Treatment Efficiency and Optimization of Patient Care with IBA ProteusOne

Treatment Efficiency and Optimization of Patient Care with IBA ProteusOne Terry Wu, Ph.D. Chief Physicist, Radiation Oncology Department Willis-Knighton Cancer Center/Proton Therapy Center Shreveport, LA, USA

Willis-Knighton Cancer Center/Proton Therapy Center Willis-Knighton Health System 4 Hospitals in Shreveport/Bossier City, Louisiana 1100 Bed 4 Hospitals in Shreveport/Bossier City, Louisiana Cancer Center Opened in 2000 Radiation Therapy- early users of Peacock IMRT, Tomotherapy, Varian Linacs with OBI/CBCT

Willis-Knighton Radiation Oncology 900 patients per year, 90 patients per day and 500 Brachytherapy procedures per year 2 Elekta Versa Linacs, Tomotherapy, Nucletron HDR and IBA ProteusOne 5 physicians, 5 physicists, 2 physics residents, 3 dosimetrists and numerous therapists Staff adding specifically for proton 1.5 Physicist, 1 Dosimetrist, 3 Therapists & 2 Office assistants

IBA ProteusOne Project Timeline Entered Negotiations May 2011 Contract Signed Sep. 2011 Groundbreaking Feb. 2012 Cyclotron Arrival Aug. 2013 Gantry Arrival Oct. 2013 Started Beam Tuning Dec. 2013 Started PBS Calibration Feb. 2014 Acceptance Test and Commission July 1 st, 2014 First Patient Treated Sept. 9 th, 2014 CBCT Installed Sept. 24 th, 2015 CBCT LFOV Upgraded Jun. 30 th, 2017 More than 500 patients treated Sept. 20 th, 2018

To Date Proton Treatment Statistics More Then 500 Patients Treated Brain 15% H/N 10% Lung 9% GI 7% GU-GYN 5% Other 6% Breast/CW 4% Spine 1% Sacroma 2% GU-other 1% GU-Prostate 43% Lymphoma 2% Re-treat 8%

Unique Design of ProteusOne Open Gantry Environment 220 degree Ambient Experience Imaging Solutions Instantaneous on-board oblique imaging On-board CBCT with various FOV Beam Delivery Modality Pencil beam scanning (PBS) only Treatment field size 20x24cm 2 Remote operation of accessories

ProteusOne Technology Beam Energy 70-230 MeV Range in Patient 0.1-32 g/cm 2 Dose Rate 2 Gy/min (10x10x10 cm 3 ) Beam Sigma 3.5 & 4.7 mm at Range 32 & 15 g/cm 2 6 Degree Robotic Couch Energy Layer Switching Time ~0.9 sec

Compact (Open) Gantry Design

220 Degree Compact Gantry -35 Deg 0 Deg 90 Deg -5 Deg 180 Deg

6 Degree Robotic Couch

ProteueOne Imaging System Fixed Imaging System at Isocenter Stereo Oblique Stereo X-ray Flat Panels Nozzle Imager (CBCT&Ortho) X-Ray Tube Under Ground X-Ray Source Flat Panel

ProteueOne Imaging System Specification Specifications Stereo Oblique Nozzle Imager Flat Panel Type Amorphous silicon Amorphous silicon Image Mode 2D 2D, 3D Scan Diameters (FOV) n/a 25cm (currently) Scan Length (S-I FOV) n/a 26 cm Source to Axis Distance 250 cm 100 cm Imager to Axis Distance 82 cm 55 cm Flat Panel Array 1440 x 1560 px 2881 x 2881 px Flat Panel Physical Size 38.0 x 32.8 cm 2 50.8 x 51.8 cm 2 Panel Sensitive Area at ISO 22 x 20 cm 2 28 x 28 cm 2 Pixel Size at Isocenter 0.1 mm 0.1 mm Max. Gantry Speed (CBCT) n/a 3, 6 deg/s CBCT Frame Rate n/a 7.5 fr/s Elekta Versa XVI Amorphous silicon 2D, 3D and 4D 27, 41 & 50 cm Up to 27cm 100 cm 54 cm 1024 x 1024 px 42.5 x 42.5 cm 2 27 x 27 cm 2 0.25 mm 6 deg/s 5.5 fr/s

