Chapter 41 New Facilities: Plans and Proposals

Transcription

1 Chapter 41 New Facilities: Plans and Proposals Ramona Mayer and Stanislav Vatnitsky Abstract Ion beam facilities that have either become operational since 2001 or are at present under construction or in development are reviewed. The concepts of four upcoming European dual ion beam facilities will be described in more detail Introduction In contrast to the early years of ion beam therapy (IBT), where patients were treated at physics research facilities when beam time was available, the last decade has clearly seen a trend towards hospital-based facilities. The overview on new and upcoming facilities shows a distinct market for proton facilities in the United States. In contrast to that, in Asia and Europe an interest in both, proton and carbon ion treatments, or combined treatments as provided in dual ion beam facilities can be noticed. A comprehensive summary of all existing, closed, and planned ion beam facilities can be found on the homepage of the Particle Therapy Cooperative Group (PTCOG), where also the number of patients treated worldwide is regularly updated ( R. Mayer ( ) EBG MedAustron GmbH, Viktor Kaplan-Straße 2, 2700 Wiener Neustadt, Austria ramona.mayer@ebgmedaustron.at U. Linz (ed.), Ion Beam Therapy, Biological and Medical Physics, Biomedical Engineering, DOI / , Springer-Verlag Berlin Heidelberg

2 688 R. Mayer and S. Vatnitsky 41.2 Situation in Europe Proton Therapy Facilities The first ion beam patient in Europe was treated with protons in Uppsala, Sweden, in The first proton therapy (PT) facility in Western Europe has been in operation at the Paul Scherrer Institute (PSI) in Villigen, Switzerland, since The spot scanning technique with a proton gantry was established in this institution in 1996 [1]. In 2010, a total of nine proton facilities are operational in Europe, four of them are dedicated to eye treatment, only. Additionally, three centers are running in Russia; however, none of them is hospital-based. Four new proton centers (Table 41.1) are under construction or in development stage in Europe. The existing facility in Orsay will be enlarged and at the final stage, it will be equipped with one gantry and four fixed-beam rooms. The facility at PSI in Villigen, Switzerland, will soon start to use an additional gantry with modern beam scanning technology (cf. [2] and Chap. 24 for details) Carbon Ion Beam Facilities Pioneer work in carbon ion radiotherapy (CIRT) has been done at the Helmholtz Research Centre for Heavy Ions (GSI) in Darmstadt, Germany. For example, much of the important research work on the relative biological effectiveness (RBE) was performed at the GSI [3, 4]. At this research center from 1997 to 2008, beam time was used during several weeks per year to treat more than 440 patients for tumors in the head or neck region [5, 6]. For many years, the GSI was the only facility in Europe providing CIRT. With the opening of the dual ion beam facility at Heidelberg, Germany, in 2009, patient treatment at GSI was abandoned. A carbon ion facility called ARCHADE is under development in Caen, France. At this center, in contrast to all other carbon ion facilities worldwide, a cyclotron will be used instead of a synchrotron. The facility, which is primarily research orientated, will be equipped with one research room and one fixed-beam treatment room Dual Ion Beam Facilities In 2009, the first European dual ion beam facility HIT (Heidelberg Ion-Beam Therapy Center) started operation in Heidelberg, Germany. Currently, however, the patients are only treated with the fixed-beam lines. The first carbon ion beam gantry worldwide shall start operation within Additional dual ion beam centers are under construction or in development in Europe. Four of these are introduced, here, in more detail.

3 41 New Facilities: Plans and Proposals 689 Table 41.1 New ion beam facilities in Europe. Top: Opening after Bottom: Under construction or in development Center City State Particle Max. clin. Beam delivery system Start European facilities which opened after 2001 Istituto Nazionale di Fisica Nucleare Laboratori Nazionali del Sud (INFN-LNS) energy (MeV) Gantry Fixed-beam Catania Italy p Rinecker Proton Therapy Center Munich Germany p Heidelberger Heidelberg Germany p, C-ion 430/u Ionenstrahl-Therapiezentrum (HIT) Central Military Hospital Proton Ruzomberok Slovak Republic p Therapy Center Narodwe Centrum Radioterapii Krakow Poland p Hadronowej New European facilities under construction or in development Centro Nazionale di Adroterapia Pavia Italy p, C-ion 430/u Oncologica (CNAO) Westdeutsches Essen Germany p Protonentherapiezentrum (WPE) Partikel-Therapie Zentrum (PTZ) Marburg Germany p, C-ion 430/u a Nordeuropäisches Radioonkologisches Kiel Germany p, C-ion 430/u a Centrum Kiel (NRoCK) Proton Therapy Center Czech Prague Czech Rep. p Skandion Clinic Uppsala Sweden p Agenzia Provinciale Per la Protonterapia (ATreP) Trento Italy p HollandPTC Delft The Netherlands p n.a. n.a. n.a. n.a. MedAustron Wiener Neustadt Austria p, C-ion 400/u ARCHADE Caen France p, C-ion 400/u ETOILE Lyon France p, C-ion 400/u a In the summer of 2011, the provider Siemens announced to disontinue any IBT work in this facility

