Workshop on Hadron Beam Therapy of Cancer Erice, Sicily April 24-May

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1 IONTRIS Synchrotron based PT Solutions from Siemens AG Workshop on Hadron Beam Therapy of Cancer Erice, Sicily April 24-May Matthias Herforth VP Business Development and Communications Siemens AG All rights reserved.

2 Status Siemens Takes Complete Responsibility for Combined Systems 2003 Siemens decided to provide combined proton & heavier ions systems Positive clinical trials for protons and carbon ions including biological advantages of carbon ions to treat radio-resistant tumors Economic advantage of carbon ions due to potential hypo-fractionation Siemens licensed GSI patents and initiated knowledge transfer 10 years of clinical experience in active scanning technology with carbon ions Siemens decided to take responsibility for the complete system Workflow driven top down design of PT system and its subcomponents 2004 Joint development of Siemens with Danfysik Medical engineering knowhow and accelerator technology within one collaboration 2008 Acquisition of PT branch of Danfysik A/S Danfysik has been integrated into PT and became a 100% subsidiary of Siemens

3 Status Achievements of Siemens in the Particle Therapy Order: Patient environment for HIT, Heidelberg University, Germany Order: complete PT equipment for PTZ Marburg University, Rhoen Clinic, Germany Order: Treatment planning system for CNAO, Pavia, Italy 2008 Order: complete facility including building for NRoCK Kiel, University of Schleswig-Holstein, German 2009 Order: complete PT equipment for a project in Asia

4 Status - Implementation has Top Priority We focus on Implementation - Acquisitions of new Projects are Suspended Resources have to be focused on developing, implementing, optimizing and innovating the systems under contract Sales activities are being discontinued, our customer relationship management will stay present for the Particle Therapy community Siemens PT has increased R&D spending furthermore and is still ramping up staff Siemens continues to develop PT technology further together with our existing clinical and industrial partners Siemens is committed to long-term maintenance and uptime service contracts

5 Market Situation Let us Face the Challenges Together! Revenues More approved clinical applications (clinical trials/protocols) Long term secured reimbursement rates medical community healthcare payers Patient numbers Excellent workflow to support high patient numbers Long term technical operation secured by maintenance contract vendors / users vendors Patient benefits More proven clinical outcomes Short treatment courses, e.g. by hypo fractionation High patient comfort Best treatment precision (conformity and positioning) medical community medical community vendors vendors

6 Market Situation Let us Face the Challenges Together! Long system lifetime Flexible and future proven technology (e.g. additional ions and medical applications) vendors / operators Risk sharing Technical risk (installation and maintenance) Market risk (patient referral) vendors operator or PPP model (public private partnership) Economic feasibility Fits to customers and vendors business plan Overall cost and time optimization (incl. project execution) vendors / operators vendors

7 Accelerator Design Specs Energy range MeV/u (Carbon) MeV (Protons) more than 200 energy levels Range up to 30 cm in water Ramping speed til max. energy 0.5 s (protons) 1.0 s (carbon ions) Extraction time from 1 to 10 s Maximum intensity 2 x protons/cycle 1 x 10 9 carbon ions/cycle Synchrotron diameter 22 m Short switching times 10 s same ion species 30 s with change of ion species

8 Revised HIT Accelerator Design by a Cooperation of GSI, Danfysik and Siemens The GSI / HIT accelerator design has been modified to improve technical capabilities to reduce construction and operating costs Examples 12 dipoles (each 8 tons) instead of 6 (each 25 tons) cost reduction, easier installation and handling Smaller and lighter quadrupoles cost reduction, less power consumption Optimized injection and extraction system higher intensity, shorter treatment times 3 sources more flexibility, other ions species Preventive and condition based maintenance concept high uptime Courtesy of HIT and Danfysik

9 PT-System Architecture Highest Precision for Treatment Courtesy of GSI, Darmstadt, Germany

10 Improved GSI Detector System Design Specs - Beam Application and Monitor System * Development based on GSI concept: Detector system with highly integrated readout electronics Beam position and profile measurement 2 redundant multi-wire proportional chambers Position measurement: every µs Position accuracy: circle with r = 0.5 mm * Intensity measurement 3 parallel plate ionization chambers (redundant and diverse) Readout every 10 µs - Data on file -

