 2002 174NORTH AMERICA• UCSF San Francisco USA p 60 1994 1285• TRIUMF, Vancouver Canada p 72 1995 152

Comment:Place of origin Boston (Harvard) p150 since the 80'sThe largest amount of treated patients with Proton Therapy A rare disease …


RUNNING FACILITIES in the world

• USA Type Rooms Acc. Start Pats. CompanyLoma Linda CA p 250 3g1h synchr 1990 15000 Optivus

• NPTC, MGH Boston p 235 2g1h cycl 2001 4967 IBA• MPRI(2) Bloomington p 200 2g1h cycl. 2004 1145 IBA• MDA Houston p250 3g1h synchr. 2006 1700 Hitachi

– spread beam and beam scanning since 2008• UFPTI Jacksonville p 230 3g1h, cycl. 2006 2679 IBA• ProCure Oklahoma p 230 1gh2h/60 cycl. 2009 21 IBA• UPenn, Philadelphia p 230 4g1h cycl. 2010 150 IBA• CDH , Warrenville, IL p 230 1g1h2h/60 cycl 2010 started IBA

• Boston (previously Harvard cyclotron) has provided most of the clinical evidence for PT• Loma Linda has been the first hospital-based proton facility in the world (15000 patients)

• In the USA we have only proton facilities mainly cyclotrons• All facilities use proton gantries and scattering• Scanning is being developed as an addition to scattering (for competing with IMRT)

• No ion therapy in the US since the shutting down of the Berkeley facility



JAPAN Type Rooms Acc. Start Pats. Company• HIMAC, Chiba C800 1h1hv sync, 1994 5497 many• NCC, Kashiwa p235 2g cycl. 1998 680 Sumitomo• HIBMC,Hyogo p230 2g sync. 2001 2382 Mitsubishi• HIBMC,Hyogo C320 1h1v sync. 2002 638 Mitsubishi• PMRC Tsukuba p250 2g sync. 2001 1849 Hitachi• Shizuoka p235 gh sync, 2003 986 Hitachi?• WakasaTsuruga p200 1h1v sync 2002 62 ?• GHMC, Gunma C400 3h1v sync. 2010 started ? compact

• Chiba: was the first dedicated facility using only carbon ions– The place producing the most important clinical results with carbon (5500 patients)

• With scattering with strong interest in new developments (sync. and scanning) • Hyogo – the only running facility with combined carbon and proton therapy

• Reported patient treatments– Proton = 2382 Carbon = 638 (20%)



• EUROPE Type Rooms Acc. Start Pats. Company• Uppsala S p200 1H sync. 1989 929 • Orsay F p230 1g1h cycl. 1991 5216 IBA

sync.cycl. - new cyclotron+gantry operational since Oct 2010• PSI, CH p250 1g cycl. SC 1996 704

degraded beam until 2006; dedicated 250 MeV cyclotron since 2007• GSI Darmstadt D C430 1h sync. 1997 440 stopped• RPTC Munich D p250 4g1h cycl. SC 2009 446 Varian• HIT Heidelberg D p250 2h sync. 2009 started …/Siemens

HIT Heidelberg D C430 2h sync. 2009 started

The new European facilities are based solely on active scanning (except Orsay)– Despite the fact that the organ motion problem with scanning is still unsolved– Protons facilities are all with gantry (and cyclotron)– Carbon facilities are only with horizontal beam lines (except HIT in Heidelberg)

• PSI and GSI have pioneered beam delivery by pencil beam scanning



RUSSIA • ITEP, Moscow Russia p250 1h sync 1969 4246• St.Petersburg Russia p1000 1h 1975 1362• Dubna Russia p200 1h 1999 720AFRICA• Cape Town S-Africa p200 1h cycl. 1993 511CHINA• WPTC, Zibo p230 2g1h cycl 2004 1078 IBA?• MPCAS, Langzou C400 1h sync 2009 126 Siemens?KOREA• NCC, IIsan p230 2g1h cycl. 2007 648 IBA


FACILITIES under construction …

USANorthern Illinois, p250 SCcycl 2g2h Varian??PTCenter, Chicago p230 cycl 2h2dual fixed beams IBAHUPBTC, Hampton, V p230 cyclotron 4g1h IBAProCure facilities (initiative of Indiana Un. )

New Jersey … Seattle … Florida … Michigan …coming soon…TAIPEIChang Gung Taipei Taiwan p235 cycl 4g1h JAPANSouthern Tohoku,Fukushima p230 cycl 2g1hMedipolis, Ibusuki Kagoshima p250 sync 3gRUSSIAPMHPTC, Protvino Russia p250 sync 1h ??

