1. Hartmut Eickhoff, GSI 1 Developments in Hadrontherapy -the role of Basic Research Institutes H. Eickhoff GSI/Darmstadt

2. Hartmut Eickhoff, GSI 2 Contents 1.General aspects 2.Treatment principles and modalities 3.The GSI Therapy pilot project 4.The HIT project 5.future developments 6.Summary /conclusions

3. Hartmut Eickhoff, GSI 3 Hadrontherapy-Facilities Location Distribution of Hadrontherapy- facilities (p, C-ions)

4. Hartmut Eickhoff, GSI Ref.: Particle Therapy Cooerative Group (PTCOG), 2013 Hadrontherapy-Facilities

5. Hartmut Eickhoff, GSI Total treated patients (1957-2012): about 110.000 (Ref.:PTCOG) Hadrontherapy-Facilities Treated patients Hadrontherapy-Facilities Treated patients

6. Hartmut Eickhoff, GSI 6 - Early facilities (until 1990) had been mostly installed in basic research institutes (e.g. LBL, PSI, Dubna,..) and operated by them - Also for hospital based facilities research institutes play a significant role, e.g.: -accelerator development of FERMILAB for Loma-Linda -Proton-Ion-Medical-Machine-Study group (coordinated by CERN) -Accelerator related support of CERN for CNAO and MEDAUSTRON -Activities of GSI at HIT and CNAO General aspects

7. Hartmut Eickhoff, GSI 7 n Radiotherapy principle n Destruction of a localised cancer via irradiation with ionising radiation n and maintaining of dose in the surrounding healthy tissue low, in tolerable limits n Requirements to radiation source n Adequate dose depth profile of radiation n Geometrical flexibility of radiation direction and beam size Treatment principles and modalities

8. Hartmut Eickhoff, GSI 8 n Sequential treatment n Irradiation with different energies => slicing of the tumor in isoenergetic planes n Intensity variation per plane to get flat dose distribution Treatment principles and modalities Spread-out Braggpeak (SOBP)

9. Hartmut Eickhoff, GSI 9 n Treatment with C-Ions n Better ratio of dose inside/outside tumor volume (larger RBE-factor) n Only small enhancement of beam diameter vs. penetration depth -> better control for deep seated tumors n Online dose-control possible (Positron Emission Tomograph) n Treatment with protons n Large medical data base for proton treatments available Treatment principles and modalities comparison, p, ions

10. Hartmut Eickhoff, GSI 10 Treatment principles and modalities ‚passive‘ treatment modality - constant beam properties (accelerator) - mechanical devices for adequate manipulations of beam properties - fragmentations - not optimal tumour adaption

11. Hartmut Eickhoff, GSI 11 n Intensity-controlled Rasterscan-method Treatment principles and modalities ‚active‘ treatment modality

12. Hartmut Eickhoff, GSI 12 The GSI-Therapy Pilot project 1990-2008 (GSI, DKFZ, FZD) Goals Technical developments of a new treatment modality (the ‚intensity controlled rasterscan method‘) Development of new diagnostic tools (e.g. ‚on- line‘-PET) Patient treatments with carbon ions; evaluation of the medical attributes / properties

13. Hartmut Eickhoff, GSI 13 The GSI-Therapy Pilot project (GSI-facility) The GSI-accelerator facility (with experimental areas)

14. Hartmut Eickhoff, GSI 14 The GSI Therapy pilot project Overview of GSI main-research topics

15. Hartmut Eickhoff, GSI The GSI-Therapy Pilot project additional hardware installations

16. Hartmut Eickhoff, GSI 16 Parameter (GSI-project): 255 energy-steps (88-423 MeV/u) 15 intensity-steps (10 6 -10 8 ions/puls) 7 beamwidths ( 4-10 mm FWHM) The GSI-Therapy Pilot project Rasterscan requirements (1)

17. Hartmut Eickhoff, GSI 17 n Beam-Position feed-back n Intensity-distribution (isoenergy-slice) Feed-back Scanner /MWPC with feedback without feedback Preirradiation has to be considered _> highly inhomogenious distribution The GSI-Therapy Pilot project Rasterscan requirements (2)

18. Hartmut Eickhoff, GSI Challenges (accelerator operation system) : More than 20.000 beam parameter settings have to be provided with high accuracy within second-range Realization-concept: Generation of a set value-library for the accelerator systems for all requested beam parameters, that provides reproducable beam accuracy and can be activated from the treatment operation system The GSI Therapy pilot project Operating aspects

19. Hartmut Eickhoff, GSI 19 The GSI Therapy pilot project beam position accuracy (<1 mm) For all requested beam energies Over longer times

20. Hartmut Eickhoff, GSI Th. Haberer, Heidelberg Ion Therapy Center Scanning-ready pencil beam library (25.000 combinations): 253 energies (1mm range steps) x 7 spot sizes x 15 intensity steps Rasterscan method incl. approved controls and safety Beammonitors follow the scanned beams (v <= 40 m/s) in real-time In-beam Positron Emission Tomography QA system Prototype of the scanning ion gantry Biological interactionmodel (LEM) based on 25 years of radiobiological research Physical beam transportmodel Planningsystem TRiP The GSI Therapy pilot project Key-developments at GSI

