Status of Hadrontherapy facilities worldwide

Transcription

1 Status of Hadrontherapy facilities worldwide Vienna The Gantry 1 of PSI Eros Pedroni Center for Proton Radiation Therapy Paul Scherrer Institute SWITZERLAND Author s competence: Gantry with proton pencil beam scanning High LET radiation - with pion therapy 1

2 Outline of the presentation 1. Motivation for Hadrontherapy Physical selectivity Radiobiology of High LET radiation 2. Scanning beams vs. passive scattering 3. Tour of the world of the hadrontherapy facilities 4. The point of view of PSI: past experience and future plans 5. New accelerator concepts 6. Conclusions 2

3 1. Hadrontherapy: the context 3

4 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 4

5 1A. Physical selectivity goal Protons Proton beams: the best external radiation therapy with low-let 5

6 The rationale for using protons Physical selectivity Finite range Bragg peak Photons Protons (and ions) SOBP dose depth (cm) depth (cm) 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 6

7 1B. Different radiobiology heavier (light) ions Carbon ion: the best external radiation therapy with high-let 7

8 What is high-let radiation? 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 DNA For the tumor cells Increased efficiency of killing BULLET For the healthy tissues Increased collateral damage?? Acute effects Late effects vs. Secondary cancer induction Sensitive tissues within or outside of the target? CANNON BALL X-rays Protons Ions (a wikipedia image) 8

9 The strength of carbon ions: High LET with very good physical selectivity 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? 9

10 2. Technical options Gantry vs. Horizontal beam Scanning beams vs. passive scattering 10

11 The price to pay for the ions : the increased size of the facility 70m Carbon ions 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 37m Protons 11

12 Passive scattering The established traditional method (of the 60s) range-shifter wheel collimator patient target volume scatter foils entrance dose 100% dose compensator 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 12

13 Pencil beam scanning DEPTH ~ 20 cm Lateral position 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 13

14 Advantage of using a scanning gantry: IMPT 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) Disadvantage of scanning Sensitivity to organ motion Need to develop Faster scanning Repainting Gating Tracking 14

15 3. Tour of the world of hadrontherapy facilities 15

16 EYE treatments - dedicated - at low energy EUROPE PSI, Villigen Switzerland p OPTIS2 since Nov 2010) Clatterbridge England p Nice France p HZB (HMI), Berlin Germany p INFN-LNS, Catania Italy p NORTH AMERICA UCSF San Francisco USA p TRIUMF, Vancouver Canada p Comment: Place of origin Boston (Harvard) p150 since the 80's The largest amount of treated patients with Proton Therapy A rare disease 16

17 RUNNING FACILITIES in the world USA Type Rooms Acc. Start Pats. Company Loma Linda CA p 250 3g1h synchr Optivus NPTC, MGH Boston p 235 2g1h cycl IBA MPRI(2) Bloomington p 200 2g1h cycl IBA MDA Houston p250 3g1h synchr Hitachi spread beam and beam scanning since 2008 UFPTI Jacksonville p 230 3g1h, cycl IBA ProCure Oklahoma p 230 1gh2h/60 cycl IBA UPenn, Philadelphia p 230 4g1h cycl 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 17

18 RUNNING FACILITIES in the world JAPAN Type Rooms Acc. Start Pats. Company HIMAC, Chiba C800 1h1hv sync, many NCC, Kashiwa p235 2g cycl Sumitomo HIBMC,Hyogo p230 2g sync Mitsubishi HIBMC,Hyogo C320 1h1v sync Mitsubishi PMRC Tsukuba p250 2g sync Hitachi Shizuoka p235 gh sync, Hitachi? WakasaTsuruga p200 1h1v sync ? GHMC, Gunma C400 3h1v sync 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%) 18

