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Center for Proton Therapy  ::  Paul Scherrer Institut  ::  #1_10/2013

Dear Colleagues

abroad, given the lack of prospective trials added value of this therapy to patients and so-

Lastly, intra- and inter-fractional motion is a

demonstrating clear benefit over other radiation ciety. This was indeed the mission given by the major issue for PBS. Our forth insert deals with Welcome to the first-quarter edition of this PSI treatment options that are currently available.

Highly Specialized Medicine scientific commit-

4Dplanning for proton therapy. Parenthetically,

newsletter. It is of upmost importance that PSI’s

The keen interest in proton therapy is based on tee of the GDK to CPT. This will allow proton a workshop is organized end of November at PSI.

Center for Proton Therapy (CPT) informs radiation

mainly theoretical advantages. Key to these is therapy to more fully reach its potential as a For more information, do not hesitate to visit our

oncologists and medical physicists working in

to reduce radiation-exposure to normal tissue

Switzerland of the clinical program and foreseen and the possible minimization of acute and long

valuable and effective treatment to help fight web site: for Swiss patients. At CPT, protons are

planning-workshop-2013/. Ultimately, careful

technical developments of proton therapy at PSI.

term side effects. As we move toward compara- used currently for a number of cancers, including, science and clinical expertise are keystones for

As such, I have made the decision, and commit-

tive effectiveness research, value-based medi-

ment, to publish info-news several times yearly cine, care paths, and emphasis on cost-effective

but not limited, to cranial meningiomas, pedi- proton beam therapy moving forward. I value the atric cancers and skull-base or sacral tumors.

in order to keep the Radiation Oncology com- care, the value and benefit from protons will In this newsletter we also give some information

expertise in the Swiss Radiation Oncology, be it from the physician’s side or the medical physi-

munity informed.

have to undergo additional scrutiny. Unfortu- on our new treatment unit Gantry 2, which has cist’s side. As in the previous decade, CPT is open

In this edition, two of our inserts deals with

nately, little consensus exists on whether the just been clinically commissioned. The beam to any initiative stemming from this community.

prospective clinical trials of proton therapy for dosimetric advantages translate to better out-

characteristics are a game changer in the proton As Chairman, I can only stress on the significance

sarcoma and breast cancer patients. Importantly, comes, except for pediatric cancers, and skull therapy field, with beam sigma values of 2.2 mm of networking. Should you have any input to give these trials are open to all Swiss-resident cancer

base and sacral tumors. In my opinion, it is for Pencil Beam Scanning (PBS) at high energy.

in our program, do not hesitate to contact one of

patients. Should you have any queries, please

important that current and future users of this This Gantry will enable the CPT team to deliver

my team or myself. Let us bring together this

contact the respective PIs. It is of paramount technology participate in clinical trials, apply PBS to cancer patients in an unmatched conforimportance that patients should be accrued in

this treatment modality cautiously, and conduct mation, with rescanning and repainting capa-

prospective clinical trials in Switzerland and treatment and follow-up that can assess the true

bilities in due time.

technology in full clinical maturity together. Sincerely, Prof. Damien Charles Weber, Head of CPT

Newsletter of the Center for Proton Therapy :: Paul Scherrer Institut :: October 2013 :: # 1

Radio-Oncology News,,Identifier IdentifierNCT01904565 NCT01904565

AA Phase PhaseI/II I/IIstudy studyofofConcurrent ConcurrentHyperthermia Hyperthermiaand andProton ProtonBeam BeamRadiotherapy RadiotherapyininPrimary Primaryand andRecurrent RecurrentUnresectable UnresectableSoft SoftTissue TissueSarcoma Sarcoma

Phase I/II Study of Phase during I/II Study of Concurrent Hyperthermia and Proton Beam 6.4 treatment and up would be 4.4. 55&&6). 6.4 Pre Pretreatment, treatment, during treatment andfollow follow upassessments assessments would berecorded recorded(Appendices (Appendices 6).Postoperative Proton Radiotherapy for Loco-Regional Radiotherapy in Primary and Recurrent Unresectable Soft Tissue Sarcoma (HYPROSAR)

0Treatment Treatmentdesign: design:Proton Protontherapy therapyand andhyperthermia hyperthermia

Breast Cancer Irradiation for Women with Left Side Stage III-A or III-C Breast Cancer with and without unusual anatomy (Study ID: PSI-CPT-02)