4 690 R. Mayer and S. Vatnitsky Fig Artist s view of NRoCK. Courtesy of NRoCK GmbH, Kiel, Germany Fig Treatment level at NRoCK. Courtesy of NRoCK GmbH, Kiel, Germany North European Radiooncological Center Kiel ( The North European Radiooncological Center Kiel, Germany (NRoCK), was intended to be the first center worldwide to offer external beam therapy with photons, electrons, protons and carbon ions, brachytherapy, systemic therapy, and state-of-the-art diagnostic imaging under one roof (Figs and 41.2). Construction of NRoCK began in July A public-private partnership wanted to share the estimated cost of 250 million Euros. Patients should receive (R. Kampf, Personal communication 2010). Advanced radiation therapy as well as systemic therapy in close cooperation with partner institutions in Northern Germany and the neighboring Baltic states. Projected Technical details: Protons and carbon ions are generated in an ion source and injected into a two-stage linear accelerator where they are brought to an energy of approx. 7 MeV/u. A medium energy beam transport line guides the particles to a synchrotron where they are accelerated up to 250 MeV/u for protons and 430 MeV/u for carbon ions. Inside the treatment rooms two fast scanning magnets deflect the ion beam in directions perpendicular to the beam axis to fully cover the shape of the tumor (raster scanning). All beam parameters with the exceptions of energy should be switched within tenths of a second. Three treatment rooms are projected, each with a horizontal beam line, one with an additional vertical beam line and one with an additional 45 ı beam line.

5 41 New Facilities: Plans and Proposals 691 The use of robots together with kv imaging should provide highest treatment precision and a new level of comfort for the patient. The equipment for conventional radiotherapy at NRoCK comprises two stateof-the-art linacs to perform photon and electron radiation treatments across a wide energy range. Image-guided radiation therapy (IGRT) and intensity-modulated radiotherapy (IMRT) can be performed. In addition, two bunkers are dedicated to brachytherapy capable of delivering high, low, and pulsed dose rate brachytherapy. The imaging area is equipped with a sliding gantry computed X-ray tomography unit, a whole-body 1.5 T magnetic resonance imaging (MRI) system, and a combined positron emission tomography and computed X-ray tomography (PET-CT) system. In September 2011, when most of the technical equipment was already installed, Siemens announced that it would only equip the facility with conventional radiotherapy instrumentation and would discontinue the work related to IBT [7] ETOILE: The First French CIRT Center in Lyon ( The ETOILE project has emerged since the beginning of It gained governmental support and juridical structure as a Health Cooperation Grouping (Groupement de Coopération Sanitaire, GCS-ETOILE). The call for bids was released in February 2008 in the frame of a public private partnership. Three industrial consortia initiated the competitive dialog with the GCS-ETOILE in July This negotiation phase ended in March Finalization of the contract and launching of the construction are expected in 2011 (J. Balosso, P. Pommier, G. Wasmer, et al., Personal communication). The project is characterized by the parallel course of seven programs, which are all together necessary for the final success of the project. These are 1. Application to the health authorities for the validation of the initial core indications 2. Detailed economical modeling to define the level of reimbursement for the carbon ion treatments in close relation with the governmental health services 3. A new round of epidemiological studies to obtain a real-scale image of the recruitment, and the organization of the national network 4. Discussions with neighboring countries to attract patients from a larger area than France only for the early indications 5. Information and lobbying activities to ascertain the national position of the ETOILE Center 6. Necessary financial conditions to obtain state warranties for the loan and the financial security of the project 7. Research and technological developments other than the clinical activities of CIRT and PT

