160 MLC Multileaf Collimator. The best-in-class collimator available. Fighting cancer fast and focused.

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1 160 MLC Multileaf Collimator The best-in-class collimator available. Fighting cancer fast and focused.

2 Fighting cancer fast and focused. The philosophy behind We are convinced that successful radiation therapy calls for the optimal resultant of speed and precision. Because speed alone at the cost of precision means to unacceptably increase the chance of affecting healthy surrounding tissue. And precision alone at the cost of speed means to lose short treatment times, high patient throughput, and a convenient patient experience out of sight. That s why our radiation therapy solutions aim to incorporate the optimum of both, an intelligent balance of speed and precision to help you fight cancer fast and focused. 2

3 You require high speed without compromising quality? With the fastest collimator available. The 160 MLC TM Multileaf Collimator, one of the core components of our ARTISTE TM Solution and as well optionally available for our ONCOR TM, helps you fight cancer fast and focused. The 160 MLC combines fast leaf movement of up to 4 cm per second and excellent resolution with very low leakage. These features make it possible to treat patients with surgeonlike precision, spare healthy surrounding tissue regardless of the tumor shape, and provide more convenient therapy due to a shorter length of the treatment session. The 160 MLC is best-in-class and as such the center point of our overall solution for fast IMRT, IM-Confident TM Plan. From patient setup and imaging to quality control, IM-Confident together with the 160 MLC permits fast and precise radiation therapy as effective and as efficient as possible. 3

4 Content Fighting cancer fast and focused Treating cancer faster Treating cancer more focused Experiencing excellence in all aspects Clinical cases Adenoid cystic carcinoma, male, 29 years Head & Neck, male 56 years Product specifications Mechanical specifications Dosimetrical specifications System specifications Automation and workflow 160 MLC dimensions and ranges Positioning and calibration, Service and maintenance features, Additional space requirements 16 Clinical case / Quality assurance Head & Neck, male 56 years

5 Treating cancer faster Higher speed translates for the radiation therapy department into a smoother workflow, and for patients into shorter and less stressful therapy sessions. The 160 MLC turns our ARTISTE into one of the fastest and most precise medical radiation delivery devices on the market. What makes our 160 MLC so fast? The 160 MLC has numerous features that speed up radiation therapy. The collimator enables interdigitation, which makes therapy planning easier and quicker. When opening or closing the collimator, opposite leaves can smoothly pass one another. This means higher flexibility, enabling you to generate several segments within one field at the same time. And, of course, the impressive leaf speed of up to 4 cm / second enables quick and efficient treatment delivery. Fast IMRT therapy that s also focused at the max in less than 5 minutes It s simple maths: ARTISTE plus 160 MLC plus intelligent treatment planning software for further optimization of the treatment time equals quick and precise IMRT therapy. In short: IM-Confident a simple and efficient Intensity-Modulated Radiation Therapy (IMRT) solution designed to deliver fast, high-quality IMRT treatments. Combining the 160 MLC with Direct Aperture Optimization (DAO*) or Direct Machine Parameter Optimization (DMPO**), it provides not only better tumor conformity. IM-Confident can also reduce the IMRT treatment time to less than five minutes as it fully utilizes the MLC technology. First of all, you have as few MLC segments as possible per gantry setting. Moreover, the setting of the MLC sequences happens in one direction only so the leaves don t have to move forward and backward again and again. IM-Confident means for you faster treatment delivery and improved treatment plan quality. At the same time, quality assurance remains fast, simple, and safe. A higher level of patient care One major benefit of speed is that your patients have to spend less time on the treatment table. This again results in many more advantages: First, patients will appreciate shorter treatment times. Second, you gain extra time you can spend caring for your patients. And third, less treatment time also leads to less patient movement, which in turn increases treatment precision. As you see, a good balance of speed and precision leads to the maximum effect. and workflow efficiency The fully integrated 160 MLC and IM-Confident optimize and speed up your workflow. You have all important data when you need them and where you need them. The unique control system of the 160 MLC is designed for seamless system handling. Thanks to fully automated procedures, it takes only a click to align the leaves to the tumor shape. The two monitors at the syngo RT Therapist provide a transparent display of treatment set-up and system control, showing the needed information in a clear and concise manner. This saves unnecessary workflow steps so your staff can work as efficiently as they always wanted. ** Panther DAO IMRT a product of Prowess Inc. ** p 3 IMRT a product of Philips Medical Systems 5