Patients PSI for and The study as a single center non-ranPatientswould wouldbe bereceiving receivingproton protonbeam beamtherapy therapyatatCentre Centrefor forProton ProtonTherapy Therapyunit, unit, PSI foris5designed 5toto99weeks weeks and domized phase I/II study evaluating the feasidepending depending on on the the intent intent ofof bility of spot scanning based proton therapy as treatment ororradical treatment–postoperative –preoperative preoperative radical loco-regional radiotherapy moradiotherapy, aaindose ofof 55-60 Gy dality non-metastatic left breast radiotherapy, dose 55-60 Gy cancer. The therapy will be reimbursed bybe the (RBE) ––76Gy(RBE) would (RBE)oror72 72 76Gy(RBE) would behealth insurance. The study will be open for patient accrual delivered aa daily delivered atat daily given given dose dose ofof in December 2013 for all institutions in Switzer1.8Gy oror2.0 1.8Gy(RBE) (RBE)land. 2.0Gy Gy(RBE) (RBE)(Fig.9). (Fig.9). The treatment will be delivered The treatment will be delivered 55 Objectives: days while daysaaweek, week, whileonce onceaaweek; week;the the a) To determine the technical safety, the feasipatient would be treated with patient would be treated with bility and the reproducibility of the daily patient The proposed study is a non-rand- structure and function after preoperahyperthermia at ofspot-scanning hyperthermia at Department Department positioning of postoperative of omized phase I/II study using combined tive combined hyperthermia and proton Radiation based proton Kantonsspital, radiotherapy for complex locohyperthermia and spot scanning based therapy. Radiation Onkologie, Onkologie, Kantonsspital, regional irradiation in women with left-sided proton therapy for unresectable soft Aarau Aarau(KSA). (KSA).On Onthe thedays, days,ininwhich which breast cancer; b) To determine the rates of acute tissue sarcomas as a novel therapeuti- Main Inclusion Criteria: hyperthermia would hyperthermia would be be delivered delivered cal approach. The therapy will be reim- • Men and women over age 18; toxicity. along with radiotherapy, along with radiotherapy, proton proton bursed by the health insurance. The • Histopathologically proven primary at PSI would precede study will be open for patient accrual in or recurrent soft tissue sarcomas radiotherapy Main Inclusion Criteria: radiotherapy at PSI would precede Fig. 9:9:Schema of the hyperthermia and proton therapy Fig. Schema proton therapyand trunk; Women, ≥ 18 and ≤ 65 years old, with stage IIIA November 2013 of forthe all hyperthermia institutions in and (STS) of extremities hyperthermia hyperthermia treatment. treatment. Following Following (T1N2 with internal quadrants tumor, or T2N2 or • Deemed inoperable by the surgeon; Switzerland. proton to KSA any delay. The gap between radiotherapy and protontherapy therapyatatPSI, PSI,the thepatient patientwould wouldtravel travel KSAwithout without radiotherapy and or stage IIIC T3N2 with tumor of any quadrant) • ECOGto performance scale 0 any and 1 delay. The gap between hyperthermia would be kept around 90 to 150 minutes, taking into consideration the time required to travel hyperthermiaObjective: would be kept around 90 to 150 minutes, taking into consideration the time required to travel (T1N3, T2N3, T3N3), invasive ductal or lobular between the 2 centres. carcinoma of the left breast, with no evidence Achievement of complete tumour reFor any information, please refer to CPT, between the 2 centres. moval – both macroscopic and micro- Dr. Ralf Schneider,

of metastatic disease. Women must have under-

scopic (R0 resection) – without func-

gone either breast conserving surgery or modi-

Tel. 056 310 37 89,

7.1 Therapy atatPaul Institute disability andScherrer loss of organ 7.1 Proton Protontional Therapy Paul Scherrer Institute Patients Patientswould wouldbe beconsidered consideredfor for

fied radical mastectomy.

Main Exclusion Criteria: Patients presenting with synchronous multifocal or bilateral invasive or non-invasive breast cancer; or receiving neo-adjuvant chemotherapy; or with positive surgical margins at pathologic evaluation; or with pre-existing severe pulmonary or clinically active cardiac disease. For any further information, please refer to CPT, Dr. Carmen Ares Tel. 056 310 54 12 or Dr. Ulrike Kliebsch Tel. 056 310 55 82

Newsletter of the Center for Proton Therapy :: Paul Scherrer Institut :: October 2013 :: # 1


Physics News: Gantry 2 Getting ready for patient treatments with PSI’s next generation of scanning gantry

PSI Winter School for Protons 2014 25th – 29th of January 2014

energy changes below 100 ms were reached For imaging, the new approach is to use an for typical energy steps.

in-room CT (16B) for patient positioning as

Topics: • Basics in radiation physics, radiation

For energy modulation, a degrader system opposed to the out-of-room positioning of

biology of particles and Proton RBE

right after the cyclotron is used which Gantry 1. This commercial CT-on-rail is in

• Accelerator and beam line technology

The technical commissioning of the second substitutes the range shifter right in front reach of the patient table and is comple-

• Active beam scanning

gantry at PSI was finished towards the end of the patient. The advantage is a small mented by a Beam’s-Eye-View (BEV) X-ray

• Clinical outcomes of proton radiation

of last year. The main work during this year

spot size of 5 mm sigma for low energy system installed on the gantry. Gantry 2

was the clinical commissioning, establish-

(70 MeV) down to 2.2 mm sigma for the fulfills all requirements for discrete spot

• OAR Constraints and toxicities

ing the quality assurance program and the

high energy (230 MeV.)

