Integration of PT in an existing radiation oncology center

Integration of PT in an existing radiation oncology center Tom Depuydt, PhD Head of medical Physics, Radiation Oncology UZ Leuven-KU Leuven and ParTICLe proton therapy project tom.depuydt@uzleuven.be 1

Milestones in the history of Proton Therapy (PT) Custom built installations First patients treated with PT at Harvard Cyclotron Lab. and Massachusetts General Hospital 1946 1961 1984 2000 First patients treated with Pencil Beam Scanning 2010 2013 Founding father of PT *PBS = Pencil Beam Scanning

History of Proton Therapy (PT) facilities PT facilities evolves from being A by-product NUCLEAR PHYSICS RESEARCH FACILITY PT

PT as add-on to large nuclear research infrastructure Large nuclear research facility (Paul Scherrer Institute) Clinical proton therapy facility

PT as add-on to large nuclear research infrastructure One clinical beamline connected to large research accelerator facility (shared) Non-commercial custom built systems by facilities own physics/engineering team Often access to other particles beside protons such as carbon ions Low patient through-put Not in close proximity of a hospital Available a few months per year due to maintenance Limited support, remote involvement of a conventional radiotherapy clinical Staff are mainly scientist from research facility High number of people required to run the facility Experimental stage and not cost effective PRICE:??? (cannot be seen separate from research facility) Research facility layout

Milestones in the history of Proton Therapy (PT) Custom built installations Commercial installations First patients treated with PT at Harvard Cyclotron Lab. and Massachusetts General Hospital 1946 1961 1984 2000 Founding father of PT First patients treated with Pencil Beam Scanning 2010 PBS in other facilities (MGH, MDA, ) 2013 *PBS = Pencil Beam Scanning

History of Proton Therapy (PT) facilities PT facilities evolves from being A by-product NUCLEAR PHYSICS RESEARCH FACILITY PT Dedicated stand-alone facility PT

PT as a large dedicated stand alone facility APSS Trento, Italy Holland PTC, Delft, The Netherlands Scripps, San Diego, USA

PT as a large dedicated stand alone facility Large facility built for the purpose of proton therapy Mostly commercial systems Dedicated accelerator serving typically 2 to 5 treatment rooms including fixed beam and gantry rooms Mostly only proton beam Not directly connected or in close proximity of hospital Potentially high throughput Different PT techniques available in one facility (PS, PBS, eye-beam-line) Stand-alone facility not sharing equipment or work-flow with existing radiation oncology department Usually its own treatment preparation imaging (CT, PET, MRI, ) Clinically oriented staff, but usually proton therapy only specialized experts, and large technical staff to run the system Sometimes one room available for research PRICE: projects of 100M Euro

Gartner Hype Cycle for Proton Therapy -Too expensive anyway -Too experimental -Not cure more patients -No level 1 evidence -Moving tumors impossible - Climbing the slope of enlightenment

Milestones in the history of Proton Therapy (PT) Custom built installations Commercial installations Compact commercial installations First patients treated with PT at Harvard Cyclotron Lab. and Massachusetts General Hospital 1946 1961 1984 2000 Founding father of PT First patients treated with Pencil Beam Scanning 2010 PBS in other facilities (MGH, MDA, ) 2013 First compact system clinically used *PBS = Pencil Beam Scanning

PT embedded in existing radiation oncology clinic The metaphors in PT Size measure of PT centers Range uncertainty 60x100 meter

PT embedded in existing radiation oncology clinic Compact systems as enabling technology for embedding PT? 11x24 meter 15x28 meter

History of Proton Therapy (PT) facilities PT facilities evolves from being A by-product NUCLEAR PHYSICS RESEARCH FACILITY PT Dedicated stand-alone facility PT Embedded Facility HOSPITAL PT

PT embedded in existing radiation oncology clinic dose Photons, electrons dose Charged particles (e -,p +, ) depth PT seen as an additional modality, rather than an separate facility depth