6 Treating cancer more focused In radiation therapy, it s most important to deliver highly precise dose. To irradiate the tumor in a targeted way. And to save as much healthy surrounding tissue as possible. The 160 MLC turns our ARTISTE into one of the most accurate systems on the market. What makes our 160 MLC so precise? The 160 MLC comes with a unique design concept: it provides 160 leaves 80 on each side. With a leaf thickness of 5 mm over the full field, the leaves provide incredibly accurate conformity to the actual tumor shape for homogeneous dose coverage. The improved leaf positioning accuracy of 0.5 mm is even comparable to the gold standard of dedicated stereotactic systems. Our 160 MLC also offers exact leaf positioning reproducibility. This is particularly advantageous when treating small targets or volumes close to organs-at-risk where a precise placement of the leaves is especially required. Moreover, the 160 MLC provides full 40 x 40 cm field coverage with a maximum circular field diameter of 40 cm at the isocenter. This is an important factor when rotating the collimator or during whole-body irradiation. Last but not least: The leaves are made of Tungsten, which also adds to precision thanks to the extraordinary radiopacity of the material. Precision for conventional and advanced treatment techniques The MLC shape downloads quickly to the linear accelerator and adjusts all leaves to their prescribed positions, increasing accuracy and improving tumor conformity. Thanks to the small penumbra of the 160 MLC, you and your patients will benefit from maximized dose to the target tissue and minimized dose to the healthy surrounding tissue. 6

7 As we use a new design principle of slightly tilted leaves instead of the common tongue-and-groove design, leakage is remarkably low. The small leaf resolution of 5 mm at the isocenter over the whole field enables you to perform complicated cases such as head and neck, spinal cord, lungs or pediatric cases as well with highest possible precision. And besides conventional radiation therapy, you can also treat complex IMRT cases. So whatever the challenge, the 160 MLC helps you provide best possible treatment quality for your patients. Precision that even exceeds our specifications An independent study with our 160 MLC was conducted at the Department of Medical Physics in Radiation Oncology, German Cancer Research Center, in Heidelberg, Germany, by Prof. Uwe Oelfke and Dr. Martin B. Tacke with their colleagues. Their article was published in the Medical Physics magazine and presents the first detailed experimental investigation of the 160 MLC. The assessment included typical MLC characteristics such as leakage, tongue-and-groove effect, penumbra, leaf speed, and leaf positioning accuracy with a 6 MV treatment beam. Martin B. Tacke and his colleagues performed several typical intensitymodulated radiation therapy treatments. And the results even exceed our specifications. 160 MLC Multileaf Collimator Inter-leakage average Inter-leakage maximum Inter-leakage leaf tip Measured 0.37% < 0.75% 0.63% < 1.5% 13.5% < 15% Specified (160 MLC data sheet) Penumbra (mm) 4.1 ± 0.5 mm* < (energy dependence) Tongue-andgroove effect Leaf resolution at isocenter (mm) Maximum field size 19% Not specified 5 mm 5 mm 400 x 400 mm 400 x 400 mm Evidence of 160 MLC precision proven by Tacke et al., Medical Physics, Volume 35 No. 5, May 2008 * Longitudinal penumbra for central field section, ranging from -10cm to +10cm at depth d max of 15mm 7

8 Experiencing excellence in all aspects Whether treatment quality, clinical use or economic aspects the 160 MLC holds a great number of benefits you and your patients will appreciate. Increased patient convenience Thanks to the intelligent design of our ARTISTE, the 160 MLC is placed close to the radiation source. Even if the accessory holder is mounted, you still have a high patient clearance of 430 mm. The benefit: free patient access at any time and patients won t feel crowded when lying on the table. This in combination with the shorter treatment time ensures that your patients feel as comfortable as possible during radiation therapy. Higher efficiency all along the line With the 160 MLC, you will experience efficiency in more than one aspect. Thanks to a more streamlined workflow and shorter treatment times, you will benefit from time savings. This again can increase both your patient throughput as well as the level of patient care. Designed for easy serviceability Moreover, you benefit from investment protection over the entire life cycle. Our calibration concept improves leaf accuracy and reduces service time: All set data can be electronically saved and called up again whenever needed. And an automatic diagnostic check helps assure system reliability, as leaf positions can be stored in databases and evaluated at any time. 8

