wavelength february 2011 volume 14 no.1
TRANSCRIPT
VOL. 14 NO.1 | FEBRUARY 2011
4The “all-Elekta” route to exceptional cancer care
Dutch partner improves stereotactic capabilities
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Opera star Zheng Cao battles brain mets
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Advanced cancer care streams into India
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NEWS AND ADVANCES IN THE MANAGEMENTAND TREATMENT OF SERIOUS DISEASE
Global cancer rates could increase 50% by 2020
Treatments aim to cure, prolong life and improve quality of life
Cancer emerges as major health problem in developing countries
Clear evidence that 1/3 of cancers can be cured
CONTENTSofTable
Dear friends,
Since its inception, Elekta has worked diligently to provide products and services that bring the highest value to you and your patients. Our vision is simple: we want to provide the best technology and service in the industry, with an ongoing commitment to open systems that you need and expect.
Elekta has continuously strengthened its marketplace reputation by not only developing world-class solutions, but also by acquiring companies with complementary best-in-class technology. These were careful, strategic additions to the Elekta family – based not only on how their offerings enhanced our portfolio, but also on how you, their customers at the time, perceived their respective brands.
In 2011 and beyond, Elekta will begin to consolidate these trusted brands under a single, unified Elekta brand. These efforts will help you identify the myriad cancer care products and solutions on which you’ve come to rely – including but not limited to MOSAIQ®, Monaco®, HexaPOD™ evo and Clarity® – with Elekta, a cohesive company with a solid, instantly recogniz- able identity.
Under the single Elekta brand, we will continue to focus on providing you with the best seamless, integrated, and open-system solutions. Furthermore, you can rely on Elekta to be your single point of contact to support all your clinical solutions acquired under our banner. The Elekta brand, and all it represents, is your gateway to exceptional, integrated cancer management solutions and customer service.
We look forward to continuing to serve you and providing the award-winning products and services that have become synonymous with the Elekta name.
The "all-Elekta” route to exceptional cancer care
Elekta events in your region
Introducing MOSAIQ® Data Director
Right at home in a proton clinic
Dutch partner expands Elekta linac collection
Elekta – Around the world
Zheng Cao, performance of her life
Advanced cancer care streams into India
Elekta – Case in point
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Tomas Puusepp President & CEO
ELEKTA
Published by Elekta AB, www.elekta.com
All letters, comments or suggestions for future articles, requests for reprints and permissions are welcome.Contact: Michelle Lee, Director, Global Public Relations and Brand Management, Elekta Tel: +1 770-670-2447 email: [email protected] Time zone: EST: Eastern Standard © 2011 Elekta AB. All Rights Reserved
Vol. 14 | No. 1FEBRUARY 2011Human Care Makes the Future Possible
The Elekta vision is simple: we want to
provide the best technology and service in
the industry, with an ongoing commitment
to open systems that you need and expect.
Experience the Elekta Difference.
Statistics on cover from World Health Organization, 2009, www.who.int
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The Elekta vision is simple: we want to
provide the best technology and service in
the industry, with an ongoing commitment
to open systems that you need and expect.
Experience the Elekta Difference.
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Instituto do Cancer do Estado de Sao Paulo
Wladimir Nadalin, M.D.
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Instituto do Cancer do Estado de Sao Paulo’s radiation oncology team
A comprehensive solutionAlthough two other major providers competed to be ICESP’s principal radiation therapy provider, only Elekta offered a comprehensive solution that included advanced treatment systems and techniques, an OIS that could integrate all systems, a field engineer based in the hospital and the opportunity to be Elekta’s South American referral and product training and development center, according to Dr. Nadalin.
“With MOSAIQ, I knew I would be able to integrate the treatment systems in the Hospital das Clinicas, so I could develop a treatment plan there or in ICESP and have it available system-wide,” he says. “After the acquisition, we were able to send two physicians to Elekta customers, University Medical Center Utrecht and University of Mannheim, where they learned not only about IMRT, IGRT and Elekta VMAT, but they also obtained a better understanding of how to use MOSAIQ.”
The Utrecht and Mannheim training was only the first component of a multi-center collaboration that Elekta facilitated on behalf of ICESP. Elekta created a formal Scientific Proposal that will enable ICESP to exchange knowledge with these and other centers on clinical protocols, training and the publication of scientific papers.
“In Brazil, we have some types of cancer that are not commonly encountered in Europe, which our European counterparts find fascinating,” Dr. Nadalin says. “Our contribution to multi-center clinical trials will be mutually beneficial.”
As ICESP ramps up to its full radiation oncology capabilities, Dr. Nadalin is confident that Elekta will provide timely service support for its new equipment.
“Francisco Mendes is our Elekta
field service engineer in Sao Paulo, and he has assisted us from the start in getting the systems ready and addressing any issues we’ve had along the way,” he says. “This was very important to us during the equipment evaluation. We can’t wait two weeks for an engineer to come to ICESP – we have too many patients waiting.”
The top indications at ICESP and Sao Paulo in general are breast and prostate cancer. To address the volume of patients needing treatment for prostate cancer, in particular, Dr. Nadalin is eagerly anticipating the start of Elekta VMAT on ICESP’s Elekta Synergy systems in early 2011.
“I need to be able to treat fast, so Elekta VMAT will be useful,” he says. “If I treat 100 patients with prostate cancer, I will still have 200 waiting for treatment. The reason is that in Brazil, there is still a lack of cancer management resources. Patients are coming not only from the state of Sao Paulo, but also from the entire country of 200 million people.”
Gearing up for 2011
Currently, ICESP is using its Elekta systems conservatively, performing 3D conformal IMRT for all cases, however clinicians have begun preparing to implement IGRT in early 2011. Also planned for 2011 are services for total body, total skin irradiation and HDR brachytherapy.
Dr. Nadalin predicts that ICESP’s ramp up in 2011 will transform the hospital into a magnet for other Brazilian centers acquiring Elekta equipment to take advantage of training opportunities. “This is very good, because it will give us another site with which to exchange information,” he adds.
Dr. Nadalin’s vision for ICESP is for the center to become a major referral center in the continent.
“In Brazil, we have some types of cancer that are not commonly encountered in Europe, which our European counterparts find fascinating,” Dr. Nadalin says. “Our contribution to multi-center clinical trials will be mutually beneficial.”
The "all-Elekta" route to exceptional cancer care
Two new centers in South and North America are the most recent examples of clinical customers that weighed their equipment options and concluded that Elekta could satisfy virtually all their cancer management needs – from treatment planning and oncology information management to treatment delivery systems. Dr. Wladimir Nadalin of Instituto do Cancer do Estado de Sao Paulo (ICESP, Sao Paulo, Brazil) and Dr. Rex Hoffman of The Roy and Patricia Disney Family Cancer Center (Burbank, CA, USA) shared their perspectives on their comprehensive Elekta solutions.
ICESP emerging as cancer treatment powerhouse in southwestern hemisphere.With the 2009 acquisition of six new Elekta treatment machines, 30 stations networked to the MOSAIQ® Oncology Information System (OIS) and 19 treatment planning systems, the Instituto do Cancer do Estado de Sao Paulo (ICESP) is reinforcing its role as the largest cancer center for adult patients in Latin America. ICESP opened in May 2008, and began radiation therapy treatments in June 2010. By December 2010, it had commissioned four of the five Elekta Synergy® systems it purchased and is scheduled to bring an Elekta Axesse™ system for stereotactic treatments – Latin America’s first – on line by February 2011.
“These four linear accelerators treat about 50 patients each day, and when Elekta Axesse is commissioned, we will treat up to 300 patients per day between these five systems,” says Wladimir Nadalin, M.D., head of ICESP’s radiation therapy department.
