Shixiong Lin

The 200-MeV proton therapy project at the Paul Scherrer Institute: conceptual design and practical realization.

The new proton therapy facility is being assembled at the Paul Scherrer Institute (PSI). The beam delivered by the PSI sector cyclotron can be split and brought into a new hall where it is degraded from 590 MeV down to an energy in the range of 85-270 MeV. A new beam line following the degrader is used to clean the low-energetic beam in phase space and momentum band. The analyzed beam is then injected into a compact isocentric gantry, where it is applied to the patient using a new dynamic treatment modality, the so-called spot-scanning technique. This technique will permit full three-dimensional conformation of the dose to the target volume to be realized in a routine way without the need for individualized patient hardware like collimators and compensators. By combining the scanning of the focused pencil beam within the beam optics of the gantry and by mounting the patient table eccentrically on the gantry, the diameter of the rotating structure has been reduced to only 4 m. In the article the degrees of freedom available on the gantry to apply the beam to the patient (with two rotations for head treatments) are also discussed. The devices for the positioning of the patient on the gantry (x rays and proton radiography) and outside the treatment room (the patient transporter system and the modified mechanics of the computer tomograph unit) are briefly presented. The status of the facility and first experimental results are introduced for later reference.

Experimental characterization and physical modelling of the dose distribution of scanned proton pencil beams

In this paper we present the pencil beam dose model used for treatment planning at the PSI proton gantry, the only system presently applying proton therapy with a beam scanning technique. The scope of the paper is to give a general overview on the various components of the dose model, on the related measurements and on the practical parametrization of the results. The physical model estimates from first physical principles absolute dose normalized to the number of incident protons. The proton beam flux is measured in practice by plane-parallel ionization chambers (ICs) normalized to protons via Faraday-cup measurements. It is therefore possible to predict and deliver absolute dose directly from this model without other means. The dose predicted in this way agrees very well with the results obtained with ICs calibrated in a cobalt beam. Emphasis is given in this paper to the characterization of nuclear interaction effects, which play a significant role in the model and are the major source of uncertainty in the direct estimation of the absolute dose. Nuclear interactions attenuate the primary proton flux, they modify the shape of the depth-dose curve and produce a faint beam halo of secondary dose around the primary proton pencil beam in water. A very simple beam halo model has been developed and used at PSI to eliminate the systematic dependences of the dose observed as a function of the size of the target volume. We show typical results for the relative (using a CCD system) and absolute (using calibrated ICs) dosimetry, routinely applied for the verification of patient plans. With the dose model including the nuclear beam halo we can predict quite precisely the dose directly from treatment planning without renormalization measurements, independently of the dose, shape and size of the dose fields. This applies also to the complex non-homogeneous dose distributions required for the delivery of range-intensity-modulated proton therapy, a novel therapy technique developed at PSI.

Treatment planning and verification of proton therapy using spot scanning: Initial experiences

Since the end of 1996, we have treated more than 160 patients at PSI using spot-scanned protons. The range of indications treated has been quite wide and includes, in the head region, base-of-skull sarcomas, low-grade gliomas, meningiomas, and para-nasal sinus tumors. In addition, we have treated bone sarcomas in the neck and trunk--mainly in the sacral area--as well as prostate cases and some soft tissue sarcomas. PTV volumes for our treated cases are in the range 20-4500 ml, indicating the flexibility of the spot scanning system for treating lesions of all types and sizes. The number of fields per applied plan ranges from between 1 and 4, with a mean of just under 3 beams per plan, and the number of fluence modulated Bragg peaks delivered per field has ranged from 200 to 45 000. With the current delivery rate of roughly 3000 Bragg peaks per minute, this translates into delivery times per field of between a few seconds to 20-25 min. Bragg peak weight analysis of these spots has shown that over all fields, only about 10% of delivered spots have a weight of more than 10% of the maximum in any given field, indicating that there is some scope for optimizing the number of spots delivered per field. Field specific dosimetry shows that these treatments can be delivered accurately and precisely to within +/-1 mm (1 SD) orthogonal to the field direction and to within 1.5 mm in range. With our current delivery system the mean widths of delivered pencil beams at the Bragg peak is about 8 mm (sigma) for all energies, indicating that this is an area where some improvements can be made. In addition, an analysis of the spot weights and energies of individual Bragg peaks shows a relatively broad spread of low and high weighted Bragg peaks over all energy steps, indicating that there is at best only a limited relationship between pencil beam weighting and depth of penetration. This latter observation may have some consequences when considering strategies for fast re-scanning on second generation scanning gantries.

