treatment efficiency and optimization of patient care with ......tps: raystation 7.0; r&v:...
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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
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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
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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
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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 1st, 2014
First Patient Treated Sept. 9th, 2014
CBCT Installed Sept. 24th, 2015
CBCT LFOV Upgraded Jun. 30th , 2017
More than 500 patients treated Sept. 20th , 2018
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To Date Proton Treatment StatisticsMore Then 500 Patients Treated
Re-treat – 8%
GU-Prostate43%
Brain15%
H/N10%
Lung9% GI
7%
GU-GYN5%
Breast/CW4%
Lymphoma2%
Spine1%
Sacroma2%
GU-other1%Other
6%
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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 20x24cm2
– Remote operation of accessories
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ProteusOne Technology
Beam Energy 70-230 MeV
Range in Patient 0.1 - 32 g/cm2
Dose Rate 2 Gy/min (10x10x10 cm3)
Beam Sigma 3.5 & 4.7 mm at Range 32 & 15 g/cm2
6 Degree Robotic Couch
Energy Layer Switching Time ~0.9 sec
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Compact (Open) Gantry Design
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220 Degree Compact Gantry
180 Deg
90 Deg
0 Deg-35 Deg
-5 Deg
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6 Degree Robotic Couch
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ProteueOne Imaging SystemFixed Imaging System at Isocenter
Stereo ObliqueNozzle Imager
(CBCT&Ortho)
X-Ray Source Flat Panel
Stereo X-ray
Flat Panels
X-Ray Tube
Under Ground
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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 cm2 50.8 x 51.8 cm2
Panel Sensitive Area at
ISO22 x 20 cm2 28 x 28 cm2
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 cm2
27 x 27 cm2
0.25 mm
6 deg/s
5.5 fr/s
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ProteusOne Imaging System – CBCT Dose
13
Scan
ProtocolFOV
(Field of View)
Acquisition
Angle
Gantry
Speed (°/s)
Scan Parameters CTDIweighted
(mGy)kVp mA ms
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
AI 2.0 (Large FOV)
Thorax Large434
(dual half scan)6 110 50 12 10.6
Pelvis Large434
(dual half scan)6 120 64 12 15.7
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WK Imaging Protocol
Treatment SiteImage Modality Daily 2nd Field
VerificationStereo Oblique CBCT
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
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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
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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
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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
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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
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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
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Four Common Clinical Cases to Demonstrate the
Efficient Treatment Workflow with ProteusOne
Simple – Prostate
Intermediate – Brain/Head&Neck
Advance – Lung
Challenge – Breast/Chest Wall
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ProstateStandard Opposed Lateral Beams
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
Level of Difficulty for setup and treatment Simple
Robotic Couch Yes
3D CBCT Weekly, SFOV (2 mins)
Stereo X-ray Yes, avg. 2 sets per field (1 min)
Remote Operation of Accessories Yes
# of time re-enter treatment room during treatment 0
Overall treatment time, including patient set up, imaging
guidance and electronic charting
12-15 minutes
Stereo Oblique
CBCT
CBCT
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Brain2-3 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
Level of Difficulty for setup and treatment Intermediate
Open Gantry Advantage Yes
Robotic Couch Utilization Yes
3D CBCT Daily, SFOV (2 mins)
Stereo X-rays Yes, each couch movement
Remote Operation of Accessories 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
Stereo CBCT
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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
Level of Difficulty for setup and treatment Intermediate
Open Gantry Advantage Yes
Robotic Couch Utilization Yes
3D CBCT Daily, SFOV (2 mins)
Stereo X-rays Yes, each couch movement
Remote Operation of Accessories 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
TPS Planning CBCT
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LungEither 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 Advance
Open Gantry Advantage Yes
Robotic Couch Utilization Yes
3D CBCT Daily (either SFOV, 2 mins or
LFOV 3 mins)
Stereo X-rays After each couch movement
Remote Operation of Accessories 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
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Lung
CBCT
re-CT and re-Plan
Planning CT
Daily CBCT triggers for
re-CT and re-plan due to
tumor volume and other
structure changes
during treatment
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Left Chest Wall and Supra-Clavicular
Using CBCT and Stereo Oblique
Imaging Systems
A CASE STUDY
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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
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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°
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Field Matching Using Gradient
Optimization Technique
• Overlapping fields by creating
a gradient penumbra from
RayStation TPS
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Site-setup in Mosaiq
This is
CRITICAL!!
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Manually enter ISO #1
information into reference CT
image in Mosaiq Site Setup
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Daily Treatment Workflow
Breast/Chest Wall
Align patient
• lasers
1st field
• CBCT (ISO #1)
• Treat
2nd field
• Auto move to ISO #2
• Oblique verification
• Treat
3rd field
• Auto move to ISO #3
• Oblique verification
• Treat
30 – 40 minutesPt step in Pt step out
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1) CBCT using ISO #1
in Site Setup
2) Check Mosaiq 1st field
definition and Treatment
Daily Treatment Workflow
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4) Confirm 2nd field position (ISO
#2) using stereo oblique images
and treat
2nd Mosaiq
field definition
3) Use auto couch
movement to ISO #2
with pre-determined
relative couch position
from TPS
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6) Confirm the final field
position (3rd field) and Treat
3rd Mosaiq
field definition
5) Auto couch movement
again to ISO #3
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Left Chest Wall and Supra-Clavicular
Overall treatment procedure can be completed
in 30-40 minutes.
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Post Treatment Field Verification
Relative treatment position for each field can be
verified in Mosaiq
Site Setup ISO #1 ISO #2 ISO #3
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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 Challenge
Open Gantry Advantage Yes
Robotic Couch Utilization Yes
3D CBCT Daily, either SFOV or LFOV
Stereo X-rays When move to next isocenter
Remote Operation of Accessories 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
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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)
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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
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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.