6 692 R. Mayer and S. Vatnitsky Fig Projection of the ETOILE facility in the city of Lyon. Courtesy of Centre ETOILE, Lyon, France. ETOILE The First French CIRT Center at Lyon ( The French Higher Health Authority issued a preliminary favorable evaluation in March 2010 with recognition of most of the so-called consolidated indications for CIRT that comprise the former neutron indications and the major indications investigated by NIRS and GSI/HIT. These indications accumulate to an incidence of about 1,200 cases per year in France. A set of more frequent (3,000 6,000 cases per year) but less investigated prospective indications will necessitate successful clinical trials to be progressively added to the first set. This second set will be subjected to multicentric prospective clinical trials in the frame of the ULICE (Union of Light Ion Centres in Europe) network, an EU-funded project set up by 19 research organizations and European industrial partners. The ETOILE Project has generated a strong scientific environment with specific funding since Many doctoral and postdoctoral positions have thus been financed. Researchers are supported by specific funding from various public regional institutions, such as the City of Lyon, and constitute the so-called Regional Program of Research in Hadron therapy (PRRH: Programme de Recherche Régional en Hadronthérapie), linked to a similar national program (PNRH). Research teams involved in PRRH are part of established research and teaching institutions such as neighboring universities or the French Public Research Institutions INSERM and CNRS. Major PRRH topics are the medical project itself; economic simulations; in-silico modeling; study of the particles generated in the target volume and realtime control imaging; radiobiology of particles; dosimetry and dose deposition simulation; moving targets, organ motion and distortion; and technological developments associated with the former (Fig. 41.3) CNAO: The National Center for Oncological Hadron Therapy in Pavia, Italy ( The founders of CNAO are five major hospitals, seated in Milan and Pavia, plus the Italian TERA Foundation. Since 2003, the National Institute of Nuclear Physics (INFN), the Universities of Milan and Pavia, the Polytechnic of Milan, and the Town

7 41 New Facilities: Plans and Proposals 693 Fig Outside view of the CNAO ion beam facility in Pavia. With permission of Fondazione CNAO, Milan, Italy of Pavia are additional institutional participants of CNAO (P. Fossati, M. Pulia, R. Orrecchia, S. Rossi, Personal communication). The CNAO project has a long history which began in 1996 at CERN, Geneva, Switzerland, with the design of an optimized synchrotron for proton and light ion therapy with the acronym PIMMS (Proton-Ion Medical Machine Study) [8]. PIMMS was a collaboration of CERN, Med-AUSTRON (Austria), Oncology 2000 (Czech Republic), and TERA. GSI contributed and gave expert advice. The PIMMS group had as mandate the design of a synchrotron and beam lines for center unconstrained by financial and/or space limitations. In fact, PIMMS was never intended to be built in its final layout. It was more an open design study from which different modules could be taken for the design of various centers according to their requirements. Based on that work, the TERA Foundation, with the collaboration of many institutions, including INFN, CERN, GSI and a few Italian universities, engineered the PIMMS synchrotron and made a more compact design of the extraction and injection lines. The resulting project has recently been completed in Pavia (Fig. 41.4). The CNAO synchrotron, shown in Fig. 41.5, has a diameter of approximately 25 m and accelerates protons and carbon ions to 250 MeV and 400 MeV/u, respectively. The injector is almost identical to that of the HIT facility differing only in the geometry of the low-energy beam transport (LEBT) system. Sources and linac are placed inside the main ring, making the accelerator very compact. The two ion sources run continuously and can be individually monitored; the particle species to be accelerated are selected by just changing the LEBT magnet settings. The CNAO facility has three treatment rooms in which the beam can be delivered with horizontal lines. The design of the extraction lines is particularly compact thanks to the use of a switching magnet that directs the beam to the selected treatment room. In one of the rooms, a vertical line is available, additionally, to deliver the beam at the same isocenter as the horizontal one. CNAO will employ an active spot scanning system.

8 694 R. Mayer and S. Vatnitsky Fig CNAO accelerator complex. With permission of Fondazione CNAO, Milano, Italy The CNAO building has been constructed to allow expansion by two additional treatment rooms. The reserved space for such a second phase is dimensioned to also provide sufficient room for two carbon ion gantries. The facility will be equipped with one CT scanner, one PET/CT scanner, and one MRI scanner dedicated to treatment simulation and in-treatment response evaluation. Treatments will be performed with patients immobilized on specially designed couches or chairs that will be docked to a state-of-the-art, 6-degrees-offreedom positioning device. Set-up verification will be performed with orthogonal kv images of diagnostic quality. Additionally, an optoelectronic system with marker detection and surface detection capability is projected. CNAO aims to have a high patient throughput. Therefore, dedicated positioning rooms exist for computeraided positioning (CAP) on a couch or on a chair outside the treatment room. The patients will be transported into the treatment room on a trolley which docks to the positioning device. Three-dimensional set-up verification will be available in the CAP room with CT on rails [9]. Seven areas of interest have been identified for treatment: lung cancer, liver cancer, head and neck malignancies, pediatric solid cancers, eye tumors, sarcoma, and central nervous system cancers. In the future, gynecological and digestive (pancreas, biliary tract, and rectum) tumors might be further indications. Diseasespecific working groups will define selection criteria and protocols to be used at CNAO. All patients will participate in clinical trials in order to establish optimal indications for IBT. Commissioning of the first treatment room was completed, recently, and the first patient was treated in September of 2011.