Intensity modulated proton therapy: A clinical example

In this paper, we report on the clinical application of fully automated three-dimensional intensity modulated proton therapy, as applied to a 34-year-old patient presenting with a thoracic chordoma. Due to the anatomically challenging position of the lesion, a three-field technique was adopted in which fields incident through the lungs and heart, as well as beams directed directly at the spinal cord, could be avoided. A homogeneous target dose and sparing of the spinal cord was achieved through field patching and computer optimization of the 3D fluence of each field. Sensitivity of the resultant plan to delivery and calculational errors was determined through both the assessment of the potential effects of range and patient setup errors, and by the application of Monte Carlo dose calculation methods. Ionization chamber profile measurements and 2D dosimetry using a scintillator/CCD camera arrangement were performed to verify the calculated fields in water. Modeling of a 10% overshoot of proton range showed that the maximum dose to the spinal cord remained unchanged, but setup error analysis showed that dose homogeneity in the target volume could be sensitive to offsets in the AP direction. No significant difference between the MC and analytic dose calculations was found and the measured dosimetry for all fields was accurate to 3% for all measured points. Over the course of the treatment, a setup accuracy of +/-4 mm (2 s.d.) could be achieved, with a mean offset in the AP direction of 0.1 mm. Inhalation/exhalation CT scans indicated that organ motion in the region of the target volume was negligible. We conclude that 3D IMPT plans can be applied clinically and safely without modification to our existing delivery system. However, analysis of the calculated intensity matrices should be performed to assess the practicality, or otherwise, of the plan.

The PSI Gantry 2: a second generation proton scanning gantry

PSI is still the only location in which proton therapy is applied using a dynamic beam scanning technique on a very compact gantry. Recently, this system is also being used for the application of intensity-modulated proton therapy (IMPT). This novel technical development and the success of the proton therapy project altogether have led PSI in Year 2000 to further expand the activities in this field by launching the project PROSCAN. The first step is the installation of a dedicated commercial superconducting cyclotron of a novel type. The second step is the development of a new gantry, Gantry 2. For Gantry 2 we have chosen an iso-centric compact gantry layout. The diameter of the gantry is limited to 7.5 m, less than in other gantry systems (approximately 10-12 m). The space in the treatment room is comfortably large, and the access on a fixed floor is possible any time around the patient table. Through the availability of a faster scanning system, it will be possible to treat the target volume repeatedly in the same session. For this purpose, the dynamic control of the beam intensity at the ion source and the dynamic variation of the beam energy will be used directly for the shaping of the dose.

Initial experience of using an active beam delivery technique at PSI

SummaryAt PSI a new proton therapy facility has been assembled and commissioned. The major features of the facility are the spot scanning technique and the very compact gantry. The operation of the facility was started in 1997 and the feasibility of the spot scanning technique has been demonstrated in practice with patient treatments. In this report we discuss the usual initial difficulties encountered in the commissioning of a new technology, the very positive preliminary experience with the system and the optimistic expectations for the future. The long range goal of this project is to parallel the recent developments regarding inverse planning for photons with a similar advanced technology optimized for a proton beam.