“We want to be the first referral in South America,” he says. “We will most likely have equipment and techniques that won’t be found in neighboring countries, so patients there will come here for treatment. In that sense, we will be like M. D. Anderson Cancer Center in the United States or The Royal Marsden, University of Mannheim and University Medical Centre Utrecht in Europe.”
The Roy and Patricia Disney Cancer Center at Providence Saint Joseph
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Providence Saint Joseph Medical Center’s utilization of MOSAIQ OIS also has migrated successfully to the Disney Family Cancer Center. All of the staff in Radiation Oncology and Integrative Medicine currently use MOSAIQ 2.0. In the next six to 12 months, Medical Oncology and other sub-specialties within the Disney Cancer Center will be implementing MOSAIQ into their practices.
“From a radiation oncologist’s viewpoint, MOSAIQ is very user-friendly. It streamlines communication between different aspects of the department,” he says. “We have become more efficient because of MOSAIQ – and it has some nice checkpoints in place to avoid any potential issues related to process.”
A multi-faceted approach to improve the patient experienceIn addition to having the best treatment equipment and software available for its patients, the center also prioritized investments to distinguish the patient experience. One important aspect of this effort was the unique adaptation of Philips Ambient Experience – typically implemented in diagnostic imaging settings – for the radiation oncology environment.
Ambient Experience technology gives patients the ability to create a personalized, calming environment as they undergo the rigors of cancer treatment.
“There are two components of Ambient Experience, a radio-frequency identification card [RFID] that patients are given when they start a treatment course and the ability to modify treatment room ambience,” Dr. Hoffman says. “As the patient walks through different parts of the department, the RFID card activates different functions based on patient pre-selects, such as music preference, types of lighting and temperature. It also benefits us by showing us where the patient is in the facility and queuing it up on MOSAIQ. The other part of Ambient Experience is empowering patients to choose from 10 different treatment room scenes depicting landscapes from around the world.”
treatment – all overseen by the same company has helped greatly to coordinate treatment delivery for our patients,” explains Rex Hoffman, M.D., Medical Director of Radiation Oncology. During the planning process, we thoroughly evaluated technology from all of the major radiation therapy vendors and concluded that “Elekta was the company to go with,” he says.
Providing clinical value with the Elekta solution Disney clinicians currently use Elekta Infinity to treat eight head and neck cancer patients per day with Elekta VMAT, using Monaco to plan VMAT cases.
“We try to use Elekta VMAT for most head-and-neck patients if we can,” he says. “Frequently, we
Coordinated treatment delivery with all-Elekta solution
The Roy and Patricia Disney Cancer Center at Providence Saint Joseph Medical Center provides state-of-the-art oncology treatment in a 4-floor, 55,000 sq. ft. integrated facility in Burbank, California. Equipped with the full portfolio of Elekta equipment and software, including two Elekta Infinity™ systems with VMAT, one Elekta Axesse system, Monaco® and XiO® treatment planning systems and MOSAIQ, the Disney Cancer Center is experiencing a high level of efficiency and treating patients effectively, quickly and safely.
“Having the three most essential components of the treatment process – planning, EMR and
generate both IMRT and VMAT plans to see if we can get an advantage from VMAT. The whole benefit is increasing throughput and getting patients on and off the table more quickly without sacrificing accuracy. It’s working quite nicely.”
Prior to opening last February, Disney also elected to substitute Axesse for a TomoTherapy® unit in order to have a machine dedicated to stereotaxis for body cases, according to Dr. Hoffman.
The volume of Elekta Axesse stereotactic cases is, on average, two to five patients per week, but this is likely to increase in coming months, Dr. Hoffman predicts. The case mix is divided between brain, lung and liver tumors, with spine tumors on the horizon.
The "all-Elekta" route to exceptional cancer care
from left to right: Rex Hoffman MD , Medical Director, Radiation Oncology; Marc Botnick MD, Radiation Oncologist; Lauren VanderSpek MD, Radiation Oncologist; Mona Sanghani MD, Radiation Oncologist
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MOSAIQ UK & IRE Users Meeting Birmingham, UK March 29-20, 2011
International Symposium on Stereotactic Radiosurgery with Gamma Knife Shaio Clinic Foundation Bogotá, Colombia April 15-16, 2011
Monaco / Monaco VMAT workshop London, UK May 6, 2011
ESTRO Elekta Users Meeting London, UK May 7, 2011
11th Biennial ESTRO Meeting - ESTRO Anniversary, EIOP, GEC-ESTRO-ISIORT London, UK May 8-12, 2011
2011 Elekta Cancer Registry Users Meeting Orlando, Florida, US May 15, 2011
2011 PowerPath Users Meeting Clement Intercontinental HotelMonterey, California, United States May 18-20, 2011
2011 Leksell Gamma Knife Administrators Meeting of North America LaPlaya Beach Resort Naples, Florida, US June 6-9, 2011
5th European Users' Conference Warnemünde, Germany June 16-19, 2011
Elekta Australasian Users Meeting Shangri La Hotel Sydney, Australia September 9-11, 2011
20th North America Users Meeting Radiation and Medical OncologyMiami, Florida, US October 1, 2011
31st Annual Conference of Association of Medical Physicists of India (AMPICON 2011) Vellore, India November, 2011
24th Annual Meeting of Japan Japanese Society for Therapeutic Radiology and Oncology (JASTRO) Tokyo, Japan November 18, 2011
* events sponsored by Elekta and for customers only
Advances in cancer treatment techniques have improved the lives of millions of patients worldwide. The consequence of enhanced oncology methods has been an explosion in the volume of images and data for each patient’s case. Now more than ever, oncology professionals need a way to organize and direct the flow of vital images and data throughout the patient’s treatment journey. To address the requirements of the modern oncology workflow, Elekta has introduced MOSAIQ® Data Director, the next evolutionary step in oncology information management.
“A traditional clinical departmental PACS can archive and move images well, but it is under-equipped to meet the diverse demands of the oncology environment,” says David Nikolai, Business Line Manager, Oncology Information Systems at Elekta. “MOSAIQ Data Director was explicitly developed to handle all DICOM and non-DICOM images and data, particularly DICOM RT objects, and enables the user to orchestrate all data and image traffic through tight integration with the patient chart.”
Fully integrated with Elekta’s mainstream MOSAIQ® Oncology Information System, MOSAIQ Data Director transforms the patient chart into the centralized control point to
manage, view, move and archive patient images and data. Tight integration with the patient chart also eliminates the need to access stand-alone applications and separate log-ins or patient searches.
Web-based viewer ideal for oncologyUsers can also harness the new Web-based viewer to explore data and archived images or objects online using powerful 3D function-ality. The new Web-based DICOM RT 3D viewer enables centers to avoid installing a viewer application in discrete stations. Any workstation with Internet access can interface with the MOSAIQ Data Director viewer, increasing convenience and efficiency.
The viewer’s powerful 3D functionality allows physicians to manipulate all applicable data sets required for the patient’s treatment.
“Clinicians want to see dose distributions, beam trajectories and structure sets in a three-dimensional view – and to be able to rotate around that view to see how the dose is delivered,” says Michele Verst, Chief Physicist at Hux Cancer Center at Union Hospital (Terre Haute, Ind.), which tested much of the functionality of MOSAIQ Data Director.
“The functionality is specific to the RT domain,” says Terry Michaelson, Director of Technical Systems at Princess Margaret Hospital (Toronto, Canada), one of Elekta’s technology development partners. “And, all of this information – the discrete DICOM RT elements, in addition to DICOM and non-DICOM images and other files – can be viewed and analyzed in the context of the patient’s treatment from a single point of access. This is very compelling functionality from both a clinical and a research perspective.”