9 41 New Facilities: Plans and Proposals MedAustron, Wiener Neustadt, Austria ( The ion beam cancer treatment and research center MedAustron in Wiener Neustadt, Austria is designed to be a dual ion beam center, where proton and carbon IBT can be compared under identical technical conditions. The company EBG MedAustron GmbH has the overall responsibility for the construction and operation. Collaborations for the realization of the MedAustron accelerator complex have been established with CERN and CNAO. Recently, a scientific collaboration was also signed with PSI. The planning and construction of the building were contracted to a consortium of architects (Fig. 41.6). In 2009, the civil engineering preplanning was finished and the documents for the mandatory Environmental Impact Assessment were submitted. Approval was obtained in December 2010 and the construction work started in February The first patient treatment is scheduled in The ground floor of the MedAustron facility will house the medical, the research, and the accelerator wing. The technical infrastructure for the building services and the accelerator will be accommodated in the basement and the administrative area will be situated in the upper floor. The MedAustron accelerator complex is designed to support active beam delivery. The accelerator complex will cycle with a typical repetition rate of 0.5 Hz. Beam energy, size, and intensity can be changed on a cycleto-cycle basis. A change of the ion type, i.e., protons or carbon ions will also be possible on a subminute level. The injector will comprise three ion sources with the possibility of adding a fourth source. Protons and carbon ions will be the standard configuration for medical treatment, the third source will serve as spare and the alternative fourth source is intended for research with a further ion type. The LEBT brings the beam from the active source to the RFQ, which serves as preinjector for a drift tube linac. The synchrotron is based on the PIMMS concept [8] and was further developed into a Fig Schematic view of MedAustron. MedAustron, Wiener Neustadt, Austria (

10 696 R. Mayer and S. Vatnitsky technical design by the CNAO group. Its energy range is MeV for protons and MeV per nucleon for carbon ions. The MedAustron facility will be equipped with one horizontal beam line for protons and carbon ions, one horizontal and vertical beam line for protons and carbon ions and one proton gantry. A fourth treatment room, possibly equipped with a carbon ion beam gantry, is a medium- to long-term idea. Its implementation, however, will depend on the experience of existing facilities and further technological progress. Beam scanning will be available at all beam lines in order to provide greater flexibility in treatment plan optimization and superior dose distributions with reduced neutron doses to the patient. The MedAustron facility and the hospital nearby will be equipped with CT, MRI, PET-CT, and ultrasound to meet the requirements for adaptive radiotherapy. Thus, time-variable effects, such as weight loss, changes in organ filling, or tumor shape could be accounted for in the course of the treatment by repeated imaging Cooperations Within the Ion Beam Community The European Commission helped to establish active cooperations between European ion beam facilities and interested institutions. One example is the European Network for Light Ion Hadron Therapy (ENLIGHT), which was established in 2002 [10] and comprises, presently, more than 50 partners from academia and industry. The more recent projects ULICE ( or the Particle Training Network for European Radiotherapy (PARTNER) ( are equally intended to strengthen collaboration and exchange in IBT. Moreover, cooperations with facilities beyond the European Union are also strongly encouraged Situation in the USA In 2010, there are seven clinical proton facilities operational in the United States and eight centers are under construction or in development (Table41.2). All facilities have at least one rotating gantry. The maximum energy varies between 200 and 250 MeV with a tendency to higher maximum energy for the projected units. The University of Florida Proton Therapy Institute (FPTI) in Jacksonville is the first facility in the USA where the accelerator floor is at ground level. Previously, this was underground to facilitate radiation shielding. But due to the high water table in Florida, the entire building was raised to ground level and the exterior walls had to be thickened in some areas to approx. 5.5 m to obtain the same level of radiation shielding.