9 Our Radiation Oncologists are finding the ability to accurately shield around sensitive organs extremely advantageous, while our planners are finding it much easier to meet critical organ dose constants using the flexibility associated with the 0.5mm leaves. Michael Davis Chief Radiation Therapist, St. Vincent s Hospital, Sydney, New South Wales, Australia Covering a broad clinical application spectrum Our 160 MLC can be used for all radiation therapy cases. As it conforms to any tumor shape, it enables best possible treatment techniques and personalized medical care. Increasing the chance to cure cancer patients. from IMRT cases such as Chest treatment Head & Neck Brain treatment ASN treatment Prostate cancer Pancreas cancer to non-imrt cases such as Mamma with IMC (internal mammary chain) Head & Neck with super clavicle Sarcoma (full muscle) Hodgkin s disease (mantel fields) Stereotactic treatment Pleuramesothelioma Courtesy: Dept. for Radiooncology and Radiation Therapy, University Heidelberg, Germany 9

10 Courtesy Catholic Medical Centre Seoul, South Korea Clinical case Adenoid cystic carcinoma Gender: Age: Tumor type: Stage: Male 29 years Adenoid cystic carcinoma T4 N0 M1 Initial diagnosis steps Diagnosis Adenoid cystic carcinoma of right lacrimal gland extending to skull base, maxillary sinus, nasal cavity, and soft tissue of right cheek. Tumor metastasized to C7 spine and clivus. Diagnosis made with PET CT and MRI. PET CT Challenge Best local tumor control and sparing of right frontal lobe brain parenchyma, right vision, brain stem, spinal cord, and oral mucosa. Because of the treatment plan described below, the gross tumor area may be considered to be a very risky area for late complications and the acute treatment morbidity is expected to be high as well. MR Patient positioning and tumor localization Solution IMRT treatment with simultaneous integrated accelerated fractionation schedule. Dose prescription: 72 Gy over 33 fractions to gross target volume, 66 Gy over 3 fractions to high risk CTV area, and 56 Gy over 33 fractions to low risk CTV area. CTVision TM System is used for daily tumor volume control and target localization verification. System: ARTISTE with 160 MLC and CTVision System with SOMATOM Sensation Open 24 CTVision and Adaptive Targeting application Treatment course and success Even though he lost 10 kg of weight during the entire IMRT procedure, the patient completed the planned radiation therapy. After 50 Gy of RT, his right eye ball protrusion got better. Due to the substantial change of weight of patient, target volume, and organs-at-risk (OAR) such as right optic nerve or optic chiasm IGRT with CTVision was a must and could effectively support this process. 10

11 Clinical case Head & Neck Courtesy Dr. med. Jörg Dahle, Priv. Doz. Dr. med. Cordula Petersen, Priv. Doz. Dr. med. Florian Würschmidt, Radiologische Allianz Hamburg, Germany, Radiation Therapy Gender: Age: Tumor type: Stage: Male 39 years Glottic carcinoma of the larynx (recurrence) pt4 pn0 (0/ 29) M0 Diagnosis Head & Neck cancer. ED glottic carcinoma of the larynx in 2006 and R2 resection (transoral laser-surgery) upon recurrence (June 2009). Result: decision for laryngectomy. Challenge Radiation protection of the spinal cord and the back of the cervical with complete dose coverage of the PTV. 3D Room s eye view with tumor volume Solution IMRT treatment using ARTISTE with 160 MLC and DAO IMRT optimization. Treatment technique: 6 MV photon 7 gantry angles, 2 or 3 segments per beam Fractions: 25 Total MU: 313 Total number of segments: 16 Treatment time: 4:16 minutes Dose distribution in Gy coronal view This case shows a significant reduction in treatment time to 4:16 minutes. Dose distribution in Gy axial view 11

12 Product specifications The new Siemens 160 MLC offers a combination of industry-leading specifications with outstanding performance and a high degree of reliability. 160 MLC was designed specifically for Intensity-Modulated Radiation Therapy (IMRT) and Adaptive Radiation Therapy (ART), and to address the most challenging trends in radiotherapy while protecting immediate surrounding healthy tissues. Mechanical specifications Special care has been used in the development process to provide high overall positioning accuracy independent of leaf, gantry, or carriage position. 160 MLC Number of leaves 160 Absolute leaf positioning accuracy at isocenter (mm) ±0.5 Leaf positioning reproducibility at isocenter (mm) ±0.3 Maximum circular field diameter (cm) 40 Leaf resolution at isocenter (mm) 5 Variance of leaf resolution at isocenter (µm) 200 Interdigitation Maximum leaf speed (cm / s) 4 Servo-control speed Reticule Built in Maximum field size (cm) 40 x 40 Minimum field size (cm) 0 x 0 Maximum leaf movement of a single leaf (cm) 20 Overtravel of leaves (cm) 20 Leaf material Tungsten Leaf height (mm) 95 Individual leaf guide to ensure reliable leaf distance and friction minimization Jaw height (mm) 77 Jaw positioning accuracy Field sizes of 5 cm x 5 cm Non-overtravel region: ±1 mm or ±1% Overtravel region: ±1.25 mm Overtravel of jaws (cm) 2 Jaw speed (mm / sec) 20 Jaw end design Pivoting 12