New commercial machines for protons: all with passive scattering ?


FACILITIES under construction …

EUROPEPSI P-Gantry 2, p250 1g cycl parallel scanningWPE, Essen Germany p230 3g1h cycl. IBA-scanningTrento Italy p230 1g1h cycl. IBA-scanningPTC Czech Rep. p230 3g1h cycl ?CMHPTC, Slovak Rep. p250 1h synch ?Heidelberg C-Gantry p,C430 CG sync. ScanningCNAO, Pavia Italy p,C430 3h sync. ScanningPTC, Marburg p,C430 3h145° sync. Scanning SiemensNRoCK, Kiel p,C430 1h 1(v45)1hv Scanning SiemensMed-AUSTRON p,C400 1pG,1h 1hv sync. Scanning

1 dedicated Proton Gantry

New commercial machines in Europe: all based on scanning


The two centers pioneering pencil beam scanning in the last decade

• The gantry 1 of PSI (since 1996 )– Protons delivered with a cyclotron and a degrader– The first scanning gantry in the world – Discrete spot scanning (magnetic scanning – range shifter – patient table motion)

• Horizontal beam line at GSI (since 1997)– Carbon ions - synchrotron with slow extraction – 2D magnetic scanning – dose painting in energy layers (fixed energy per pulse)– Raster scanning technique (Beam stays ON from spot to spot)

• Same type of indications


• At the new proton therapy facility in Houston• One of the 3 gantries equipped with scanning

– First patient treated with proton pencil beam scanning on 19-May-2008 at the M. D. Anderson Hospital (Texas)

• Varian and IBA are now offering scanning-only based facilities

Scanning developments in the USA


ACCEL VARIAN

• The RPTC in Munich– The first industrial proton facility based solely on

scanning– Same accelerator as used at PSI

• Treating lung tumors with apnea under anesthesia


The University of Heidelberg ProjectHeidelberg Ion Therapy Center (HIT)

• The first and only gantry for carbon ions therapy in the world

– 600 tons • Facility design by GSI

– Commercial partnership with Siemens

Courtesy of Siemens And the University of Heidelberg, Germany


Courtesy ofSiemens and Rhön-Klinikum AG,Germany

Rhön Klinikum AG - University of Marburg /Giessen

66m

110m

The first commercial system for carbon therapy in Europe4 identical horizontal beam lines for carbon ion treatments


CNAOCentro Nazionale di Adroterapia Oncologica, Pavia, Italy

• Combined system for protons and carbonInitiated by Ugo Amaldi at CERN (TERA project) – Synchrotron – 3 areas with fixed beams– One area with horizontal and vertical

beam line

• Open possibility to expand the facility with proton gantries later– Eventually a good idea …


5. The strategy of PSI

past experience and concepts for the future


The expansion of the PSI proton therapy project

Medical cyclotron

Gantry 2Degrader

• A new dedicated accelerator (superconducting cyclotron COMET)• Treatments with Gantry 1 restarted in April 2007• A new Gantry 2 (for the further advancement of our scanning technology)• Optis 2 (transfer of the eye treatments from Injector 1 to COMET)

Gantry 1

Optis 2

Split beam


Continuation of the successful treatments with Gantry 1

• 15 patients/day (8:00-16:00)• Clinically proven indications

– Base of skull and spinalchord and low pelvis

– Only non moving tumors (due to scanning)

• Excellent results• Of great interest

– Pediatric tumors (1/3 patients)– Below 5 years with anesthesia

• Gantry 1 is fully booked– Not possible anymore to explore

new indications

– Example of a child treatment under anesthesia at PSI

Courtesy of B. Timmermann PSI


• 250 MeV superconducting cyclotron (COMET)– Delivered by ACCEL Varian in 2005

• DC beam– Very stable beam at the ion source

• Dynamic control of the beam intensity– Deflector plate at the first turn of the spiral