• Iintegral dose, neutron irradiation, sec-

communication with the responsible author-

Optimal access to patient in every treatment few weeks, regular dummy treatments and

scanning and is technically ready. Since a

ities for permission. This Gantry 2 is based configuration is achieved by the iso-centric machine specific measurements are peron 17 year patient operation with the first layout of Gantry 2 and restricting the gantry formed for practice and staff training in gantry and includes many improvements.

rotation to 210°. Despite this limitation, 4 pi

order to start successfully with patient treat-


ond malignancies • Treatment planning for scanned proton beams, IMPT • Future of proton therapy

The two dimensional sweeper magnets treatments are still possible in combination ments. This seminar is almost fully booked.

offer now a quicker beam scanning and fast with the flexible treatment table.

Further information can be found under

Gantry 2 treatment room with sliding in-room CT and extracted beam’s-eye-view imager.

Newsletter of the Center for Proton Therapy :: Paul Scherrer Institut :: October 2013 :: # 1

4D treatment planning workshop In 2009, a workshop on topics related to the About 20 people from 4 institutes (GSI, DKFZ,

ipants agreed on capping the attendance for the [1] Knopf et al 2010 “Special report: workshop

treatment of moving targets was organized by University of Tübingen and PSI) attended this future format of the meeting. To achieve this aim,

on 4D-treatment planning in actively

the research team of the proton therapy center initial workshop. A special report was published the number attendants per institute will be

scanned particle therapy-recommendations,

at PSI. The workshop focused on technical as-

as a result of the discussions in the plenary limited to two people. To stimulate discussions

technical challenges, and future research

pects of 4D treatment planning and delivery in sessions [1]. It summarizes recommendations on confidential research projects, and to enable

directions” Medical physics 37, 4608-4614

the context of intrafractional motion. The topics for the treatment of mobile targets with active-

an open controversy about failures, represent-

[2] Bert et al 2013 “Advances in 4D treatment

ly-scanned particle beams and contained a list atives of commercial vendors will be excluded.

planning for scanned particle beam therapy

• methods to take into account intra-fractional, of requirements to elaborate on and apply these An annual report will be established to summa-

– report of dedicated workshops” special


non-rigid anatomical changes and resulting guidelines. The paper was awarded with the rize all innovations reported in the meeting. For variations in densities through the use of SGSMP/Varian recognition award 2010. Follow-

last year’s workshop in Erlangen this report was

deformable image registration and dose cal-

ing this initial success, this first workshop turned published in a special issue of TCRT journal [2]

culation techniques, together with the inher-

into an annual series of workshops. In 2010, the

and reported recent progress in the field of

ent uncertainties of these approaches;

2nd edition was carried out at GSI with about 30

mobile tumor treatment with scanned particle

• advanced treatment planning approaches

participants; the


edition 2011 at the CNAO

including 4D optimization for proton and facility, Pavia, Italy attracted more than 40 par-

beams. The 5th workshop will take place on the 28th–29th

ticipants. The 4th edition of the workshop last of November 2013 at PSI.

heavy ion therapy; • treatment simulations and experimental val-

year was held at the University of Erlan-

Further information can be found under

idation of scanning in the presence of motion gen-Nuremberg, Germany and included around quantify the effects for different delivery 60 participants from 15–20 institutions, with planning-workshop-2013/ strategies;

also representatives of commercial vendors

• latest developments in beam tracking, gating, present. To restore the original aim of the work-

This year, the topics of the workshop have been

shop, i.e., an informal platform to discuss cur-

extended to include treatment of moving targets

rent approaches, challenges and future research

with conventional radiotherapy. Speakers from

Mo3on quan3fica3on   using   4DCT   and  4planning, DMRI   the particdirections in 4D treatment

10 institutes (PSI, University Hospital Heidelberg,

and rescanning.



4D planning using different motion mitigation strategies.

NKI, Aarhus University Hospital, Hokkaido University, CNAO, ICR, HIT, MGH, GSI) will give talks

no mi&ga&on  





in 5 different sessions focusing on clinical aspects of the treatment of mobile targets, 4D dosimetry, motion monitoring and modeling, 4D treatment planning and 4D optimization. We are looking forward to an informal, lively and fruitful 4D workshop!

4D planning  using  different  mo3on  mi3ga3on  strategies  

issue ICTR

Imprint Editor Dr. Ulrike Kliebsch Chairman Prof. Damien C. Weber Chief Medical Physicist Prof. Tony Lomax Design and Layout Monika Blétry

Contact Center for Proton Therapy CH-5232 Villigen PSI Tel. +41 56 310 35 24 Fax +41 56 310 35 15 Villigen PSI, October 2013

PSI Protontherapy Newsletter Nr. 1 (10/2013)