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© 2017 Ion Beam Applications SA. All rights reserved.
RadKor 2017 - Ankara
Latest development in Proton Therapy
Gregory Saive, MEng, MBA
ProteusONE Global Product Manager
Disclaimer
PROPRIETARY INFORMATION
THE INFORMATION CONTAINED IN THIS DOCUMENT IS CONFIDENTIAL AND IS THE EXCLUSIVE PROPERTY OF IBA S.A. BELGIUM. THIS
INFORMATION IS SHARED FOR INFORMATION PURPOSES ONLY. THE REPRODUCTION, TRANSMISSION OR USE OF THIS INFORMATION IS
FORBIDDEN, UNLESS PRIOR WRITTEN PERMISSION OF IBA IS PROVIDED.
This document may contain express or implied forward-looking statements, opinions, expectations or analysis (the “Statements”). The Statements are
subject to a variety of risks and uncertainties, many of which are beyond IBA’s control, and some of which could cause actual results that differ materially from those contemplated in the Statements. IBA assumes no obligation nor makes
any warranty or commitment with respect to the Statements.
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IBA CONFIDENTIAL
Head & Neck example with unilateral radiation
Study conditions:
Unilateral irradiation
Similar target dose, schedule and constraints
4
Characteristic IMRT (N=23) Median PBT (N=18) Median P value
Target volume parotid only 129.5 cc 78.3 cc 0.934
Target volume parotid and ipsilateral neck 373.0 cc 314.3 cc 0.442
PTV max dose to 0.15 cc 72.0 Gy 71.5 CGE 0.554
Photons Protons
Courtesy of Dr Nancy Lee, MSKCC
Study conditions:
Unilateral irradiation
Similar target dose, schedule and constraints
IBA CONFIDENTIAL
Example with unilateral radiation - analysis and outcomes
5
Courtesy of Dr Nancy Lee, MSKCC
Brain stem DVH
Dose (cGy)
Dose (cGy)
Spinal cord DVH
Vo
lum
e (
%)
Vo
lum
e (
%)
Brain stem DVH
Spinal cord DVH
Dysgeusia Mucositis Nausea
20%
40%
60%IMRT
IMRT
IMRT
PBT
PBT
PBT
Dosimetric advantage of protons
translated into lower rates of acute
treatment-related toxicities
Dutch Model : 4 Categories Of Indications – 11.7% Of RT Patients
Standard : 0.4% of RT Improved Local Control : 2% of RT
Reduced Side Effects : 8% of RT Reduced 2nd Cancers : 1.3% of RT
- Eye
- Pediatrics
- Base of Skull
- Brain
- Intracranial
- Head & Neck
- Urologic (prostate & bladder)
- Lung (NSCLC)
- Sarcoma
- Reirradiation
- Breast
- Lymphoma
- Testis
- Intracranial
- H&N
- Urologic
- Lung
- Breast
- Gynecological
- GI (Esophagus, gastric,
rectal, pancreas)
- Lymphoma
- Sarcoma
« Model Based »
7
Update of NCCN guidelines in the US
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 leading cancer centers devoted to patient care, research, and education
7
Update in March 2017
5 new indications where proton therapy is appropriate or may be appropriate in specific situations
Central Nervous System CancersIt is reasonable to consider proton beam for craniospinal irradiation where available as it is associated with less toxicity.
Head and Neck CancersIMRT or other conformal techniques (3-D conformal, helical tomotherapy, VMAT, and proton beam therapy [PBT]) may be used as appropriate depending on the stage, tumor location, physician training/experience, and available physics support.
Non-Small Cell Lung CancerMore advanced technologies are appropriate when needed to deliver curative RT safely. These technologies include (but are not limited to) 4D-CT and/or PET/CT simulation, IMRT/VMAT, IGRT, motion management, and proton therapy.
Hepatocellular CarcinomaProton beam therapy (PBT) may be appropriate in specific situations.