ProteusOne Imaging System CBCT Dose Scan Protocol FOV (Field of View) Acquisition Angle Gantry Speed ( /s) Scan Parameters kvp ma ms CTDI weighted (mgy) Head HD Small 205 3 100 25 12 8.2 Head SD Small 205 6 100 25 12 4.4 Thorax Small 205 3 110 25 12 6.4 Pelvis Small 205 3 120 40 12 12.5 Thorax Pelvis Large Large 434 (dual half scan) 434 (dual half scan) AI 2.0 (Large FOV) 6 110 50 12 10.6 6 120 64 12 15.7 13

Treatment Site WK Imaging Protocol Stereo Oblique Image Modality CBCT Daily 2 nd Field Verification Brain V A Y Head/Neck V A Y Thorax/Lung V A Y* Breast/Chest Wall V A Y* Abdomen V A Y* Pelvis V A Y** Prostate A & V A Y** Prostate Bed V A Y* Extremities A & V A Y* A: Patient Position Alignment *: Only when couch moved V: Patient Position Verification **: 5 days evaluation

Remote Operation All mechanical and imaging systems can be activated from either inside or outside the room No need to enter the room between fields or isocenters Significantly increases the efficiency of workflow Multiple in-room cameras system prevents any possible collision during treatment from remote operation 4 viewing Cameras

Open Environment and Ambient Experience The relaxing and welcome atmosphere provided by an open gantry environment and ambient experience allows for fast patient loading and positioning

Open Environment and Ambient Experience The relaxing and welcome atmosphere provided by an open gantry environment and ambient experience allows for fast patient loading and positioning

Open Environment and Ambient Experience The relaxing and welcome atmosphere provided by an open gantry environment and ambient experience allows for fast patient loading and positioning

Fast and Efficient Workflow Achieves by Integrating the Following Systems 220 Degree Open Gantry 6 Degree Robotic Couch IBA Image-Guided System 2D Stereoscopic Oblique X-ray and 3D CBCT systems Remote Operation Multiple In-room Camera Monitoring System Open Environment and Ambient Experience Record and Verify System Elekta Mosaiq

Four Common Clinical Cases to Demonstrate the Efficient Treatment Workflow with ProteusOne Simple Prostate Intermediate Brain/Head&Neck Advance Lung Challenge Breast/Chest Wall

Standard Opposed Lateral Beams Prostate Gantry is at fixed lateral position. Couch has to rotate 180 deg to treat the opposed side (75 sec). Use Stereo imaging to align with fiducial markers daily and CBCT to check bladder filling and rectal balloon position weekly Stereo imaging allows quick and accurate patient position confirmation and monitoring after each couch movement Stereo Oblique CBCT Level of Difficulty for setup and treatment Robotic Couch 3D CBCT Stereo X-ray Remote Operation of Accessories Simple Yes Weekly, SFOV (2 mins) Yes, avg. 2 sets per field (1 min) Yes CBCT # of time re-enter treatment room during treatment 0 Overall treatment time, including patient set up, imaging guidance and electronic charting 12-15 minutes

Brain 2-3 non-coplanar SFUD fields Open gantry provides no limitation for any non-coplanar beam. No short couch top needs to switch. No limit of any SSD setup CBCT with SFOV is the best imaging system to align Use Stereo X-ray to confirm patient position after each couch movement Treating a vertex field is easy compared with closed gantry Stereo CBCT Level of Difficulty for setup and treatment Open Gantry Advantage Robotic Couch Utilization 3D CBCT Stereo X-rays Remote Operation of Accessories Intermediate Yes Yes Daily, SFOV (2 mins) Yes, each couch movement Yes # of time re-enter treatment room during treatment 0 Overall treatment time includes set up, image guidance, treatment and electronic charting 15-20 minutes

Head and Neck 3 coplanar IMPT fields (LAO, RAO &PA) Open gantry environment and ambient experience offers faster patient loading and positioning CBCT with SFOV is the best imaging system for initial patient setup alignment Use Stereo x-ray to confirm positioning after each couch movement TPS Planning CBCT Level of Difficulty for setup and treatment Open Gantry Advantage Robotic Couch Utilization 3D CBCT Stereo X-rays Remote Operation of Accessories Intermediate Yes Yes Daily, SFOV (2 mins) Yes, each couch movement Yes # of time re-enter treatment room during treatment 0 Overall treatment time includes set up, image guidance, treatment and electronic charting 15-20 minutes