21. Hartmut Eickhoff, GSI -The extraordinary requirements for the accelerator system could be realized and successfully demonstrated; -The irradiation by means of C-ions and the rasterscan modality was established; -Reliable patient-treatments and the medical advantages could be successfully demonstrated for more than 450 Patienten (about 10000 fractions); -The path to a dedicated, clinic-based facility with the rasterscan treatment modality was shown. The GSI Therapy pilot project Results

22. Hartmut Eickhoff, GSI 22 The Heidelberg project HIT Requirements (1) General requirements for a hospital based Ion-Therapy Facility with rasterscan-method n High availability -> ‘conservative’, testet technology n Cost effectivness design (investment- and operation costs) n Easy to handle (‘one knob’-machine) Special requirements for the rasterscan modality n large variety of set parameters (energy, focus, intensity) n Fast change of set-parameters (sec-range) n Reliable, tested complete set-parameter library n Safety requests (correct parameters), spill-interruption channels

23. Hartmut Eickhoff, GSI 23 n Low LET (proton, helium) and high LET (carbon and oxygen) treatment n Ion penetration depth of 20 – 300 mm => Ion energy range of 50 – 430 MeV/u n Rasterscan method => FWHM of beam: 4 – 10 mm in both planes => Beam intensity: 1·10 6 – 4·10 10 ions/spill => Extraction time: 1 – 10 s n Treatment of 1000 patients per year in hospital environment with about 15 fractions each => total of 15000 irradiations per year => three treatment areas n One isocentric gantry The Heidelberg project HIT Requirements (2)

24. Hartmut Eickhoff, GSI 24 n Subproject Accelerator n No general contractor found -> subsystems ordered n Tasks of GSI (by contracts): n technical planning (specs of accelerator, treatment-technique) n Technical consultant during tender n Technical supervisor of firms n Assembly of (most of the) components n Training of operation team n Commissioning to ‘treatment beam quality’ The Heidelberg project HIT Role of GSI

25. Hartmut Eickhoff, GSI 25 n Accelerator sections n Two ECR sources n RFQ n IH drift tube linac n Synchrotron n Extraction via RF knock out n Two areas for horizontal treatment n One isocentric Gantry n One quality assurance place 1. patient-treatment: 2. half 2009 The Heidelberg project HIT Facility layout

26. Hartmut Eickhoff, GSI 26 Ion-source-sectionLinac-section The Heidelberg project HIT Realization (1)

27. Hartmut Eickhoff, GSI 27 synchrotron treatment-room The Heidelberg project HIT Realization (2)

28. Hartmut Eickhoff, GSI 28 n First Light ion Gantry n weight: 600 to n 13 m diameter n beam position accuracy at isocenter : 0.5 mm n Integration of hor. and vert. scannermagnets Ref.: MT Aerospace The Heidelberg project HIT Isocentric Gantry

29. Hartmut Eickhoff, GSI 29 The Heidelberg project HIT Isocentric Gantry part of the Gantry structure

30. Hartmut Eickhoff, GSI 30 Future developments Major development goals - Extension of the treatment application (e. g. treatment of ‚moving targets‘ - Optimization of the operation- /treatment time - Reduction investment and operation costs (e.g. reduction of size, application of sc-systems)

31. Hartmut Eickhoff, GSI 31 magnetic scanner system PMMA wedge system suitable motion tracking system dynamic treatment plan staticmoving, non-compensated moving, compensated  real-time, highest precision, passive energy variation Future developments Treatment of moving targets

32. Hartmut Eickhoff, GSI 32 Future developments reduction of treatment time (fast) active energy-variation within a synchrotron cycle at HIMAC (Noda, Erice, 2009)

33. Hartmut Eickhoff, GSI 33 Laser accelaration Small accelerator structures due to large acceleration voltage Problems: - Continuous energy- spectrum -Rel. low energies (few MeV) - repetition rate -Reliability, reproducability -Long term development Creation of ‚monoenergetic beam‘ Future developments Laser acceleration

34. Hartmut Eickhoff, GSI Research Institutes (and existing Hadrontherapy-Facilities)  First steps of new concepts (including feasibility studies) and early stages of developments are often performed by research institutes (e.g. feasibility of rasterscan treatment modality, laser acceleration,..)  Existing hospital based Hadrontherapy-Facilities also push technological developments to optimize the treatment conditions  (e. g. NIRS, beam extraction procedures, …  CNAO, field regulation…,  HIT, intensity feed-back,…) Summary/ conclusion (1)

35. Hartmut Eickhoff, GSI Industries  Industrial firms are very competent to develop technical solutions for optimized cost efficiency  There are several industrial firms to provide technical subsystems for medical accelerators (magnets, RF-systems,..)  There are only a few industrial firms that act as general contractors for treatment facilities (mostly cyclotron based p- facilities). -> Information exchange / collaboration to institutes, and industries in an early project stage desirable Summary / conclusion (2)

36. Hartmut Eickhoff, GSI 36 Thanks for your attention