13 Dosimetrical specifications The improved leaf positioning of 160 MLC provides homogeneous dose coverage, independent of tumor size. When used for IMRT, it helps maximize dose to target tissue while minimizing dose to normal tissue. Penumbra Penumbra for 10 cm x 10 cm field (mm) 6 MV: 7 According to IEC and ( Penumbra is the maximum distance along the major axes between the 80% and 20% points of the ABSORBED DOSE at the standard measurement depth; the 80% and 20% points refer to the absorbed dose on the radiation beam axis at 10 cm) 10 MV: MV: 8.5 Transmission (% of unattenuated beam) Between leaves inter-leaf < 1.5 Through leaves intra-leaf < 0.75 Through jaws < 0.5 Leakage (% of unattenuated beam) as per IEC Average (average of measurements at 24 specific locations in patient plane, outside area M) Maximum (maximum of measurements at 24 specific locations in patient plane, outside area M) < 0.1 < 0.2 Transmission along in-plane profile of leaves (% of unattenuated beam) Closed leaves at the central beam axis* < 15 * Can be influenced by treatment planning system 13

14 System specifications Advanced treatment techniques such as IGRT and ART enable more sophisticated approaches in treatment setup. Flexibility for non-coplanar patient setups is significantly improved with isocenter clearance. 160 MLC provides an enlarged patient clearance combined with open access to patient, helping ensure patient comfort. Siemens is committed to providing flexible, easy-to-use solutions for automation and workflow optimization of complex treatment applications. As a result, 160 MLC s design provides an isocenter clearance that significantly improves non-coplanar patient setups and accommodates the more sophisticated approaches enabled by advanced treatment techniques such as IGRT and ART. Isocenter and leaf orientation Isocenter clearance without accessory holder (cm) 47.5 Isocenter clearance with accessory holder (cm) 42.8 Leaf orientation with collimator at 0 reference frame, as defined in IEC 1996 Light field to radiation field coincidence Normal treatment distance 10 cm x 10 cm Maximum (square or rectangular) 2 mm 3 mm or 1% 1.5 times normal treatment distance 10 cm x 10 cm Maximum (square or rectangular) 4 mm 6 mm or 2% For multi-element radiation fields, the maximum distance between the centers of the radiation field and the light field Normal treatment distance 2 mm 1.5 times the normal treatment distance 4 mm Automation and workflow The Automatic Field Sequencing (AFS) allows for fast download of all required fields and parameters. Virtual Wedges also represents a procedure for automatic delivery of dose distributions. Treatment automation Maximum number of MLC fields for an Automatic Field Sequencing (AFS) treatment Maximum number of MLC segments per gantry angle for an IMRT Unlimited Unlimited Virtual wedge Angle values (º) Angle increments (º) 1 Wedge orientation Y-jaw direction 14

15 160 MLC dimensions and ranges The graphic below illustrates how the 160 MLC is integrated within the whole design of ARTISTE or ONCOR, and the distances seen from the target. The distance between isocenter and target is 1,000 mm. 0 Target 106 Bottom Flattening Filter Bottom Scattering Foil 222 Top Y-Jaws 222 Bottom Y-Jaws 95 mm 95 mm 357 Top Level Upper Leaf 365 Top Level Lower Leaf 452 Lower Level Upper Leaf 460 Lower Level Lower Leaf 525 Bottom MLC 560 Slot #3 572 Bottom Accessory Holder 1000 All Dimensions are in mm. 15

16 Positioning and calibration A completely new MLC control system has been devised for 160 MLC in order to achieve the highest possible accuracy and reliability. The absolute position of every single leaf is continuously monitored by two independent measuring devices, significantly improving MLC calibration time and frequency. Initialization is not required. Absolute leaf and carriage positioning Two independent position sensors per leaf and carriage Calibration procedure Semi-automatic using calibration blocks Time for complete calibration procedure (min) Approx. 30 Calibration data backup support Service and maintenance features Siemens offers one of the most comprehensive remote medical systems service solutions in the industry. Through a combination of advanced medical engineering with leading-edge information technology, services are available remotely via data transfer instead of traditional onsite visits enabling proactive monitoring of customers systems. Siemens Remote Service Boot-up check Continuous self-check Remote service check Relays, contacts, voltages, and others Safety-relevant parameters like potentiometer voltages, board connections, and others Via syngo RT Therapist, allows for motor currents, look-up of calibration values, calibration, and others Additional space requirements Besides the parameters below, please also refer to Product Planning Guide for ARTISTE or ONCOR for relevant roomreadiness requirements. MLC controller dimensions Height Width Depth 720 mm 915 mm 815 mm Additional requirements Additional cable space required in conduit Additional power requirements Additional electrical requirements No No 16