11 41 New Facilities: Plans and Proposals 697 Table 41.2 New ion beam facilities in the United States. Top: Opening after Bottom: Under construction or in development Center City State Particle Max. clin. Beam delivery system Start US facilities which opened after 2001 Francis H. Burr Proton Center at MGH (FHBPC) Midwest Proton Therapy Institute (MPTI) M.D. Anderson Proton Therapy Center (MDAPTC) Univ. of Florida Proton Therapy Institute (FPTI) energy (MeV) Gantry Fixed-beam Boston MA p Blomington IN p Houston TX p Jacksonville FL p ProCure Proton Therapy Center Oklahoma City OK p Roberts Proton Therapy Center Philadelphia PA p Hampton Univ. Proton Therapy Hampton VA p Institute New US facilities under construction or in development Northern Illinois Proton Therapy W. Chicago IL p Center ProCure CDH Proton Therapy Center Warrenville IL p ProCure Proton Therapy Center Somerset NJ p ProCure Proton Therapy Center Seattle WA p South Florida Proton Center Miami FL p Broward General Medical Center Fort Lauderdale FL p King Center for Proton Therapy, Barnes-Jewish Hospital St. Louis MI p ?

12 698 R. Mayer and S. Vatnitsky The PT center in Oklahoma City and three of those under development are supplied by the US company Procure in cooperation with local hospitals or institutions. This company is the only worldwide to provide a Training and Development Center dedicated to PT (cf. Chap. 40). In addition to the PT facilities listed in Table 41.2 as being under construction or in development, there are several more hospitals considering the construction of similar facilities. Regularly, updated information can be found on the homepage of the National Association for Proton Therapy (NAPT) ( an independent, nonprofit, public benefit corporation founded in 1990 to promote the clinical benefits of PT for cancer patients and their affiliates. In contrast to Europe or Asia, there is no carbon ion beam center running in the United States, and other than in Europe, there is hardly any public funding for it. The National Institutes of Health (NIH), e.g., the most relevant funding agency of medical research in the USA, is not supporting CIRT [11]. Alleged scarcity of data and difficulty to predict long-term effects are common explanations. They ignore, however, the fact that the Lawrence Berkeley Laboratory (LBL) in Berkeley, California, pioneered the therapy with ions heavier than protons already in the 1970s or that more than 7,000 patients have been treated with carbon in the meantime, most of them at NIRS in Chiba, Japan, with up to 15 years of follow-up (cf. Chap. 36 for details). It is more likely that cost and the differences in the reimbursement of medical services between the US and other industrial countries (cf. also Chap. 3) are the major barriers for more commitment. A few US institutions intend to invest, nevertheless, in CIRT; among them the Mayo Clinic in Rochester, NY, Vanderbilt University in Nashville, TN, and Touro University in Vallejo, CA [11] Situation in Asia PT Facilities In 2010, a total of eight PT facilities are running in Asia, most of them are located in Japan. In the near future at least five more centers will be added, three of them also in Japan (cf. also Chap. 37) Carbon Ion Beam Facilities Japan has the longest experience in the clinical application of CIRT. At the Heavy Ion Medical Accelerator (HIMAC) at the National Institute of Radiological Sciences (NIRS) in Chiba, the first patient in the world was treated with carbon ions in Until 2010 more than 5,000 patients underwent this treatment option in the framework of clinical studies performed in Chiba ([12, 13], cf. also Chaps. 14 and 36).

13 41 New Facilities: Plans and Proposals 699 Table 41.3 New ion beam facilities in Asia. Top: Opening after Bottom: Under construction or in development Center City State Particle Max. clin. Beam delivery system Start Asian facilities which opened after 2001 Proton Medical Research Center (PMRC) Hyogo Ion Beam Medical Center (HIBMC) energy (MeV) Gantry Fixed-beam Tsukuba Japan p Hyogo Japan p C C-ion 320/u Wakasa Wan Energy Research Center Tsuruga Japan p (WERC) Shizuoka Cancer Center Shizuoka Japan p Wanjie Proton Therapy Center Zibo China p (WPTC) National Cancer Center IIsan South Korea p Southern Tohoku Proton Therapy Koriyama Japan p n.a. n.a. n.a Cancer Center Gunma Heavy Ion Medical Center Gunma Japan C-ion 400/u (GHMC) New Asian facilities under construction or in development Fukui Prefecture Proton Therapy Fukui Japan p Center Chang Gung Memorial Hospital Taipei Taiwan p ? Sino-Japanese Friendship Hospital Beijing China p n.a. Fudan University Shanghai China p C C-Ion 430/u 4 n.a. Heavy Ion Tumor Therapy Facility Lanzhou China C-ions 430/u n.a. n.a. n.a. Southern Tohoku Proton Therapy Cancer Center Fukushima Japan p n.a n.a. n.a. n.a. Medipolis Medical Research Institute Kagoshima Japan p n.a. n.a. n.a. n.a.