Elekta introduces MOSAIQ® Data Director, image and data management for oncology
Designation as an Elekta technology show siteLess than a year old, Disney is already thriving with its all-Elekta solution, Dr. Hoffman says.
The opportunity to witness multiple Elekta solutions operating in a single clinical environment is attracting prospective and existing customers to Disney, which, as an Elekta show site, hosts routine visits from the United States and international clinics.
Most often clinicians are interested in visiting the facility to better understand what VMAT can do, Dr. Hoffman explains. “They also are interested in the integration of XiO and Monaco with the treatment systems and seeing how the center has experienced workflow benefits.
In February 2011, we were excited about an XVI update with Symmetry and Intuity we received this month, which will allow us to perform four-dimensional CT imaging. This technology will enables us to reduce – to a greater degree than we have been able to – the area in one’s body exposed to radiation. Accordingly, this should translate into less treatment-related side effects.
“Since we opened, I have been very pleased with Elekta regarding what their equipment can offer – in treatment quality and in terms of response time if there is an issue and we need their help,” he continues. “It certainly has been a very positive experience. I feel comfortable recommending Elekta solutions.”
Rex Hoffman, M. D., Medical Director of Radiation Oncology
“Elekta was the company to go with.”
Directing image, data trafficMOSAIQ Data Director can serve as the central repository and director of the department’s data and enables users to locate and move images and data from other PACS, with its Query Spanning and Move Forwarding features.
“Move Forwarding will allow us to move images from one entity to another,” Verst says. “For instance, we can move a CT image from the radiology PACS and push it directly to the treatment planning system, bypassing Data Director altogether. Once the TPS is done with the CT image, it can come to Data Director with the plan and all of the RT structure objects attached to it. It’s smart data management and we’re excited to get it.”
MOSAIQ Data Director viewer showing 3D surface rendering with beams
Slice View can display beams, structures, dose and other plan data
Don’t miss out on Elekta events* in your region!
UFPTI at a glance
• Established: 2006
• Square footage: 98,000 sq. ft.
• Staff: 8 physicians, 7 physicists, 8 dosimetrists, 25 therapists
• Services: proton therapy, photon therapy, infusion and anesthesia, psychosocial, dietary
• Daily proton treatments: 122
• Daily photon treatments: 45
• Imaging equipment: PET-CT, large bore CT, 0.23 T open MRI
• Proton therapy: IBA Proteus 235 Proton Therapy System (3 gantries), 230 MeV cyclotron
• Photon therapy: two Elekta Synergy systems, one equipped for couch-mounted Leksell Stereotactic System®
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Elekta OIS, respiratory management and immobilization solutions for radiation
Oncology a great fit at University of Florida Proton Therapy Institute (UFPTI).
account for workflow changes,” Dr. Li observes. “We can specify privileges based on staff functions to a very detailed level, which has proven to be extremely useful to us and prevents errors.”
Options for respiratory, patient motion management Because organ motion is more critical in proton therapy versus conventional radiotherapy from a dosimetry standpoint, UFPTI employs three different options: Active Breathing Coordinator™, BodyFIX® or free-breathing. Determining which alternative to use is patient-specific, he says.
“For every proton therapy patient, lung cancer patient or Hodgkin’s patient treated with protons, we always evaluate organ motion, quantify the motion magnitude and determine which strategy gives us the smallest organ motion magnitude or reproducibility of respiration accuracy,” Dr. Li
explains. “Typically, we will use Active Breathing Coordinator when we can predict at least a 30 percent improvement in the magnitude of motion. So, while it is used infrequently for proton cases, when we need to use it Active Breathing Coordinator is very effective.”
BodyFIX, used in concert with BlueBAG™, is Elekta’s dual vacuum immobilization system and is also used in select proton therapy cases (e.g., pancreatic cancer) to provide non-invasive, accurate and reproducible patient positioning and breathing motion reduction, he adds. It finds it greatest use for UFPTI’s lung stereotactic body radiation therapy cases.
For proton therapy cases that require firm yet gentle head fixation, UFPTI clinicians use HeadFIX™, Elekta’s vacuum-activated head frame system. HeadFIX uses a mouthpiece with the patient’s upper palate impression and solid vacuum bonding with the hard palate.
“We use HeadFIX on all patients with an optical sheath meningioma and for some patients with brain tumors,” Dr. Li notes.
Right at home in a proton clinic
While they are both radiation therapy techniques, proton therapy and traditional (photon) radiotherapy differ significantly in hardware requirements, physics and especially workflow. Fortunately, for centers such as University of Florida Proton Therapy Institute, proton clinics needn’t seek out dedicated proton therapy solutions for their treatment services. Since its inception in 2006, UFPTI has relied on Elekta’s MOSAIQ® Oncology Information System and respiratory management and immobilization solutions in a practice that also includes photon-based radiation therapy using Elekta linear accelerators.
UFPTI’s parent organization, the University of Florida (UF, Shands Jacksonville) trusted on the success it had achieved dating back to 1997 and currently has two Elekta Synergy® systems currently in use at UFPTI.
“It was a natural solution for us to continue to use MOSAIQ for proton
therapy as well as for combined photon/proton therapy,” says Zuofeng Li, D.Sc., UFPTI Director of Physics. “In 2006, we worked with Elekta to interface to the IBA proton system and that work continues in terms of product improvement.”
MOSAIQ directs informationAmong the most critical MOSAIQ features for a proton-photon center is the capability to enable access to patient records from a single database, particularly when patients receive both therapy forms.
“We have head and neck protocols that specify IMRT followed by proton boost, prostate pelvic lymph node treatments followed by proton boost to the prostate, and several other joint-therapy protocols, including those for Hodgkin’s disease, pancreatic cancer, sarcomas, chordomas and chondrosarcomas,” Dr. Li says. “That is the number one case in which a single database is indispensable. We need to have a
complete record of all the patient’s treatments regardless of the treatment modality, where MOSAIQ allows us to be certain of all the doses and provides us with set up notes for review on the same database. I can’t imagine treatment using different modalities and not having the patient record consolidated.”
The proton therapy workflow often is unpredictable due to uncertainty when custom-fabricated patient accessories, such as apertures and compensators, will become available for a given patient, in addition to the need to barcode scan these components and immobilization devices. MOSAIQ has provided considerable flexibility in its record-and-verify functionality to accommodate UFPTI’s proton workflow, he adds.
“MOSAIQ allows us to schedule all treatments in the treatment calendar in an unambiguous way, and in a way that is easily adjustable to
‘In proton therapy, we don’t have a way to put everything together in one shot, so the distributed approval process that MOSAIQ provides is very helpful.”
Zuofeng Li, D.Sc., UFPTI Director of PhysicsUniversity of Florida Proton Therapy Institute (UFPTI)
Elekta Axesse serves as the centerpiece of the hospital’s new stereotactic cancer treatment unit, and is the 10th Elekta linear accelerator currently operating at the site.
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“Precision in radiation therapy comes not only from image guidance, but also from patient comfort,” Dr. van Herk observes.
NKI-AVL’s Elekta-only collection of linear accelerators speaks both to the center’s trust in Elekta radiation therapy technology and to the strength of their longtime research and development relationship.
“I am extremely pleased about continuing our collaboration with Elekta – we make a very good team,” he says. “Every time there is a new release there is a bit of stress and we think things should go faster, but in the end we get there. The features we are jointly adding to the market are quite unique, and that is a good thing for both of us and for radio- therapy in the world.”