Eosophagial and Esophagogastric Junction CancersIntensity-modulated radiation therapy (IMRT) or proton beam therapy is appropriate in clinical settings where reduction in dose to organs at risk (eg. Heart, lungs) is required that cannot be achieved by 3-D techniques.
Update of ASTRO model policies for PT
Updated in June 2017
Recommendations for medical insurance coverage regarding the use of proton therapy to treat cancer
8
Based on new evidence published since the original
policy was issued in 2014, the updated model policy
outlines two categories of appropriate clinical indications,
or diagnoses, for proton beam therapy.
Group 1 Group 2
lists disease sites that frequently support
the use of Proton Beam Therapy
include all other indications for Coverage
with Evidence Development (CED)
Group 1 - May 2014 Ocular tumors, including intraocular melanomas
Tumors that approach or are located at the base of skull,
including but not limited to ;
Chordoma
Chondrosarcoma
Primary or metastatic tumor of the spine where the spinal cord
tolerance may be exceeded with conventional treatment or where
the spinal cord has previously been irradiated
Primary hepatocellular cancer treated in a hypofractionated
regimen
Primary or benign solid tumor in children treated with curative
intent and occasional palliative treatment of childhood when at
least one of the four criteria of the poly apply
Patient with genetic syndromes making total volume of irradiation
minimization crucial such as but not limited to NF-1 patients and
retinoblastoma patients
Group 1 - June 2017 Ocular tumors, including intraocular melanomas
Tumors that approach or are located at the base of skull,
including but not limited to ;
Chordoma
Chondrosarcoma
Primary or metastatic tumor of the spine where the spinal cord
tolerance may be exceeded with conventional treatment or where
the spinal cord has previously been irradiated
Primary hepatocellular cancer treated in a hypofractionated
regimen
Primary or benign solid tumor in children treated with curative
intent and occasional palliative treatment of childhood when at
least one of the four criteria of the poly apply
Patient with genetic syndromes making total volume of irradiation
minimization crucial such as but not limited to NF-1 patients and
retinoblastoma patients
Malignant and benign primary CNS tumors
Advanced (eg T4) and/or unresectable head and neck cancers
Cancers of the paranasal sinuses and other accessory sinuses
Non-metastatic retroperitoneal sarcomas
Re-iradiation cases (where cumulative critical structure dose
exceed tolerance dose)
Group 2 - May 2014 Head and neck malignancies
Thoracic malignancies
Abdominal malignancies
Pelvic malignancies, including genitourinary, gynecologic and
gastrointestinal carcinomas
Update of ASTRO model policies for PT
9
Group 2 - June 2017 Non T4 and resectable Head and neck malignancies
Thoracic malignancies, including non-metastatic primary lung
and esophageal cancers, and mediastinal lymphomas
Abdominal malignancies, including non-metastatic primary
pancreas, biliary and adrenal cancers
Pelvic malignancies, including genitourinary, gynecologic and
gastrointestinal carcinomas non-metastatic rectal anal, bladder
and cervical cancers
Non-metastatic prostate cancer
Breast cancer
IBA CONFIDENTIAL
Proton Therapy is growing
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2020: 41
2015: 21
2010: 10
2005: 4
2000: 3
2020: 44
2015: 20
2010: 13
2005: 11
2000: 10
2020: 35
2015: 15
2010: 7
2005: 5
2000: 1
* PTCOG 2017 Data including centers with eye treatments only
Centers treating from 2000 to 2020 per region*
IBA CONFIDENTIAL
IBA – a global leader in proton therapy
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Share of installed base - rooms
Total accumulated: 250 rooms
Including commercial PT rooms at end 2016
IBA market share is 56% in US, 54% in APAC
ex. Japan and 56% in EUR & ROW
IBA CONFIDENTIAL12
At the end of 2016 almost 60 000patients* treated on IBA equipment. More than all competitors combined
* Source: PTCOG 2015
61% of patients treated on IBA equipment
Number of patients treated
On commercial PT systems at end 2016
Dutch report applied to Turkey
PT : 11,600 patients annually
Needs : 32 rooms today
Top 5 cases : Lung (32 %)
Breast (20%)
Colorectum (14%)
Prostate (8%)
Pediatrics (5%)
15
3%4%
20%
1%
14%
1%1%
5%2%
32%
0%1% 2%
2%
1% 8%1%
0%
PT Patients Mix
Bladder
Brain, nervous system
Breast
Cervix uteri
Colorectum
Corpus uteri
Hodgkin lymphoma
Pediatrics
Lip, oral cavity
Lung
Nasopharynx
Non-Hodgkin lymphoma
Oesophagus
Other (Reirradiation)
Pancreas
Prostate
Stomach
Testis
0
10
20
30
40
50
60
0
50000
100000
150000
200000
250000
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Cancer incidence PT rooms
Globocan
data
Turkish MOH
data
10% yearly increase
extrapolation
Needed Room in 2020 : 45
How to improve affordability?