• Control at a few 100 s time scale• Fast dynamic energy changes

– With degrader and beam line– 80 ms for a 5 mm step of proton range

• Much faster than with a synchrotron

The cyclotron used as an active component for the beam delivery


• Gantry with sliding CT• BEV X rays • Parallel scanning

The system which will be cloned in the Medaustron facility

For proton therapy delivery

Installations in the Gantry 2 area completed by the end of 2010


• Double parallel magnetic scanning– Continuous scan - speed up to of 2 cm / ms (equivalent to 2 kHz pulses on a 5 mm grid )

• Dose control through– Dynamic modulation of the beam intensity (1mm = time scale of 100 s)

• Fast energy variations (for volumetric repainting)– With degrader and beam line 80 ms per energy step (90° gantry magnet is the limit)

• Repainting capability– Factor 10 compared to

Gantry 1

Dynamic beam energy Repainting

Parallel scanningBeam intensitymodulation

GatingTrackingBreath hold

A new system for developing advanced scanning: ….


6. New accelerator concepts


The “dream” solution

• Why not proton therapy like photon therapy?– From Photon-Tomotherapy to Proton-Tomotherapy ?

• Distal tracking? Rotational therapy with protons?– (T.R. Mackie)

High gradient (100 MeV/m) Linac(dielectric wall)

Caporaso et al, Nucl Instr Meth B 261 (2007) 777


…going for further simplifications?

• Still/River company (USA)– Passive scattering

• Neutron background?– How many compromises?

• Half a dozen of system already sold beforehand?

• ACCEL Varian– Compact synchrocyclotron on gantry– With degrader and beam analysis

• Very compact synchro-cyclotron (first beam extracted in 2010)– Single room solutions for small size hospitals


New developments of accelerators related-to-therapy

• New interesting concepts– Cyclinac: isotope production cyclotron coupled to a boosting Linac (Ugo Amaldi)– Fixed Field Alternating Gradient (static beam line)

• FFAG Gantry (energy changes as fast as in lateral direction – ideal for tracking?)– Laser driven acceleration (how to control energy and dose simultaneously?)– Plasma wake field acceleration ??

• Common to the mentioned solutions: the idea to provide– Variable energy with the accelerator (to avoid the use of a degrader – a big issue?)– Short beam pulses

• To compete with a continuous fast scanning with a cyclotron (for repainting – for mitigation of organ motion errors) one needs a

• High repetition rate of ~ 1 KHz? • Control of the dose pulse by pulse: with pulse dose precision of < 1%?

• The general difficulty …– How can we reduce size and costs without loosing quality of beam delivery?


7. Conclusions


The general trend in hadrontherapy today in the world • The field is “booming”• Proton therapy

– Is a well established indications • with more indications to discover:

– Developments towards treatments of moving targets (faster scanning)– Exploration of hypo-fractionation

– Decision based only on the quality of the dose distribution (comparison protons-photons) – Costs reimbursed by the health insurances– Estimate: 10-15% of all radiation therapy patients should profit from protons– Worldwide experience: 67000 patients treated with protons worldwide

• Equipment is available on a commercial basis how well optimized?– Big industry entering the field

• Pencil beam scanning is accepted as a need yet available?– For competing with IMRT


The general trend in hadrontherapy today in the world • Carbon ion therapy

– A very interesting research topic (link to molecular radiobiology - a new field) – Treatment reimbursed?– More experience needed

• Total number of treated ion patients is only ~10% of hadrontherapy total– Recently good results with hypo-fractionated lung treatments in Chiba

• Exciting results - but the comparison with hypo-fractionated protons is missing • Ion therapy has more potential for surprises than protons (radiobiology)

• Ion facilities delivering ions and protons (mixed facility)– Not fair to use protons at low quality, if this is only for cross-financing carbon therapy– Yes, if proton therapy is properly done

• With a (proton) gantry ?• With nozzle optimized for proton therapy (for a small pencil beam)

– Very pleased that Medaustron is following this strategy• Certainly a field with new things to discover


Thank you

Documents

Vienna The Gantry 1 of PSI Eros Pedroniinfo.tuwien.ac.at/.../Pedroni_HadronTherapyWorld_compr.pdf · 2014-11-15 · E. Pedroni Center for Proton Radiation Therapy - Paul Scherrer