Lung Either Breath-Hold (BH) or Free-Breathing (FB) treatment For BH, Qfix SDX system is used to ensure the correct and consistent level of deep inspiration 4D-robust optimization with Monte Carlo dose calculation for planning Acquire CBCT (with pause and resume function for BH) for initial patient setup and stereo images for verification after each couch movement. Utilize both layer and volumetric repainting for treating moving target Level of Difficulty for setup and treatment Open Gantry Advantage Robotic Couch Utilization 3D CBCT Stereo X-rays Remote Operation of Accessories Advance Yes Yes Daily (either SFOV, 2 mins or LFOV 3 mins) After each couch movement Yes # of time re-enter treatment room during treatment 0 Overall treatment time includes set up, image guidance, treatment and electronic charting 20-25 minutes

Lung Daily CBCT triggers for re-ct and re-plan due to tumor volume and other structure changes during treatment CBCT Planning CT re-ct and re-plan

A CASE STUDY Left Chest Wall and Supra-Clavicular Using CBCT and Stereo Oblique Imaging Systems

Left Chest Wall and Supra-Clavicular with ProteusOne PBS System Concerns Field size limitation 2 or 3 enface fields Field matching Multi-isocenter No light field and ODI IGRT Workflow

Three Field Matching Treatment 1st field: ISO#1, LAO medial CW, G=15 2nd field: ISO#2, LAO lateral CW, G=55 3rd field: ISO#3, AP s clav, G=0

Field Matching Using Gradient Optimization Technique Overlapping fields by creating a gradient penumbra from RayStation TPS

Site-setup in Mosaiq This is CRITICAL!!

Manually enter ISO #1 information into reference CT image in Mosaiq Site Setup

Daily Treatment Workflow Breast/Chest Wall Align patient 1 st field 2 nd field 3 rd field lasers CBCT (ISO #1) Treat Auto move to ISO #2 Oblique verification Treat Auto move to ISO #3 Oblique verification Treat Pt step in 30 40 minutes Pt step out

1) CBCT using ISO #1 in Site Setup Daily Treatment Workflow 2) Check Mosaiq 1 st field definition and Treatment

3) Use auto couch movement to ISO #2 with pre-determined relative couch position from TPS 2 nd Mosaiq field definition 4) Confirm 2 nd field position (ISO #2) using stereo oblique images and treat

5) Auto couch movement again to ISO #3 3 rd Mosaiq field definition 6) Confirm the final field position (3 rd field) and Treat

Left Chest Wall and Supra-Clavicular Overall treatment procedure can be completed in 30-40 minutes.

Post Treatment Field Verification Relative treatment position for each field can be verified in Mosaiq Site Setup ISO #1 ISO #2 ISO #3

Breast/ Chest Wall Integration with Mosaiq, remote operation and setup automation play a major role to increase workflow efficiency Level of Difficulty for setup and treatment Open Gantry Advantage Robotic Couch Utilization 3D CBCT Stereo X-rays Remote Operation of Accessories Challenge Yes Yes Daily, either SFOV or LFOV When move to next isocenter Yes # of time re-enter treatment room during treatment 0 Overall treatment time includes set up, image guidance, treatment and electronic charting 30-40 minutes

Fast and Efficient Treatment Workflow with ProteusOne Simple Prostate (12-15 mins) Intermediate Brain/Head&Neck (15-20 mins) Advance Lung (20-25 mins) Challenge Breast/Chest Wall (30-40 mins)

Current Status of the WK ProteusOne TPS: Raystation 7.0; R&V: Mosaiq 2.6.4 31 patients treated on August 3, 2018 from 7:28am to 6:48pm (11.3 hours) 16 prostate, 3 lung, 4 brain, 5 H&N, 1 anal/rectum, 1 lymphoma, and 1 chest wall Morning QA starts at 6:30am Average proton treatment takes about 16 minutes per patient (range from 12 to 30 minutes) Average 2.4 fields per patient for treatment Current up-time is 97.7% since Sept. 9th, 2014

Conclusion With over 500 proton treatment experiences since 2014, Willis- Knighton Proton Therapy Center has shown the open gantry feature combined with volumetric CBCT and stereo image guidance can be safely and efficiently delivered to a wide range of body sites. The open gantry design allows to large variety of treatments. Furthermore, the open gantry environment shows advantage when dealing with non-coplanar fields and offers the most efficient workflow.