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Proteus®ONE*
Significant cost reduction
thanks to compactness
Less than
15 min
including CBCT for a 2 fields pelvic
treatment
Gantry and PPS22%
Imaging19%
Irradiation7%
Setup beam52%
Treatment beam48%
Setup beam52%
Efficient workflow similar to
linear accelerator
How to improve affordability?
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20%more efficient
Ambient
Experience
Solution
Open
environment
Wireless
Hand
Pendant
Shallow
tumor
optimization
Fixed oblique
flat panelsFast Delivery
Fast Room
Availability
~ +1500*extra fractions can be delivered per year in your
institution!
* 350 patients
Pencil Beam Scanning: Smallest spot size
Best in class for cancers where lateral penumbra is critical Conformality improved
Treatment planning improved
Dosimetric advantage of IMPT
IBA
3 mm
Competitor 1
4 mm
Competitor 2
5 mm
Spot size comparison (σ)
20
Image-Guided Proton Therapy
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Medium Field View CBCT Fully Integrated In-Room CT Large Field View CBCT
34cm x
34cm
50cm x
34cm
Complete toolset for motion management
22
Fast and various
repainting strategyGating interfaceHigh speed irradiation for
breath-hold techniques
15seconds to irrediate
a 5x5x5 volume
Shallow tumor optimized treatment
23
Small airgap improves critical organ sparing
Lateral penumbra typically decreased by 50%
IBA CONFIDENTIAL25
LFOV
CBCT
Fast irradiation
Repainting
15s
Gating
Interplay
simulator
Treating moving targets
Ambient
Experience
RPD
Multiframe
imaging
Imaging
Beam
Integration
Workflow
What does already exist?
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motion
management?
patient-
specific
motion
mitigation
Planning phase Treatment phase
Verification
if planning
hypotheses
remain
validApply motion
mitigations as
planned
no
yes
Repainting
strategy ?
Repainting
strategy?
