# Presentation: 410945

## 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

## Dose vs. Depth in patient for    various Radiation Fields

## 50 to 250 MeV is clinical range of interest 

- Eye Tumors at 50 MeV; Prostate Tumors at 250

## Prostate Cancer Treatmentusing Proton radiation 

- 37 Daily Tx’s , 2 Gray per fraction, Right and Left Lateral beams on alternate days

## Patient in Treatment Position

## Conformal Proton Beam Dose Distribution

## Prostate CancerEffect of Initial PSA on Disease-free Survival

## Prostate Cancer10 year Disease-free SurvivalStage T1 - T2

| Pretreatment
PSA | Radical 
Prostatectomy
Johns Hopkins*
2123 pts | Protons
74-75 Gy
LLUMC
1102 pts |
| --- | --- | --- |
| < 4.0 | 91% | 92% |
| 4.1 – 10.0 | 79% | 81% |
| 10.1 – 20.0 | 57% | 64% |
| > 20.0 | 48% | 53% |

- *Han, Partin et al.:  Urol Clin of N Amer,  2001

## Early Stage Lung Cancer Tx : 60 Gray in 10 Fractions (46 patients)

|  | Published  X-ray Tx
Results | Published LLU Proton Tx Results |
| --- | --- | --- |
| 3 yr. local control |     56%  |     74% |
| 3 yr. disease free survival |     43% |     72%                  |
| 3 yr. overall survival |     32% |     55% |

## Breast Cancer Treatment using Proton Radiation at LLUMC

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

## Breast Cancer Tx using X-rays   Prone Position for better targeting

## Patient Tx Position in Gantryusing Protons at LLUMC

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

## Body Mould for Breast Tx

## CT slice with isodose curves for 3 proton beams

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

## Vertical CT slice through Tx Region 

## Mass General Hospital Proton Facility ( 25-30 patients/day)

## Loma Linda Proton Therapy Facility 130-150 patients/day

## Fermi Lab Proton Therapy Accelerator Offered by Optivus Technology

## Indiana Univ. Proton Therapy Facility (12-18 patients/day)

## Heidelberg Light Ion Therapy Facility ( 1st Tx in summer 2006)

## Heidelberg Medical SynchrotronOffered by Siemans for Proton and Carbon Therapy

## 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

## Lateral Beam Spreading using Pb 

## Beam Spreading using Magnetic Deflection of Pencil Beams

## Passive beam spreading vs. dynamic beam spreading techniques 

## Slide 29

## 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)

## 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”

## 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

## 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

## Accel ( Germany)

- Have world’s only super conducting cyclotron for proton therapy at fixed energy, approx. 250 MeV
- World’s 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

## 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

## 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 Linda’s 90 ton gantry)
- Offers only scanned beam delivery systems

## Current Vendor Activity Score

|  | IBA | Hita-chi | Mitsu-bishi | Opti-vus | Accel | Sie-mens |
| --- | --- | --- | --- | --- | --- | --- |
| Complete Built |     2 |    1          |    1 |   0 |     1 |    0 |
| Complete
In Prog. |     3 |    1 |    0 |   0 |     0 |     1 |
| Partial  Sys. Built     |     2 |    3 |    3   |   1 |    1 |    0 |
|  |     |  |  |  |  |  |

## 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

## Slide 39

## Prostate CancerLLUMC 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 **

## Slide 41

## Slide 42

## Treatment MorbidityRTOG Scale

** **

**Grade 2**

**Grade 3 & 4**

**GI**

**GU**

**Total**

- Of the 1.3 million cancer patients >50% 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

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