17 160 MLC provides faster leaf movement speed, smaller penumbra for most treatment fields, and the dose leakage rate from MLC leaves is extremely low. The quality assurance result gives very good accuracy and reproducibility. The dose distribution check shows that we can get better flatness for small field sizes compared to other MLC fields. We also benefit from treatment delivery time savings. Dr. Yang Wang, PD St. Vincent s Hospital, Sydney, New South Wales, Australia 17

18 Courtesy St. Vincent s Hospital Sydney, Australia Clinical case Head & Neck Gender: Age: Tumor type: Stage: Male 56 years Squamous cell carcinoma (SCC) supraglottic larynx T3 N1 M0 Diagnosis Well differentiated squamous cell carcinoma of the left supraglottic larynx with left cervical node involvement. Ulcer on the supraglottic larynx, left anterior fold expanded. Dose distributions Challenge Total laryngectomy with adjuvant radiotherapy and chemotherapy. 100,00 80,00 60,00 40,00 20,00 Tumor Node Spinal cord RT Parotid LT Paro tid PH1 PTV Clippe 0 20,00 40,00 60,00 80,00 Dose (Gy) Dose-Volume Histogram (DVH) Solution Radical radiotherapy with concurrent chemotherapy. Treatment technique: Intensity-Modulated Radiation Therapy (IMRT) with 8 beams (gantry positions), 16 segments per beam. Treatment goals (dose constraints): min./max. total dose to target volume 66 / 68 Gy, max. given dose at dmax = Gy Device: ARTISTE with 160 MLC 18

19 Quality assurance for 160 MLC in clinical environment For evaluation and verification reasons of this clinical case, the dose map calculated by the RTP system CMS XiO was compared with the film measurements taken with the phantom under complete Intensity- Modulated Radiation Therapy (IMRT) fraction delivery using ARTISTE Solution with 160 MLC Multileaf Collimator. The results of the measurements show excellent conformity with the dose calculation. The following pictures illustrate the high precision and conformity of calculation and delivery. Fig.1: Fluence map measurement Fig.2: RTP dose map 180,00 Comparison of dose map calculated by RTP and fluence map delivered to IMRT phantom The measurements were done using ARTISTE Solution with 160 MLC Multileaf Collimator with GafChromic film. Fig.1 and 2 already show very good conformity between data. Isodose analysis For an isodose curve analysis, the isodose curves in cross plane and in plane are compared, as shown in Fig.3. Evaluation and verification results for head and neck case According to gamma evaluation, with acceptable delta d = 2 mm and delta D = 3% for the 80% isodose curve, an area discrepancy of 0.24 cm 2 over an area of about 52 cm 2 and max. position discrepancy of 0.8 cm were detected (Fig.4). Fig 5 shows the gamma matrix, where no red color is visible (blue gamma value <1.0, red gamma value >1.0), which is a positive sign. 160,00 140,00 120,00 100,00 80,00 60,00 40,00 20, ,00 160,00 140,00 120,00 100,00 80,00 60,00 40,00 20, Fig.3: Isodose analysis in cross plane (le.) and in plane (ri.) This quality assurance corroborates the high precision that can be reached with the IMRT treatment delivered using ARTISTE Solution and 160 MLC Multileaf Collimator. Fig. 4: Isodose discrepancies Fig.5: Gamma evaluation 19

20 On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice. Some/all of the features and products described herein may not be available in the United States or Japan. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be present in individual cases. Siemens reserves the right to modify the design, packaging, specifications, and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information. All product names and company names are trademarks or registered trademarks of the corresponding companies. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced. Local Contact Information Siemens AG Healthcare Sector Oncology Care Systems Doris-Ruppenstein-Str Erlangen Germany Phone: Global Business Unit Siemens AG Healthcare Sector Oncology Care Systems Doris-Ruppenstein-Str. 4 DE Erlangen Germany Global Siemens Headquarters Siemens AG Wittelsbacherplatz Muenchen Germany Global Siemens Healthcare Headquarters Siemens AG Healthcare Sector Henkestr Erlangen Germany Phone: Legal Manufacturer Siemens AG Wittelsbacherplatz 2 DE Muenchen Germany Order No. A91OCS-614-C Printed in Germany , Siemens AG