Available solutions:
Breath hold
Gating
Abdominal compression
Layer repainting
Volumetric repainting
4D planning and 4D robust optimisation
What is still missing : checking planning hypotheses before treatment
Verify treatment planning hypothesis: free breathing
27
image orthogonal to beam axis
Multi frame: number of images in respiration cycle to reduce dose
Just before irradiation/during beam pauses
Low dose
Verify treatment planning hypotheses: 4D-CBCT
28
MOTION
ANALYSIS
Visualisation small tumours
More rigourous motion pattern analysis
Currently available in
IBA CONFIDENTIAL29
Treating the H&N region
LFOV
CBCT
In-
Room
CT
Snouts
Airgap
tuner
TPS
Coaches
and immobilization
devices
Ambient
Experience
RPD
Wireless
hand
pendant
Imaging
Beam
Integration
Workflow
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Organs at Risk Photon IMRT (70 Gy) Proton IMPT (70 Gy) Difference map
V5
V10
V15
V20
V25
V30
V35
V40
V45
V50
V55
V60
V65
V70
V5
V10
V15
V20
V25
V30
V35
V40
V45
V50
V55
V60
V65
V70
V5
V10
V15
V20
V25
V30
V35
V40
V45
V50
V55
V60
V65
V70
Esophagus inlet100 100 100 100 100 100 46 2 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 93 100 100 100 100 100 46 2 0 0 0 0 0 0
Brain stem74 72 90 80 70 60 50 30 5 0 0 0 0 0 90 70 50 30 2 0 0 0 0 0 0 0 0 0 -16 2 40 50 68 60 50 30 5 0 0 0 0 0
Spinal cord74 72 71 69 67 66 64 44 14 0 0 0 0 0 45 38 37 35 21 6 0 0 0 0 0 0 0 0 29 33 34 34 46 60 64 44 14 0 0 0 0 0
Parotid gland right100 90 69 62 58 54 50 45 38 28 1 0 0 0 68 58 52 47 42 37 32 28 22 17 3 0 0 0 32 31 17 15 16 17 17 17 16 12 -1 0 0 0
Cricopharyngeus100 100 100 100 100 100 80 50 31 15 0 0 0 0 52 34 24 17 12 9 6 4 2 0 0 0 0 0 48 66 76 83 88 91 74 46 28 15 0 0 0 0
Submandibular gland R100 100 100 100 100 100 100 100 100 100 53 0 0 0 100 100 100 100 100 100 100 100 100 100 56 0 0 0 0 0 0 0 0 0 0 0 0 0 -3 0 0 0
Carotid artery100 100 98 97 90 80 77 67 56 56 50 40 20 0 100 100 100 90 70 56 41 40 34 20 10 0 0 0 0 0 -2 7 20 24 36 27 22 36 40 40 20 0
Glottis100 100 100 100 100 100 100 99 87 69 45 28 14 3 100 96 91 85 78 69 58 47 39 32 25 17 10 5 0 4 9 15 22 31 42 52 48 38 20 11 4 -2
Thyroid gland100 100 100 100 100 98 96 95 80 59 47 30 11 3 100 100 100 100 100 100 85 72 40 6 0 0 0 0 0 0 0 0 0 -2 11 23 40 53 47 30 11 3
Middle PCM100 100 100 100 100 100 100 100 100 100 74 67 61 4 100 100 100 100 100 99 97 95 92 85 64 62 59 49 0 0 0 0 0 1 3 5 8 15 10 5 1 -45
Inferior PCM100 100 100 100 100 100 100 99 81 57 41 36 28 8 99 94 88 82 75 69 64 58 52 43 32 26 22 16 1 6 12 18 25 31 36 41 29 14 9 10 6 -9
Supraglottis100 100 100 100 100 100 100 100 100 100 98 87 74 8 100 100 100 100 100 99 98 96 93 91 86 80 71 50 0 0 0 0 0 1 2 4 7 9 12 8 3 -42
Parotid gland left100 100 100 95 76 66 58 52 46 40 34 29 23 8 92 74 64 58 53 49 45 42 38 34 30 25 20 11 8 26 36 37 22 17 13 10 8 6 4 3 3 -2
Superior PCM100 100 100 100 100 100 100 100 100 98 95 84 71 35 100 100 100 100 100 99 97 95 92 85 64 62 50 34 0 0 0 0 0 1 3 5 8 13 31 22 21 1
Submandibular gland L100 100 100 100 100 100 100 100 100 100 100 98 88 43 100 100 100 100 100 100 100 100 100 50 12 0 0 0 0 0 0 0 0 0 0 0 0 50 88 98 88 43
Body volume (scan)45 40 39 30 23 20 18 15 13 10 6 4 3 1 25 22 18 16 14 12 11 10 9 8 5 4 3 2 20 18 21 14 9 8 7 5 3 2 1 0 0 -1
∆NTCP Model-Based
Courtesy Prof. Langendijk
Propose alternative evidences
Conclusion
Proton therapy market is growing
45 rooms should be built in Turkey by 2020
Barriers still exist but IBA develops adequate solutions
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