PT embedded in existing radiation oncology clinic

PT embedded in existing radiation oncology clinic Proton therapy Conventional RT

PT embedded in existing radiation oncology clinic Existing cancer care Proton therapy Proton therapy

PT embedded in existing radiation oncology clinic UZ Leuven campus Gasthuisberg Impression of finished facility

ParTICLe Proton Therapy Project in Leuven Clinical Treatment room 1 Research room (future clinical 2) 23m A B 60m Existing+Future(2020) Radiation Oncology dept., UZ Leuven C Lab Access MRI s MRI s PET-MRI D

ParTICLe Proton Therapy Project in Leuven PT Treatment MRI FUP scans Reception Intake/Status PT rooms Induction/ recovery Diagnostic MRI facility Waiting room Radiation Oncology dept. Backup XT treatment FUP CT scan Truebeam STX Halcyon Halcyon Truebeam Treatment planning Truebeam PT fully embedded in existing RT/hospital facility

PT embedded in existing radiation oncology clinic Smaller facility truly integrated in existing radiation oncology and hospital environment Commercial compact systems with one or 2 treatment rooms Proton beam only Pencil beam scanning (PBS) only (mostly) Sharing treatment preparation imaging equipment and clinical workflow with conventional radiation oncology and hospital Clinically oriented staff, shared but PT trained staff from XT clinic, with limited technical staff to run the facility Only clinical treatment room, no research beam-line PRICE: projects of 50 M EURO

Integrated compact proton therapy facilities Users Region Treating Integration P1 with adjacent RT unit or full oncology Proton Partners International Ltd 8 Europe No Yes but RT/full oncology unit in construction Proton Partners International Ltd 7 Europe No Yes but RT/full oncology unit in construction Proton Partners International Ltd 6 Europe No Yes but RT/full oncology unit in construction Children's Cancer Hospital Egypt (Hospital MENA No Yes but RT/full oncology unit in construction 57357) QuironSalud Madrid Europe No Yes but no onsite integration Proton Partners International Ltd 5 North America No Yes but RT/full oncology unit in construction Proton Partners International Ltd 4 Europe No Yes but RT/full oncology unit in construction Florida Proton Therapy Institute North America No No, addition to currently multi-room PT system Gulf International Cancer Center MENA No Yes but RT/full oncology unit in construction ParTICLe UZ Leuven Europe No Yes Proton Partners International Ltd 3 Europe No Yes but RT/full oncology unit in construction Proton Partners International Ltd 2 Europe No Yes but RT/full oncology unit in construction Proton Partners International Ltd 1 Europe No Yes but RT/full oncology unit in construction CYCLHAD Caen Europe No Yes but no onsite integration William Beaumont Hospital North America Yes Yes Toyohashi University of Technology Asia No Yes Hokkaido University Hospital Asia No Yes Chiu Ho Medical Systems Co., Ltd. Asia No Yes Changhua Christian Hospital Asia No Yes Centre Antoine Lacassagne (CAL) Europe Yes Few miles away from RT unit but integrated with Cyberknife Willis-Knighton Medical Center North America Yes Yes

History of Proton Therapy (PT) facilities PT facilities evolves from being A by-product NUCLEAR PHYSICS RESEARCH FACILITY PT Dedicated stand-alone facility PT Embedded Facility HOSPITAL PT

Large Multi-room vs. Compact unit Location of radiation sources Cyclotron Energy Selection System Nozzle Patient Degrader Collimator Divergence slits Momentum slits 32m 60m 27m 11m

Large Multi-room vs. Compact unit Concrete activation/dismantling nuclear waste: The walls in vaults for compact systems can be closer to the cyclotron, resulting in higher intensity of neutron fluence on the wall. The specific activity after 20 years due to long-lived isotopes ( 152 Eu, 60 Co) will be larger Using a decommissioning layer of low activation concrete, Norwegian Marble aggregates with low Eu levels <0.1ppm