11 * * Advantages of the Robotic Systems Highest Precision Design and Workflow Optimization Robotic patient positioning system Identical in treatment and CT rooms Position correction in 6 degrees of freedom Absolute position accuracy independent from patient weight R 0,5 mm Robotic imaging system Orthogonal x-ray and Cone beam CT Position verification in treatment positions Workflow optimization Automated hand over of table top Automated positioning according to treatment plan Reduction of patient preparation time in treatment room Semi automated QA procedures

12 45 and 90 Beam in one Treatment Room Robotic Patient Positioner and Imaging System

13 Robotic Patient Positioning and Verification System Heidelberg Ion Therapy Center (HIT)

14 The University of Heidelberg Project Heidelberg Ion Therapy Center (HIT) Start of construction: November 2003 Start of Siemens installation: June 2006 Siemens supplies all components related to patient environment: Scanning and monitoring system Robotic patient positioner Imaging system (2D x-ray and CB CT) Therapy control system (TCS) Collaboration on syngo PT planning Courtesy of the University Hospital of Heidelberg, Germany

15 Status - Heidelberg Ion Therapy Center HIT Scanning System at HIT is in Operation Intensity and position controlled scanning system in operation Irradiation of complicated patterns (Autumn 2007) Homogeneity (Spring 2008) Homogeneity of scanned fields: ~1,7% in central 80% Position stability (Spring 2008) Better than 0.25 mm with position control Still ongoing ~0.25mm Integration of IT subsystems into overall system and system test Siemens Particle Therapy Time products [50µs/sample] and solutions are works-in-progress and require country specific regulatory approval prior to clinical use.

16 Rhön Klinikum AG University of Marburg /Giessen Project start: September 2006 Ground breaking: August 2007 First patient planned: December 2010 Configuration: 3 rooms with horizontal beams 1 room with semi vertical beam designed for more than 2000 patients /a 66m / 216.5ft 110m / 361ft All particle therapy equipment will be provided by Siemens Courtesy of Rhön-Klinikum AG, Germany

17 Rhön Klinikum AG University of Marburg /Giessen Up to now all milestones have been reached (construction and installation): Project start: September 2006 Ground breaking: August 2007 Start of installation: August 2008 Start of commissioning: January 2009 First patient planned: December 2010 Courtesy of Rhön-Klinikum AG, Germany

18 Rhön Klinikum AG - University of Marburg /Giessen Sources

19 Rhön Klinikum AG - University of Marburg /Giessen Synchrotron

20 Rhön Klinikum AG - University of Marburg /Giessen HEBT

21 University Hospital Schleswig-Holstein NRoCK Nordeuropäisches Radioonkologisches Centrum Kiel Ground breaking: July 2008 First patient planned: Conventional radiation therapy End of 2011 Particle therapy Begin of 2012 Configuration: 3 rooms for particle therapy +1 room for further extension 2 rooms for conventional radiation therapy Modalities (CT for Therapy Planning, PET-CT, MR Cyclotron, Hot Lab Brachy Therapy Therapy specific IT - Solutions Clinical care rooms (30) Public Private Partnership Project (Consortial partners: SAG, Bilfinger Berger Hochbau) Largest PPP project in the German health-care sector to date

22 Project Structure / Organization Federal State Schleswig- Holstein City Kiel Estate Estate Urban Development Contract PPP-Contract (Finance, Build, Nonmedical Service) UK S-H (University Hospital) Operating Company for Medical Service (NRoCK GmbH) Defined Rate of Payment Health Insurance Funds; Patients Sponsors (Equity) Project Company (PTZ GmbH und Co. KG.) Debt (Banks) Bidding Consortium Design & Build (Building) Bilfinger Berger Hoch/Tief Building Consortium Development & Delivery (Particle Therapy) Siemens AG PT Facility Management HSG Technical Operation and Maintenance PT Siemens AG CS

23 University Hospital Schleswig-Holstein (NRoCK) Facility Layout of the Turn Key Project