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CE - Therapy
PROTON THERAPY
Alfred Smith, Ph.D.
M. D. Anderson Cancer Center Houston, TX
Topics Covered
History of Proton Therapy
Worldwide Facilities Rationale for Proton Therapy Physics of Proton Beams Treatment Delivery Techniques Proton Treatment Technology Clinical Commissioning Treatment Planning
1991 2006
In operation
In preparation
Considering
Head/Neck Gastrointestinal Gynecologic Genitourinary Lung Breast Lymphoma Skin, Bone, Soft Tissue Brain Total
22,000 135,000 28,000 55,000 160,000 41,000 20,000 15,000 12,000 488,000
13,200 (60%) 54,000 (40%) 14,000 (50%) 27,500 (50%) 40,000 (25%) 4,920 (12%) 2,400 (12%) 5,000 (33%) 10,800 (90%) 171,820 (35%)
Photons
Protons
Photons
Protons Stop! Photons dont stop. Proton dose at depth (target) is greater than dose at surface. Photon dose at depth (target) is less than dose at dmax.
Ideal dose distribution
Protons
Proton Physics
The physics of proton beams Passive scattering systems Pencil beam scanning systems
p e
120%
100%
80%
60%
Mass Electronic Stopping Power is the mean energy lost by protons in electronic collisions in traversing the distance dx in a material of density .
40%
S/ = 1/[dE/dx] 1/v2
Where v = proton velocity
0 5 10 15 20 25 30
20%
0%
Depth in Water[cm]
Normalized (at peak) Bragg Curves for Various Proton Incident Energies Range Straggling will cause the Bragg peak to widen with depth of penetration
1.2
Relative Dose
0.8
0.6
0.4
100 MeV 130 MeV 160 MeV 180 MeV 200 MeV 225 MeV 250 MeV
0.2
0 0 5 10 15 20 25 30 35 40
Normalized (at entrance) Bragg Curves for Various Proton Incident Energies
50 40 Relative Dose 30 20 10 0 -10 0 10 20 30 Depth in Water (cm) 40 50 100 MeV 130 MeV 160 MeV 180 MeV 200 MeV 225 MeV 250 MeV
Dose depositions in water from 160 MeV protons. Beam slit delimiters with width W cm. Depth for 160 MeV Protons for Uniform particle distributions.
25
D o se (M eV /cm )
20
PDD
60 40
5 cm x 5 cm 10 cm x 10 cm 18 cm x 18 cm
15
10
20
5
0
0 0 5 10 15
50
100
Depth (mm)
150
200
250
Depth (cm)
Loss of in-scattering (charged particle equilibrium) results in deterioration of Bragg peak and non uniformity of SOBP.
George Ciangaru
Narayan Sahoo
Protons
15 MV Photons
17 cm
Paganetti
Urie
A certain fraction of protons undergo nuclear interactions, mainly on 16O Nuclear interactions lead to secondary particles and thus to local and non-local dose deposition (neutrons!) In passive scattering systems neutrons are produced in the first and second scatterers, modulation wheel, aperture, range compensator in addition to those produced in the patient.
Pedroni et al PMB, 50, 541-561, 2005 Effect on the lateral dose distribution
Primary fluence
'Primary' Dose
0 5 10 15 20
'Secondary' Dose
25 30 35
Requires custom aperture and compensator Inefficient - high proton loss produces activation and neutron production.
Chu, Ludewigt, Renner - Rev. Sci. Instrum.
Performance
Range Adjustability Max. field size Beam size in air SAD Dose compliance 4 36 g/cm2 0.1 g/cm2 30 x 30 cm 6 10mm > 2.5 m +/- 3% (2 )
250 MeV
M. D. Anderson Gantry
Clinical Commissioning
Tests for system functionality and safety Treatment Planning System commissioning Collection of data for input to planning system Validation of planning system output Beam calibration Calibration of transmission ionization chambers Measurement of dependence of dose on range modulation, field size, etc. Patient treatment and machine QA
250 MeV
G2_250MeV_RMW88_range25.0 cm_largeSnout@5cm
140MeV_Range 10 cm 120MeV_Range 6.4 cm
120 100 80
100.0
80.0
PDD
160MeV_Range 13 cm
PDD
60.0
60 40 20
40.0
20.0
SOBP 4 cm , Measured 3.9 cm SOBP 6 cm , Measured 5.9 cm SOBP 8 cm , Measured 7.9 cm SOBP 10 cm , Measured 10.0 cm SOBP 12 cm , Measured 12.2 cm SOBP 14 cm , Measured 14.3 cm SOBP 16 cm , Measured 16.6 cm
0
0.0 0 50 100 150 200 250 300 350 Depth (mm)
50
100
150
200
250
300
350
G 2 _ 1 6 0 M e V _ R M W 7 6 _ ra n g e 1 3 .0 c m _ m e d iu m s n o u t@ 5 c m
160 MeV
G2- NZL AT2.2 Modula t ion Te st( A- 3) UF10E120 R a nge 6.9[ c mH2O]
120 MeV
Depth (m m )
1 2 0 1 0 0 8 0 PDD 6 0 4 0 2 0 0 0
110%
100%
90%
80%
70%
60%
50%
40%
SOBP4cm ? 3.8cm T0521R SOBP3cm ? 2.9cm T0522L+M+P 20% SOBP2cm ? 1.9cm T0521T
30%
PTCOG 46
Educational Workshop
De pt h in Wa t e r [ mm H2O]
120.0 100.0
80.0
PDD
60.0 40.0
ICRP tissues
0 500 1000 1500
20.0 0.0
-1000
-500
HU
PTCOG 46 Educational Workshop Al Smith
0
PTCOG 46
50
100
150
200
250
300
350
G2, RMW 250 MeV, d= 23.3 cm, Cross 250 91, Mev, depth = 23.3 cm, Cross Plane ScanPlane
120
120 100
100
Relative Dose
Relative Dose
80 60 40 20
SOBP04 Calc SOBP04 Meas. SOBP10 Calc SOBP10 Meas. SOBP16 Calc SOBP16 Meas.