19 RUNNING FACILITIES in the world EUROPE Type Rooms Acc. Start Pats. Company Uppsala S p200 1H sync Orsay F p230 1g1h cycl IBA sync.cycl. - new cyclotron+gantry operational since Oct 2010 PSI, CH p250 1g cycl. SC degraded beam until 2006; dedicated 250 MeV cyclotron since 2007 GSI Darmstadt D C430 1h sync stopped RPTC Munich D p250 4g1h cycl. SC Varian HIT Heidelberg D p250 2h sync started /Siemens HIT Heidelberg D C430 2h sync 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 19

20 RUNNING FACILITIES in the world RUSSIA ITEP, Moscow Russia p250 1h sync St.Petersburg Russia p1000 1h Dubna Russia p200 1h AFRICA Cape Town S-Africa p200 1h cycl CHINA WPTC, Zibo p230 2g1h cycl IBA? MPCAS, Langzou C400 1h sync Siemens? KOREA NCC, IIsan p230 2g1h cycl IBA 20

21 FACILITIES under construction USA Northern Illinois, p250 SCcycl 2g2h Varian?? PTCenter, Chicago p230 cycl 2h2dual fixed beams IBA HUPBTC, Hampton, V p230 cyclotron 4g1h IBA ProCure facilities (initiative of Indiana Un. ) New Jersey Seattle Florida Michigan coming soon TAIPEI Chang Gung Taipei Taiwan p235 cycl 4g1h JAPAN Southern Tohoku,Fukushima p230 cycl 2g1h Medipolis, Ibusuki Kagoshima p250 sync 3g RUSSIA PMHPTC, Protvino Russia p250 sync 1h?? New commercial machines for protons: all with passive scattering? 21

22 FACILITIES under construction EUROPE PSI P-Gantry 2, p250 1g cycl parallel scanning WPE, Essen Germany p230 3g1h cycl. IBA-scanning Trento Italy p230 1g1h cycl. IBA-scanning PTC Czech Rep. p230 3g1h cycl? CMHPTC, Slovak Rep. p250 1h synch? Heidelberg C-Gantry p,c430 CG sync. Scanning CNAO, Pavia Italy p,c430 3h sync. Scanning PTC, Marburg p,c430 3h145 sync. Scanning Siemens NRoCK, Kiel p,c430 1h 1(v45)1hv Scanning Siemens Med-AUSTRON p,c400 1pG,1h 1hv sync. Scanning 1 dedicated Proton Gantry New commercial machines in Europe: all based on scanning 22

23 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 23

24 Scanning developments in the USA 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 24

25 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 25

26 The University of Heidelberg Project Heidelberg 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 26

27 Rhön Klinikum AG - University of Marburg /Giessen The first commercial system for carbon therapy in Europe 4 identical horizontal beam lines for carbon ion treatments 110m Courtesy of Siemens and Rhön-Klinikum AG, Germany 66m 27

28 CNAO Centro Nazionale di Adroterapia Oncologica, Pavia, Italy Combined system for protons and carbon Initiated 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 28

29 5. The strategy of PSI past experience and concepts for the future 29

30 The expansion of the PSI proton therapy project 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) Medical cyclotron Optis 2 Degrader Gantry 2 Split beam Gantry 1 30

31 Continuation of the successful treatments with Gantry 1 15 patients/day (8:00-16:00) Clinically proven indications Base of skull and spinal chord 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 31

32 The cyclotron used as an active component for the beam delivery 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 32

33 Installations in the Gantry 2 area completed by the end of 2010 Gantry with sliding CT BEV X rays Parallel scanning The system which will be cloned in the Medaustron facility For proton therapy delivery 33

34 A new system for developing advanced scanning:. 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 Parallel scanning Beam intensity modulation Dynamic beam energy Repainting Gating Tracking Breath hold 34

35 6. New accelerator concepts 35

36 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)

37 going for further simplifications? Very compact synchro-cyclotron (first beam extracted in 2010) Single room solutions for small size hospitals 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 37

38 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? 38

39 7. Conclusions 39

40 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: 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 40

41 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 41

42 Thank you E. Pedroni Center for Proton Radiation Therapy - Paul Scherrer Institute Wien