Flying Dutchman suite honors Elekta innovatorThe death in 2008 of Gerry van Oortmarssen, the Dutch founder and nurturer of the NKI-AVL/Elekta relationship, was a blow to the hospital’s research team, which
regarded him not only as a business associate and visionary, but also as a friend. To honor Gerry’s role in advancing concepts to improve the patient experience, Elekta and Philips Healthcare partnered to integrate Philips’ Ambient Experience for the Elekta Axesse
vault, a project enabled by a memorial fund created by his wife, Joni van Oortmarssen. Acknowledging Gerry’s love of flying and his experience as a private pilot, the NKI-AVL team named the room the Flying Dutchman suite.
Dutch R&D partner expands Elekta linac collection, improves stereotactic capabilities
The Netherlands not only uses more Elekta linear accelerators than any other brand – Elekta has a 75 percent market share – but it also is the home of Amsterdam's NKI-AVL, the country’s only comprehensive cancer center, and principle developer of critical imaging and operational software used in Elekta IGRT systems. Now, with NKI-AVL’s acquisition of Holland’s fifth Elekta Axesse™ system, Dutch patients with cancer will benefit from their country’s tradition of innovation.
Axesse is equipped with sophisticated tools to enable highly precise stereotactic radiosurgery (SRS) and stereotactic radiation therapy (SRT) and stereotactic body radiation therapy and body radiosurgery (SBRT, SBRS).
NKI-AVL clinicians are combining the precision that the 4 mm leaves of the Axesse system’s Beam Modulator™ provides with the speed of Elekta VMAT to improve performance in non-stereotactic prostate cases and stereotactic lung and brain cases.
“Within the first two months, Elekta Axesse was running a full schedule,” says Floris Pos, M.D., Ph.D.,
radiation oncologist at NKI-AVL. “For small tumors in the lung and brain, the smaller leaf width has given us more degrees of freedom. It makes us more comfortable treating these small tumors. For the stereotactic cases in particular, VMAT has substantially reduced treatment time.”
The image of a perfect partnershipWhile Elekta systems’ imaging hardware, beam shaping, patient positioning and immobilization form the functional skeleton of these IGRT systems, XVI software enables clinicians to create 3D reconstructions of acquired patient images, which can then be registered to a reference image. The integration of sophisticated hardware and software makes Elekta radiation therapy targeted, safe and effective. In 2003, just three years after Elekta’s Gerry van Oortmarssen (see Flying Dutchman sidebar) facilitated the collaboration between Elekta and the hospital, NKI-AVL received an Elekta Synergy® prototype and clinicians and scientists began developing the XVI image analysis software to guide its 3D and 4D imaging systems.
We impressed Elekta with our work, so they decided to integrate the tools we built into their product,” says Marcel van Herk, Ph.D., head of the physics research team at NKI-AVL.
The Elekta/NKI-AVL collaboration intensified over the years and has yielded some of the industry’s most important IGRT innovations, among which are the XVI version 4.5 tools, Symmetry™ and Intuity™.
Symmetry provides tools to manage shifts in the relative positions of the tumor and organs-at-risk during the respiratory cycle, and Intuity ensures that not only is the tumor’s position accounted for, but also the position of nearby healthy critical structures. Both innovations contribute to a more patient-friendly and safe treatment.
“Contrary to the earlier release, this time we played a role in formal testing,” Professor van Herk notes.
“It was interesting, because we had never done that before. We gained an understanding of why it can take awhile to introduce new function-ality. There are numerous studies you need to perform, particularly related to the GUI functions and how they behave. You have to create the full clinical use scenario and try to uncover things that could go wrong and what you should catch to optimize the system.”
From left to right: Dr. Peter Remeijer, Dr. Jan-Jakob Sonke, Dr. Marcel van Herk, Dr. José Belderbos. Elekta and Philips Healthcare partnered to integrate Philip’s Ambient Experience to the Elekta Axesse treatment room
System software developer, Netherlands Cancer Institute Antoni van Leeuwenhoek (NKI-AVL) Hospital, acquires Netherlands’ fifth Elekta Axesse
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AROUND THE WORLD
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ROUND THE WORLD
Beijing, ChinaPrototype Software Takes First Place in Two Autosegmentation Contests
Elekta continues its autosegmentation domination with first place rankings in two recent challenges for new prototype software. The top finishes were for lung, as well as head & neck at MICCAI 2010 in Beijing. We are delighted to once again gain recognition for refinements to our highly regarded prototype software,” says David Murphy, Director of Marketing, Business Area Software Systems. “It has been Elekta’s tradition to integrate new award-winning functionality into future Atlas-Based Autosegmentation (ABAS) releases, so we expect to add these methods to ABAS as soon as possible.”
Dubai, United Arab EmiratesNew Dubai Office Demonstrates Strong Commitment to Middle East Customers
In October 2010, Elekta opened an office in the upper levels of the newly-built Concord Towers in Dubai Media City. “We’ve always had good distributors and a great deal of success throughout the Middle East, but we needed to establish a direct presence there in order to support – not replace – our distributors,” says Nabil Elias Romanos, Vice President Eastern Europe and Middle East. “With a local office and staff, we can serve our customers better and show them greater responsiveness. We are able to develop and leverage face-to-face relationships in a culture in which trust is often derived from good personal contact.”
Patna, IndiaU.S. Clinicians Share Experience with Advanced Elekta Treatment Techniques in India
During the 32nd National Annual Conference of the Association of Radiation Oncologists of India (AROICON), Elekta hosted an special symposium on image guided SBRT and VMAT where Dr. Vivek Mehta (Swedish Cancer Institute) and Dr. Jatinder Palta (University of Florida) shared their clinical experience utilizing Elekta solutions. “The leadership physicians from India who attended the symposium were highly engaging with tremendous interaction with Dr. Mehta and in these discussions there was an inspiring sense to find solutions that offer the best possible care for their cancer patients,” says Rajinder Singh Dhada, Vice President Strategic Partnerships.
Otawara-shi, Tochigi-ken, JapanElekta Signs Sales and Marketing Agreement with Toshiba in Japan
Years of teamwork between Elekta and Toshiba came to fruition when Toshiba agreed to sell and market Elekta’s clinical solutions to the Japanese radiotherapy market. “I am pleased we have entered into this important agreement with Toshiba Medical Systems Corporation,” says Tim Rooney, President and Managing Director of Elekta K.K. “As a world leader in diagnostic imaging systems, Toshiba is the perfect long-term partner for Elekta K.K. This collaboration will enable both companies to extend and enhance their commitment to providing world class, cutting-edge solutions.”
Stockholm, Sweden Karolinska and Elekta Collaborate on Stereotactic Radiation Therapy Research
Each members of the Swedish medical technology industry, Karolinska University Hospital and Elekta recently signed a letter of intent to launch a joint research project that will evaluate and improve the efficacy of stereotactic radiation therapy for cancer patients and to enhance the management of metastatic lesions. “Stereotactic treatments are well-established for targets inside the skull, so with our clinical colleagues at Karolinska, our aim is to improve the sophistication of stereotactic radiation therapy to tumor targets in the body,” says Tomas Puusepp, President and CEO.
Zagreb / Split, CroatiaElekta Receives Multiple Order from Croatian Ministry of Health
Following nearly two years of strong efforts from our Business Unit in Innsbruck, Elekta, in cooperation with the local Croatian Distributor Medicem, won a tender to deliver the company’s treatment planning, oncology information management and treatment delivery systems to hospitals in Croatia. “This acquisition is a milestone for Croatia, where the majority of linacs have no MLC or portal imaging and the wait time for patients is more than three months,” says Dejan Cvetkovic, Area Sales Manager of South East Europe. “Four Elekta Synergy® linacs equipped with CMS and MOSAIQ software will bring huge benefits and improvement to radiotherapy in Croatia.”