More than 10 years experience of beam monitoring with the Gantry 1 spot scanning proton therapy facility at PSI

PURPOSE The beam monitoring equipments developed for the first PSI spot scanning proton therapy facility, Gantry 1, have been successfully used for more than 10 years. The purpose of this article is to summarize the authors experience in the beam monitoring technique for dynamic proton scanning. METHODS The spot dose delivery and verification use two independent beam monitoring and computer systems. In this article, the detector construction, electronic system, dosimetry, and quality assurance results are described in detail. The beam flux monitor is calibrated with a Faraday cup. The beam position monitoring is realized by measuring the magnetic fields of deflection magnets with Hall probes before applying the spot and by checking the beam position and width with an ionization strip chamber after the spot delivery. RESULTS The results of thimble ionization chamber dosimetry measurements are reproducible (with a mean deviation of less than 1% and a standard deviation of 1%). The resolution in the beam position measurement is of the order of a tenth of a millimeter. The tolerance of the beam position delivery and monitoring during scanning is less than 1.5 mm. CONCLUSIONS The experiences gained with the successful operation of Gantry 1 represent a unique and solid background for the development of a new system, Gantry 2, in order to perform new advanced scanning techniques.

Development of an inorganic scintillating mixture for proton beam verification dosimetry.

The availability at the Paul Scherrer Institute (PSI) of a spot-scanning technique with an isocentric beam delivery system (gantry) allows the realization of intensity-modulated proton therapy (IMPT). The development of 3D dosimetry is an important tool for the verification of IMPT therapy plans based on inhomogeneous 3D conformal dose distributions. For that purpose new dosimeters are being developed. The concept is to use a system of many millimetre sized scintillating volumes distributed in a polyethylene block, which are read on a CCD camera over a bundle of optical fibres and which can be irradiated from any direction orthogonal to the fibre axis. The purpose of this work is to investigate the composition of such small sensitive volumes. A mixture of inorganic phosphors and optical cement allows an optimal coupling between the scintillating volume and the optical fibre. Five different inorganic phosphors, available as powder, have been examined by considering their response along the Bragg curve. In particular, two phosphors have shown interesting behaviours: Gd2O2S:Tb and (Zn, Cd)S:Ag. Both phosphors have a high emission efficiency but contrasting behaviour in the Bragg peak region. The efficiency of Gd2O2S:Tb decreases with increasing stopping power (quenching of luminescence) while that of (Zn, Cd)S:Ag increases. Because of these contrasting behaviours it is possible to prepare a mixture of the two scintillating powders in a certain ratio in order to modulate the height of the measured Bragg peak relative to the entrance value so that it is in agreement with the ionization chamber measurements. We propose to use a mixture for the sensitive volume consisting of the following weight fractions: 48% Gd2O2S:Tb, 12% (Zn, Cd)S:Ag and 40% optical cement.

A NOVEL GANTRY FOR PROTON THERAPY AT THE PAUL SCHERRER INSTITUTE

PSI has gained in the last few years the unique experience of using a proton therapy system based on a beam scanning delivery technique and on a compact gantry. This knowledge is now bringing forth new initiatives. We are continuously producing significant modifications and improvements to the present system, gantry 1. The major new step is however the decision of PSI to purchase a dedicated accelerator for the medical project. In the context of the expansion of the medical project of PSI (project PROSCAN) we have also started to plan the realisation of a second proton gantry, gantry 2. In this lecture we present the main ideas for the novel gantry, which will be based on one hand on the experience with the present technology, but on the other hand should be designed as a system more open to further developments and needs. The established and the future requirements for the beam delivery on the new gantry were routed into the specification list for the dedicated accelerator.

Intensity modulated proton therapy: A first clinical example

By the end of 1999, over 40 patients will have been treated at the Paul Scherrer Institute with protons using the spot scanning technique [1]. For each of these treatments, an optimisation process has been used to calculate the weights of the many thousands of individually applied proton pencil beams which typically make up a single treatment port [2,3]. For the majority of these treatments however, the optimisation procedure has been applied on a field-by-field basis only, and in such a way as to ensure that a homogenous dose is applied across the target volume from each individual field.