80 Measured Eclipse 60 40 20
0 -15 -10 -5 0 5 10 15
0 -10
PTCOG 46
-5
10
QA of Prostate Treatment using patient treatment parameters/appliances and EBT film in water phantom.
Treatment plan on CT anatomy converted to dose distribution in water phantom.
PTCOG 46
Educational Workshop
Al Smith
PTCOG 46
Educational Workshop
Measurements in water phantom using EBT film, patient aperture, and range compensator
Cross Field Profile A to P through Isocenter
EBT film m easurement
1
Patient Treatment QA Measurements compared with treatment planning calculations converted to water phantom. Data measured in water phantom using Pin-Point ion chamber. Treatment aperture and range compensator were both inserted.
Eclipse vs. Measured - Crossplane
Eclipse
0.8
0.6
100
0.4
0.2
80
15 35 55
60
Cross Field Profile F to H through isocenter
40
1 0.8
20
0.6
0
0.2
0
10 30 50 70
4 Eclips e
6 Measured
10
12
PTCOG 46
Educational Workshop
Al Smith
PTCOG 46
Educational Workshop
Al Smith
Treatment Planning
Acquisition of imaging data (CT, MRI) Conversion of CT values into stopping power (not electron density) Delineation of regions of interest Selection of proton beam directions Optimization of the plan
Treatment Planning
Passive scattered proton beams Scanned Proton Beams Intensity modulated proton beams Comparative Treatment Plans
Target Volume
Beam
Critical Structure
Body Surface
SOBP Modulation
High-Density Structure
Target Volume
Beam
Critical Structure
Dose [%]
Depth [mm]
120
Dose [%]
Depth [mm]
120
Dose [%]
100 80 60 40 20 0 0
Depth [mm]
Output Factor
D cal iic
cGy MU
CTV
brainstem
CTV
spinal cord
Field Patching
Abutting the distal dose edge of one field to the dose boundary of other field(s). Useful if target is close to critical structures Not necessarily homogeneous dose to the target for each beam (IM!) Range an penumbra uncertainties need to be considered
Field Patching
THROUGH Field A followed by PATCH field B, followed by PATCH field C
B
EXAMPLE 3: Nasopharynx case using 14 fields (plus additional photon fields to the lower neck)
CTV-2
25 Gy 30 Gy 35 Gy 40 Gy 45 Gy 50 Gy 55 Gy 60 Gy 67 Gy
CTV-1
Spinal Cord
Treatment Planning
Passive scattered proton beams Scanned Proton Beams Intensity modulated proton beams Comparative Treatment Plans
Depth Dose
Beam Profile
G. Ciangaru, MDACC
Beam Scanning
Remedies:
Rescanning Beam Gating Real time tumor tracking with markers
to achieve uniform field 2. 1mm spot error due to delivery error or patient motion. 3. Optimum spacing/weighting to achieve sharper penumbra
Pedroni
PTCOG 46
Educational Workshop
Pedroni, PSI, Switzerland Orthogonal IC array measurements performed at different water depths using a computer controlled water column and compared with calculations.
T axis profile
Mirror M D Anderson Cancer Center CCD Scintillating Plate, Mirror and Camera
Scintillating Plate
Beam
WE R 7.82 CM
W= 7.82 cm
Measurement vs.
PTCOG 46
Calculation
Educational Workshop Pedroni, PSI, Switzerland
Treatment Planning
Passive scattered proton beams Scanned Proton Beams Intensity modulated proton beams Comparative Treatment Plans
IMPT Delivery
Spot scanning at PSI (Switzerland)
IMPT Delivery
Built-in magnets for IMPT Two (red) dipole magnets to deflect the beam in X and Y respectively Two (yellow) quadrupole magnets to focus the beam in X and Y respectively
Treatment Planning
Passive scattered proton beams Scanned Proton Beams Intensity modulated proton beams Comparative Treatment Plans
Photon IMRT
Proton IMPT
N N
Critical normal structures (always outlined): brain stem, spinal cord, optic structures parotid glands, cochlea Extra structures were outlined on 3 data sets esophagus, base of tongue, larynx minor salivary, sublingual and submand. glands mastication and suprahyoid muscles
Medulloblastoma
Medulloblastoma
Irradiation of the whole cranium and spinal axis Low Risk 23.4 CGE High Risk 36.0 CGE Spine Include Vertebral Body Cranium Constrain Auditory System < 40 CGE Pituitary / Hypothalamus ~ 45 CGE Posterior Cranial Fossa Boost Total 54 CGE
Protons
Photons
Prostate
(a)
IMRT
(b)
3D CPT
(c)
IMPT
Dose [CGE]
Dose [CGE]
Summary
Proton planning offers more options in terms of beam directions and field shaping than photon planning For specific sites IMRT and protons can be comparable in terms of dose conformality Protons are able to reduce the dose to most critical structures compared to photons Proton therapy is able to reduce the integral dose compared to photons by up to a factor of 3 IMPT is the method of choice
Thanks to Hanne Kooy (MGH, Boston) Alex Trofimov (MGH, Boston) George Chen (MGH, Boston) Martin Bues (MDACC, Houston) George Ciangaru (MDACC, Houston) for providing slides and figures