14 700 R. Mayer and S. Vatnitsky A project to construct a new treatment facility as an extension of the existing HIMAC facility has been initiated for the further development of CIRT. In the new facility, one of the treatment rooms will be equipped with an isocentric gantry employing a 3D pencil beam scanning method. Two other rooms will be equipped with fixed-beam delivery systems providing beams in both horizontal and vertical directions (cf. [14] and Chap. 37 for details). In 2010, a new facility started CIRT at Gunma University. This project has been strongly supported by NIRS. In the near future, CIRT should also be available in China, at the Heavy Ion Tumor Therapy Facility in Lanzhou, China Dual Ion Beam Facilities The world s first dual ion beam facility, providing protons and carbon ions at the same center was opened in 2002 in Hyogo, Japan. This facility is equipped with five treatment rooms; three rooms with fixed-beam lines and two rooms with isocentric proton gantries. Fudan University in Shanghai, China, is planning to have the number two dual IBT facility with fixed-beam lines in Asia (Table 41.3) Conclusion Different trends can be observed in Europe, the United States, and Asia. In the US, there is a clear priority for proton facilities, whereas in Asia and Europe there is interest in both PT and CIRT, and hence, also in dual IBT facilities. References 1. E. Pedroni, R. Bacher, H. Blattmann, et al., The 200-MeV proton therapy project at the Paul Scherrer Institute: conceptual design and practical realization. Med. Phys. 22, (1995) 2. E. Pedroni, R. Bearpark, T. Böhringer, et al., The PSI Gantry 2: a second generation proton scanning gantry. Z. Med. Phys. 14, (2004) 3. M. Scholz, A.M. Kellerer, W. Kraft-Weyrather, G. Kraft, Computation of cell survival in heavy ion beams for therapy: the model and its approximation. Radiat. Environ. Biophys. 36, (1997) 4. T. Elsässer, M. Krämer, M. Scholz, Accuracy of the local effect model for the prediction of biologic effects of carbon ion beams in vitro and in vivo. Int. J. Radiat. Oncol. Biol. Phys. 71, (2008) 5. D. Schulz-Ertner, The clinical experience with particle therapy in adults. Cancer J. 15, (2009) 6. D. Schulz-Ertner, C.P. Karger, A. Feuerhake, et al., Effectiveness of carbon ion radiotherapy in the treatment of skull-base chordomas. Int. J. Radiat. Oncol. Biol. Phys. 68, (2007)

15 41 New Facilities: Plans and Proposals Joint press release from the Ministry of Science and Economics of the state of Schleswig- Holstein and Siemens AG, Agreement in Kiel: UKSH to receive top-quality conventional radiotherapy at advantageous rates, 14 Sept 2011, press=/en/pressrelease/2011/corporate communication/axx htm. Accessed 5 Oct L. Badano, M. Benedikt, B.J. Bryant, et al, Proton Ion Medical Machine Study (PIMMS) Part I. CERN-PS DI. Accessed 20 Jan R. Orecchia, P. Fossati, S. Rossi, The National Center for oncological hadron therapy: status of the project and future clinical use of the facility. Tumori 95, (2009) 10. M.K. Dosanjh, H.F. Hoffmann, G. Magrin, Status of hadron therapy in Europe and the role of ENLIGHT. Nucl. Instrum. Methods Phys. Res. A 571, (2007) 11. V. Brower, Carbon ion therapy to debut in Europe. J. Natl. Cancer Inst. 101, (2009) 12. H. Tsujii, J.E. Mizoe, T. Kamada, et al., Overview of clinical experiences on carbon ion radiotherapy at NIRS. Radiother. Oncol. 73, S41 S49 (2004) 13. D. Schultz-Ertner, H. Tsujii, Particle radiation therapy using proton and heavier ion beams. J. Clin. Oncol. 25, (2007) 14. K. Noda, T. Furukawa, T. Inaniwa, et al., New heavy-ion cancer treatment facility at HIMAC. Proceedings of European Particle Accelerator Conference (EPAC), Genoa, Italy, June 2008, pp