Novosibirsk, RussiaLeading Research Center in Russia Offers New Hope with Elekta Axesse
The Meshalkin Research Institute of Circulation Pathology is now treating patients with Elekta Axesse™, which will, for the first time in Russia, allow clinicians to treat tumors throughout the body with ultra-high precision. “We are proud to be a part of the expansion of cancer care in Russia, and in making the latest clinical treatment solutions available to more patients throughout the country,” says Olof Sandén, Executive Vice President, Elekta Europe, Africa, Latin America and Middle East. ”Elekta has created a new structure and strategies to support our focus on emerging markets where a large number of patients can benefit from life-saving technologies at an affordable cost per patient.”
Bundang, South KoreaSouth Korea Office Opens to Support Growing Cancer Management Needs
With an installed base of 16 Leksell Gamma Knife® units, Elekta has had a presence in South Korea since 1990. And now, with the opening of a new office in Bundang, an hour drive from Seoul, Elekta excepts to build on its leading position in radiosurgery and strengthen its share of the radiotherapy market. “South Korean clinics and medical centers are addressing an increasing demand for healthcare in general, and cancer management in particular,” says Ian Alexander, Executive Vice President of Elekta’s Asia Pacific Region.
Campinas, BrazilElekta Hosts Opera Singer at Brazilian Radiotherapy Congress
Elekta Latin America was in the spotlight at the 12th Brazilian Radiotherapy Congress where San Francisco mezzo-soprano, Zheng Cao, who recently was treated with Gamma Knife® radiosurgery for brain metastases, performed at the opening ceremony as a guest of the company. “The more than 700 attendees were touched by Zheng’s powerful speech, some even moved to tears,” says Rebeca Polito, Marketing Communications Manager, Elekta Latin America. “Following this year’s congress, we hope to continue exceeding customer expectations, as well as continue to build Elekta’s image as a partner, innovator and first choice company.”
Ottawa, Ontario, CanadaThe Canadian Association of Radiation Oncology and Elekta Award Research Fellowship
In its fourth year, the 2010 CARO-Elekta Research Fellowship was awarded to Dr. Philip Wong. The fellowship will allow Dr. Wong to conduct research with the University of Toronto, Department of Radiation Oncology for a period of two years. “Dr. Wong’s fellowship will be of great benefit to the Canadian Radiation Oncology population who will benefit from the knowledge he will gain from this unique opportunity,” says Gerry Hogue, Vice President, Elekta Canada.
Crawley, United KingdomSpare Parts Management Benefits Patients, Customers and Elekta
In 2010, Elekta’s supply chain management team received the European Supply Chain Excellence Award for Innovation for its ability to reduce cost, increase performance and enhance customer satisfaction. “When an Elekta machine needs repairing, a great number of people rely on spare parts arriving as quickly as possible,” says Nigel Weston, Vice President, Supply Chain Management. “This is a backbone service for the entire company.” Currently, Elekta is involved in trials that will be very positive for the industry. These involve real-time tracking, text messaging and greater accuracy in delivery times.
Marseilles, FranceUniversity Hospital La Timone Celebrates 10,000th Radiosurgery Patient
On October 27, a group of clinicians from France, Switzerland and the U.S. gathered at University Hospital La Timone in Marseilles, France, the site of the first Leksell Gamma Knife Perfexion installed in the world, to celebrate the ten thousandth radiosurgery patient treated. Elekta’s President and CEO, Tomas Puusepp also attended. “A site of many firsts, it took only 18 years for La Timone to join the group of centers worldwide that have treated 10,000 patients,” says Per Nylund, Vice President, Leksell Gamma Knife Business Line.
New York, New York, USAElekta Among Major Sponsor of Rocks Against Cancer Fundraiser
Benefiting the Entertainment Industry Foundation’s cancer programs, including Stand Up to Cancer, an initiative created to speed the development and deployment of promising new therapies to improve and save patient lives, Elekta served as a leading supporter of the Rocks Against Cancer benefit in New York City. “As a human care company, Elekta was honored to support Rocks Against Cancer,” says Jay Hoey, Executive Vice President of Elekta North America. “It is only though the medical community and philanthropic out reach that we can complete our mission, which is putting into the hands of healthcare professionals the tools they need to treat cancer and brain disorders, and to improve and prolong and save patient lives.”
Santiago, ChileHospital Militar de Santiago Receives Chile’s First Gamma Knife
With a new neuroscience team in place, the Hospital Militar de Santiago has received the first Leksell Gamma Knife radiosurgery system in Chile, with plans to treat the first patient in early 2011. “Offering a gentler option to treat brain tumors and other disorders, the Gamma Knife installation at Hospital Militar de Santiago represents a major advance in brain radiosurgery for the people of Chile,” says Antonio Ponce, Vice President, Elekta Latin America. “To date, there are seven Gamma Knife centers in Latin America, including sites in Argentina, Brazil, Colombia, Puerto Rico and Venezuela. In 2011, Elekta will welcome the Gamma Knife Center Ecuador (Guayaquil, Ecuador), Instituto Neurológico de Curitiba (Curitiba, Brazil) and the Centro Gamma Knife Dominicano (Santo Domingo, Republica Dominicana) to the Elekta Gamma Knife family.”
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Opera star Zheng Cao battles lung cancer with Gamma Knife® surgery, chemotherapy and radiation therapy.
Non-small cell lung cancer (NSCLC) is notorious for its ability to metastasize prolifically and stealthily, often without causing any serious or notable symptoms until the disease is far advanced. San Francisco Opera mezzo-soprano Zheng Cao attributed her occasional aches and pains to the rigors of frequent stage performances. When neck pain lingered for months after an accidental fall during the September 13, 2008 world premiere of “The Bonesetter’s Daughter,” Zheng went to a physician. The doctor’s suspicions on that day, April 16, 2009, prompted a visit the next day for diagnostic scans – and the Shanghai-born performer met the only enemy she has ever made in her life. Nearly two years and many treatments later, Zheng and her loved ones continue to fight her up-and-down battle with lung cancer. In November 2010.Elekta writer Jerry Duncan spoke with Zheng Cao and the University of California San Francisco’s (UCSF) Dr. David Larson.
Zheng CaoThe performance of her life
Jerry: Zheng, would you walk through how you were diagnosed?
Zheng: On April 16th, 2009, a cervical spine MRI showed a shadow on my right lung, which really alarmed my doctor. On the 17th she ordered a chest CT. It turned out I had lung cancer which had spread everywhere. The following Monday, I went to UCSF, where I had a brain MRI and a whole body CT scan. The scans confirmed showed tumors throughout my body, and on top of that the doctor told me I had 24 tumors in my brain.
Jerry: Up to this point, though, you had been fairly asymptomatic?
Zheng: Yes, just aches and pains in my bones – some mild upper back pain and slight numbness of my left heel. I just thought I injured something from the fall during “The Bonesetter’s Daughter.”
Jerry: How many tumors in total did the doctors find?
Zheng: In addition to the 24 brain mets and the right lung tumor, they found a very large liver met, many bone mets in my spine, collar bone, ribs and pelvis, and a very large destructive mass at the level of my 6th and 7th cervical vertebrae, just behind my vocal cords. I’d say 50-something tumors.
Jerry: Based on those findings, what was the prognosis?
Zheng: The doctors said I had possibly six months to live. At the time I was just thinking ‘What’s the point’? You have never met me, but I am not that big – so I was like: Oh my God, the tumors have just completely taken over my body!