Public Exposure limits of Embedded facilities Clinical Treatment room 1 Research room (future clinical 2) Existing Offices/Public spaces Public Exposure limits (FANC): <300 μsv/year, <20 μsv/week, <10 μsv/h ParTICLe (Particle Therapy Interuniversitary Center Leuven)

Training people for PT in embedded facility XT +PT Physicians expertise Physics expertise Technologist expertise XT experience, PT-specific experience Train existing XT team rather then attract PT expertise externally? How much training? Send people abroad to other PT centers for a longer time or not? Dedicated PT team or a more integrated approach with XT? Internal organization of RT to include the PT modality?

Training people for PT in embedded facility Passive scattering (PS) Pencil beam scanning (PBS) PS Proven technology with which most PT patients are treated today, but labor intensive and not PBS Flexible technology with great potential, but... Vendors have made this choice for us in compact PT systems

Training people for PT in embedded facility Technical knowledge PT and related equipment Software environment (TPS+OIS) Most commercial TPS have PT planning Specific issues with PBS planning Introduction of robust planning

Technological cross-talk between XT and PT 1999: David Jaffray and first CBCT integrated in linac 2016: First CBCT-guided PT And the rest is history

Technological cross-talk between XT and PT XT Volumetric image guidance IMRT PT (CBCT only recently introduced in PT) (IMPT find its way to mainstream PT) Adaptive Radiotherapy (revival in XT?) RT of moving tumors Will finds its way to XT (Probably more needed in PT) (Issues to solve in PBS, triggers development of motion management strategies in PBS-only environments) PTV-less robust planning strategies Classic margin recipes invalid?! Cross-talk between XT and PT could be intensified by embedded facilities

Training people for PT in embedded facility (RTT) Treatment delivery and IGRT interfaces become similar in XT and PT PT system user interface XT system user interface

Aspects of setting up a mixed XT/PT environment System for optimal patient-specific selection between XT and PT modalities Adaptive Workflow protocols XT PT XT Less bias in choice between XT and PT in a true mixed/integrated environment? PT Courtesy M. Engelsman (TU Delft) Approaches supported by TPS+OIS environment. Interaction between TPS and OIS?

International guidelines for PT/PBS? The current activity of different guideline working groups shows that PBS is getting to maturity, but it is not there yet. It also shows that existing guidelines do not meet the current needs. (C. Goma, PhD, UZ Leuven) Publishes guidelines AAPM Report 16 (1986), Protocol for heavy charged-particle therapy beam dosimetry, no PBS ICRU Report 59 (1998), Clinical Proton dosimetry, no PBS IAEA TRS-398 (2000), The current Code of Practice for proton dosimetry no PBS ICRU Report 78 (2007), coverage PBS limited Guidelines in preparation IAEA: Update of TRS-398 (<2020?) AAPM TG-185: Commissioning of Proton Therapy Systems AAPM TG-224: Proton Machine QA NCS subcommittee on proton dosimetry EPTN ("ESTRO initiative") IPEM

Particle Therapy Interuniversitary Center Leuven 2014 Timelapse Sept. 2016 - Today

Particle Therapy Interuniversitary Center Leuven Last week Next 4 weeks In < 1 year 1x 2x In-room CT on-rails

Particle Therapy Interuniversitary Center Leuven Overview Contract signature Today 1 st Patient Construction Power supply & cooling Installation proton equipment & ATP Commissioning First patient

Concluding remarks Embedded Facility HOSPITAL PT Compact PT systems will facilitate embedding of PT facilities in an existing hospital campus Embedded facilities have an impact on the organization of PT: Located in close proximity/adjacent to existing general hospital/existing RT service Allow better integration in existing RT organization, in all aspects Potentially will amplify the interaction/crosstalk between PT and conventional RT/XT This integration can play a role in coming to optimal choice of treatment modality, PT vs XT