Jerry: Zheng, tell me how the treatment process began.
Zheng: My medical oncologist, Dr. Thierry Jahan, said my first treatment would be radiation therapy and he would refer me to Dr. David Larson. He said Dr. Larson is really the best doctor to treat your disease and right now you really need him. So, the day after I came out of the hospital I had a meeting with him.
Jerry: What did Dr. Larson tell you about your options?
Zheng: The first thing he said was I should have Gamma Knife® surgery. He did tell me about whole brain radiation therapy, and I had heard about it as well from the medical residents when I was in the hospital. It was a pretty frightening reality concerning whole brain radiotherapy – you would lose your hair, be fatigued, and I might have difficulty memorizing opera in the future. It seemed like a brutal option. I thought: Oh jeez, just to survive and stay alive, but then be
totally numb. At the time, my outcome seemed pretty grim.
Jerry: Dr. Larson, would you recount how Zheng’s case unfolded from your perspective?
Dr. Larson: I’m the former director of the Gamma Knife program at UCSF, but currently I perform Gamma Knife surgery only at Washington Hospital, Fremont. After reviewing Zheng’s case, I recommended that she have Gamma Knife surgery with Perfexion*, instead of whole brain radiation therapy [WBRT].
Jerry: Is WBRT still considered a frontline therapy for a case such as Zheng’s, in which there are multiple mets?
Dr. Larson: It depends on whoyou ask. Many clinicians who have Leksell Gamma Knife® Perfexion™ will say WBRT should be avoided. Most doctors at centers without Perfexion will prescribe WBRT. There seems to be a widespread notion that WBRT should be used in cases of more than three or four metastatic sites in the brain. In fact, many recommend WBRT even for one or two mets, although data supporting WBRT as the best choice are limited. So, which is the best option is somewhat controversial. I have often asked physicians who deliver WBRT what they you do if the patient was your mother or
father or daughter or son or spouse who needed treatment. Many have said that in that case they would probably not use WBRT. It’s somewhat disingenuous, unfortunately.
Jerry: In Zheng’s case, we’re not talking about three or four tumors, there are 24. While that’s a number Gamma Knife Perfexion is specifically designed to handle, what if you hadn’t had Perfexion?
Dr. Larson: I’m not sure what we would have done in that situation, because we have treated large numbers of tumors with a previous generation Gamma Knife – the maximum was 31 mets. But certainly, one is much more inclined to use Gamma Knife surgery if one can do it easily in a reasonable amount of time. It’s a lot easier to do that with Perfexion, since this latest generation Gamma Knife is specifically designed to treat large numbers of mets efficiently.
Jerry: Tell me about Zheng’s Gamma Knife surgery and other treatments.
Dr. Larson: We treated her on May 6, 2009, using 48 isocenters and 9,216 beams with a total Gamma Knife treatment time of five hours. She then received IMRT to the C6-7 lesion, with a dose plan designed to avoid her vocal cords. She also received conventional radiation therapy to the lumbar-sacral spine and part of her pelvis.
Thereafter she received daily Tarceva® – a targeted drug – and monthly infusions of Zometa®.
Jerry: Zheng, you had a follow-up MRI brain scan just four weeks later. What did the scan show?
Zheng: I was really anxious waiting to know what the results were, because Dr. Larson said if you have three or more metastases, the chance of developing more within 12 months is very high. The news was wonderful – 19 of the 24 lesions had disappeared or were significantly smaller, none had progressed– and there were no new ones. I was just ecstatic, all of my friends – everyone was overjoyed.
Jerry: Dr. Larson, to have this dramatic of a response only a month after Gamma Knife surgery isn’t typical, is it?
Dr. Larson: It is unusual. There is a spectrum of responses – some patients don’t respond so quickly and some respond very quickly. Fortunately for her, Zheng is in the patient category that is very responsive to radiation. For patients with non-small cell lung cancer, in particular, the response typically takes more time than in Zheng’s case. She is in the top one percentile based on her results – so it’s very dramatic and unexpected to have such a quick response and such a durable response now at 19 months post-Gamma Knife surgery.
Jerry: So, with respect to her brain metastases, what is Zheng’s present status?
Dr. Larson: Her brain is considered totally controlled.
Jerry: What about the body metastases?
Dr. Larson: Based on the July 9, 2009 whole-body PET scan, she had an impressive response for all the tumors from the therapy. Most of them had either decreased in size or were no longer considered active.
Recently, she was thought to have progression of her primary lung tumor and a few other areas of progression, including painful bone mets. Zheng received additional radiotherapy to several body sites, by Dr. Igor Barani at UCSF, with excellent pain relief. She also recently enrolled in a Stanford clinical trial of a targeted drug called XL184, which she takes in combination with Tarceva, under the direction of Dr. Heather Wakelee.
Jerry: Zheng, during the last nearly two years of treatment you’ve maintained a great deal of optimism and you’ve kept an active performance schedule. Where do you get your inspiration?
Zheng: I feel lucky I have music in my life and now, more than ever, I need it. Music gives me so much expression and hope. Whenever I am on stage singing – in that moment the cancer no longer exists. It is just me and the music on stage. That feeling just gives me tremendous peace. I am totally addicted to it because now I sing all the time. It is very hard for me to cancel a concert or singing engagement, because the singing and the music alone eliminated my fear – it took over the place where the fear should be.
Jerry: Physically, how do you feel?
Zheng: By early December 2010, I will find out for sure if the tumors are shrinking, but the doctors tell me to go with your general feeling. If you wake up every morning and you feel good, that means the tumors are not bothering you. They are either not active or they are shrinking. Around the time I was diagnosed, I know the tumors were very active because I wasn’t feeling well when I would wake up every day. So, these days if I wake up and I have no pain it is an incredible day. I was thinking no matter what new scans tell me, I feel good.
* fifth generation of Leksell Gamma Knife designed to treat multiple brain metastases with speed and accuracy.
Zheng's sister, Dan Cao, Zheng's niece, Keli Sheng, and Dr. David Larson at a Bonnie J. Addario charity event
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April 27, 2009Dearest friends:This is the first time I feel strong enough to write to all of you, and to tell you how deeply, deeply touched I am by this most incredible outpouring of love you’re all sending to me. It’s like thousands of hands are literally carrying me through the most devastating hours of my life and all those sleepless nights. I read it, and enjoying your encouraging words, every day.It has been a very tough week, but so productive. I can’t believe how this whole thing – doctors, healers, tests, and more – came together in just one week. I was lucky enough to have the Angels around me at the right place and right time.
I was a girl from China and came to this country with only $45 in my pocket, and no English – only the words “Merry Christmas!” And I remember how each one of you has come into my life and brought me so much joy and love, and taught me most of the English (even the dirty words), and now I thank God for all your love, which sure will carry me through this fight of my life, one minute at the time.I thank you from the bottom of my heart.Love,Zheng
Monday, May 4, 2009 9:53 PM, PDT
Dear Friends of Zhengie,
Zheng asked me to write to request your extra prayers and support on Wednesday, May 6.
That is the day she will undergo the most important and intense procedure of her radiation
treatment. It will last all day: from 7am into the evening. Her beloved oncologist, Dr. Larson,
will be “in charge of the zapping” (Zheng’s words). Those prayers, stories and loving words in
the guest book make a HUGE difference. Keep ‘em coming!
Thank you so much. - JakeJune 4, 2009(Zheng) admitted something yesterday to Dr. Larson, her sister, and I that was very
encouraging about her belief in her ability to survive and thrive after this illness: When
Dr. Larson told her that he would do special calculations to avoid her vocal cords, and
that he had to get the insurance company’s approval to do so, she asked him, “You mean
you think I can sing again? And go on with my career?” She says now that that was the moment she realized that her doctor believed she would
survive and go on with her life, and that even if she was encouraged by her friends and
loved ones that this is true, to hear it from him turned on a light for her. She wanted to
celebrate last night, and went out to a quiet dinner. I know she’ll want to celebrate with
you on Caring Bridge. Ya-HOOOOOOOOOOOO!!!
June 4, 2009
Hello everybody,
Zheng wanted me to write you all to let you know the wonderful news
she got Tuesday. As you know, Zheng underwent Gamma Knife radiation
four weeks ago. Yesterday, she had a follow up MRI and her oncologist,
Dr. Larson, discovered that a majority of the lesions were dramatically
smaller, and the remaining teeny, tiny ones hadn’t changed at all. AND
there were no new ones. She said that was the first time she left a doc-
tor’s appointment not depressed.
Study1: Combined SRS/WBRT therapy shows patients at greater risk of neurocognitive decline versus patients receiving SRS alone. A recent 58-patient, randomized trial evaluating the outcomes of patients who received either stereotactic radiosurgery (SRS) alone or SRS followed by whole brain radiation therapy (WBRT), to treat their brain metastases, revealed that patients in the combined therapy group were more likely to show significant deterioration in learning and memory functions than those having SRS alone. The results provide additional support for using SRS alone in the initial management of patients with one to three brain metastases, investigators reported. Researchers led by Eric Chang, M.D., at M. D. Anderson Cancer Center (Houston, Texas, USA), randomly assigned 58 patients with one to three newly diagnosed brain metastases to SRS plus WBRT or SRS alone during 2001-2007. The investigators conducted sophisticated neurocognitive and imaging tests at baseline and during follow-up visits. Dr. Chang indicated that the study probably “represents the first completed, randomized controlled trial using formal neurocognitive testing to adequately address the issue of SRS plus WBRT versus SRS alone” to manage these case types. The results showed that the patients who were randomly assigned to SRS plus WBRT were more likely to show significant neurocognitive decline (i.e. as measured by total recall) at four months than were patients randomly assigned to SRS alone (52% vs. 24%, respectively), despite the fact that patients in the SRS alone group showed a higher overall brain tumor recurrence than did those in the combined therapy group. The preliminary outcomes were sufficiently important that the trial was stopped on the basis that there was 96% confidence that total recall at four months for SRS plus WBRT was inferior to total recall for SRS alone. The researchers reported that their major findings regarding memory decline “should be applicable and relevant to other centers using the same entry criteria, given the widespread availability of SRS at many hospitals. However, applicability of the findings is dependent on the willingness of patients and their physicians to adhere to a schedule of close monitoring, having consistent access to high-quality MRI (and) a neurological team willing and able to perform salvage resections when indicated, and applying strict physics quality assurance procedures for SRS.” 1. Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, Arbuckle RB, Swint JM, Shui AS, Maor MH, Meyers CA. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomized controlled trial. The Lancet Oncology 2009; 10: 1037-1044.
Jerry: Is there anything else you wanted to add about your Gamma Knife experience in particular?
Zheng: Through my volunteer work with the Bonnie J. Addario Lung Cancer Foundation and from the publicity around my story, I have met many people who have told me they had whole brain radiation therapy. And I asked them if Gamma Knife was ever presented to them as an option and they say no, never. They didn’t even know about it.”
My message for all oncologists would be that I am so grateful that my radiation oncologist presented this alternative and explained it to me. I was able to choose an option that allowed me to live and still sing in public. It is so important for patients to have a choice. I am not against whole brain radiation therapy if patients decide to have it, but they should have a right to have all the options presented to them. I feel like I’m a patient advocate now.
I have often asked physicians who deliver WBRT what they you do if the patient was your mother or father or daughter or son or spouse who needed treatment. Many have said that in that case they would probably not use WBRT. It’s somewhat disingenuous, unfortunately.
Zheng CaoThe performance of her life
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Tejinder Kataria, M.D. Medanta - The Medicity (Gurgaon, Haryana, India)
And Varian didn’t offer an open networking system,” she says. “In addition, I wanted to rapidly start an SRS program because we have very strong neurosurgery and brain institutes here, so Elekta Synergy® S with Beam Modulator™ and VMAT seemed a more versatile option than Novalis Tx™.”
In 2009, with the facility still under construction, Medanta acquired the country’s first Elekta Infinity™
system, in addition to an Elekta Synergy S with Beam Modulator, and advanced patient positioning, immobilization and respiratory management products. Both linear accelerators are equipped with VMAT. Medanta also acquired three sophisticated Elekta treatment planning systems, as well as workstations for simulation and contouring. MOSAIQ for Radiation Oncology unites planning, treatment and the patient record in the local area network.
Elekta Synergy S became clinical when Medanta – The Medicity opened in February 2010, followed by Elekta Infinity in April. Dr. Kataria began using Elekta VMAT on Elekta Infinity in September, and – using Elekta Synergy S – treated two patients with brain metastases in December, officially launching the SRS program. From the beginning, she has used XiO as the department’s planning workhorse, and began using Monaco to plan VMAT in July and ERGO++ in December.
Medanta adds cancer care capacityAcross India, head-and-neck cancer and tobacco-related cancers (mainly lung cancer) constitute 15-20 percent of the total cancers. Among males, the top three cancer incidences are oral cavity, larynx and lung cancer, while in women cervical and breast
cancer are most common. In metro areas, such as Gurgaon, (population 640,000) prostate and breast cancer incidences are increasing.
Among the 50 patients per day treated on average at Medanta, 40 percent are for prostate cancer and nearly 30 percent each are for brain and breast cancer, followed by smaller numbers of patients with lung, GI and head-and-neck cancers.
In September, Medanta began using Elekta VMAT on its Infinity system in select brain and re-irradiation cases. Its first two cases were a male patient with a recurrent sinus tumor and a 58-year-old man with a brain stem glioma involving the pons. Clinicians have started therapy for an additional five patients with brain and neck lesions.
Ability to plan“VMAT is particularly useful for patients with tumors located near critical structures and for those
who can’t lie still for an extended time, where any movement can impair radiation delivery,” Dr. Kataria says. “It’s also beneficial for patients undergoing reirradiation, because we can achieve a sharp dose fall-off close to previously treated fields. In fact, in our evaluation of VMAT IMRS for metastatic disease, we compared the dosimetry between VMAT and IMRT and found that the dose to surrounding tissues is almost 15 percent less with VMAT. We’re obtaining a very sharp dose gradient.
“Among the most distinct differentiators of Elekta VMAT,” she continues, “is the ability to plan with Monaco, which uses the most advanced and accurate dose calculation engine, the Monte Carlo algorithm. The software accounts for many biological considerations, such as whether the organ treated is a serial [i.e., spine] or parallel [i.e. lung] organ.”
Medanta – The Medicity opens with full array of Elekta solutions, including India’s first Elekta Infinity with VMAT
India’s population of 1.15 billion significantly dwarfs the number of radiotherapy systems available to serve its residents. Among 289 radiation therapy centers country-wide are approximately 250 linear accelerators, 270 telecobalt machines and 170 HDR brachytherapy systems. To match a developed nation’s ratio of inhabitants to linear accelerators alone, India would need about 10 times as many treatment systems, says Tejinder Kataria, M.D., Chairperson of the Radiation Oncology department at Medanta Cancer Institute, part of Medanta– The Medicity (Gurgaon, Haryana, India).
“Although there is a huge shortfall in radiation therapy capacity, the situation is rapidly changing for the better,” she says. “Fifteen years ago, there were three public hospitals in Delhi that offered radiation therapy. Today, Delhi has 13 public and private hospitals now
providing radiotherapy. Moreover, the availability of health insurance is making it possible for patients to afford radiotherapy.”
Improved treatment quality
Cancer treatment quality is improving in pace with access to radiation therapy, as advanced linear accelerators gradually replace outmoded telecobalt technology.
“Especially in metro areas, the public has tasted the better side of radiation oncology,” Dr. Kataria observes. “Modern technological options are becoming increasingly available so that patients don’t have to suffer the side effects and limitations of cobalt therapy. It has whetted their appetite that they can have good treatment provided by experienced healthcare professionals.”
Medanta – The Medicity, which opened in February 2010, is among India’s largest multi-specialty
medical centers. Medanta’s founder, renowned cardiac surgeon Dr. Naresh Trehan, created the center with the vision to match the highest standards of healthcare delivery across the world. As one of Medanta’s eight super-specialty institutes, the Medanta Cancer Institute needed to offer patients the most advanced oncology treatments and techniques.
Preparing for launch
“To address the current scarcity of cancer care service providers in our country, Medanta Cancer Institute is based on a futuristic model to accommodate the rising demand for multi-modality oncology treatments provided under one roof,” Dr. Trehan says. “The Institute also will cater to the medical needs of cancer-afflicted patients through the specialized services available in the other Medanta Institutes.”
For a year, Drs. Trehan and Kataria worked within the framework of this vision to evaluate cancer treatment technology. Ultimately, several factors tipped the balance in Elekta’s favor.
“We chose Elekta as a provider because of their high precision radiation therapy equipment, their commitment to customer care, their innovation and forward-thinking attitude about technology, and because of their passion for patient care,” Dr. Trehan observes. “We are a start-up center with a scope for future expansion, so choosing Elekta gives us a flexible platform on which to build our program in the coming years.”
As a radiation oncologist, Dr. Kataria focused on specific technical advantages Elekta offered over major competitors.
“Siemens does not have kV cone beam; they use a modified MVbeam for imaging.
Advanced cancer care technology streams into India
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Dr. Kataria (right, front row) and her team
“This institution is community-oriented, looking to the needs of average people,” says M.K. Mahajan, M.D., Professor and Head, Department of Radiotherapy at CMC, also a preeminent educational and research center in the state.
In 2009, CMC officials saw an opportunity to replace its aging cobalt unit and better serve patients with more advanced linear accelerator technology. Among the offerings of three providers, CMC selected the Elekta Compact™ (6MV) system for its affordability, sophisticated capabilities, upgradeability and rapid access to field service, Dr. Mahajan notes.
The center’s Elekta Compact became clinically operational in November 2010, and will be upgraded with real-time portal imaging and MLCi in January 2011, making it the first MLC-equipped Elekta Compact in India.
“The price of Elekta Compact helped us replace our cobalt unit,” Dr. Mahajan notes. “And, it enabled us to afford a complete package that included a treatment planning system, radiation field analyzers, surveys and phantoms, so that our physicists and clinicians can confidently perform quality assurance in addition to sophisticated radiotherapy.”
Optimal combinationElekta Compact was designed for modular upgrades, to facilitate technological improvements as they become available or when CMC is ready for them, he adds
“We know that at some time in the future we can upgrade the table to permit us to provide non-coplanar beams, and that we can convert from the autowedge to dynamic wedging,” Dr. Mahajan observes.
“Since Elekta Compact was designed for modular upgrades, this will help us incorporate technological improvements as they become available or when CMC is ready for them,“ he adds.
“I’ve heard that some Elekta Compact sites are treating 70 or more patients each day,” he says. “The number of treatment centers in India is quite low in comparison to the population, so all departments have to be busy. Therefore a combination of Elekta Synergy and Elekta Compact would be a good combination for the average hospital.”
Dr. Mahajan predicts that CMC’s daily patient volume on Elekta Compact should quickly increase to 50 per day within a year. Consequently, he was encouraged to learn that Elekta was committed to providing not only a comprehensive multi-year service contract, but also rapid service response to address equipment issues.
“They were glad to tell us that they will be able to provide service to us in less than 24 hours.”
Christian Medical College (CMC) & Hospital to acquire India’s first MLC-equipped Elekta Compact
Established in 1894, Christian Medical College & Hospital’s (Ludhiana, Punjab) first foray into radiation therapy was in 1938, when it began providing brachytherapy treatments – using Irridium-192 needles, then Cesium-137 needles and tubes – for several types of interstitial and intra-cavity treatments. In 1958, CMC became the first center in Punjab to acquire a cobalt- 60 teletherapy unit. Serving Ludhiana’s current population of about 1.4 million inhabitants, CMC operates on charitable donations alone and as recently as 2008, charged $45 (USD) for a full treatment course, regardless of the number of treatment days.
In December, commissioning tests had begun to prepare Medanta’s Elekta Synergy S to use Elekta VMAT. Presently, the newly established SBRT program is treating lung and vertebral metastases using IMRT and 3D conformal techniques planned with XiO. For lung treatments, Dr. Kataria has been using Active Breathing Coordinator to manage respiratory motion.
MOSAIQ integrationMOSAIQ brings order to Medanta’s multi-faceted department, Dr. Kataria maintains.
“MOSAIQ gives me the complete picture of the patient’s treatment experience, from the time patients enter the clinic to when they return for follow-up,” she says. “We can visualize all of our clinics, schedule patients, perform record-and-verify,
transmit the plan and treat the patient through MOSAIQ. I don’t have to go through the print system to determine what has been done. We also can capture reactions and toxicity data, stage patients and create code captures. The flexibility and scope of MOSAIQ are wonderful.”
A promising new beginning in IndiaApproaching its first year of clinical operation, Medanta’s radiation oncology department of 37 healthcare professionals has achieved an admirable level of efficiency. On an average day, Dr. Kataria can turn around five to six new cases on the contouring stations and an equal number on the planning systems. Medanta’s turnaround time from simulation to treatment time is approximately four days for a complex plan.
“That’s remarkably good – it used to take six or seven days at my previous organization,” she says. “In an emergency palliative case, we can turn around a case in as few as six hours. Lastly, we’ve been able to reduce our turnaround time for an SBRT case to about two days.
Daily throughput for the Elekta Infinity system averages 27 patients, while Elekta Synergy S averages 20 patients per day.
“We have had a positive experience working with team Elekta from within and outside India and are thankful to the international office for supporting our endeavor,” says Medanta’s founder, Dr. Trehan. “We deeply appreciate the diligence and support Elekta provided to us during installation and commissioning and hope to have a long, fruitful role in their research consortium.”
Note: Approval of indications may vary between different countries and additional regulatory clearances may be required in some markets
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Background
The Department of Radiotherapy and Radiation Oncology at the University Medical Center Mannheim has been active in the application and improvement of advanced treatment techniques based on multileaf collimators (MLC). Through the use of the most advanced radiation therapy technology available, the Mannheim center has become one of the most important treatment facilities for cancer patients in the Rhein-Neckar area, treating 2,300-2,400 patients per year.
The clinical team at University Medical Center Mannheim has worked closely with Elekta on the development of Elekta Integrity*, the 6th generation Elekta digital control system.
The department has four linacs on site, including two Elekta Synergy® linacs with the Integrity digital control system and the latest Elekta MLC (MLCi2), with one additional Elekta Synergy linac at a collaborating unit off site. All are connected to MOSAIQ® (version 2.0), the image-enabled Elekta oncology information system (OIS) and electronic patient record (EMR). The department has also recently implemented the Monaco® treatment planning system (TPS) for IMRT with static gantry and VMAT, incorporating the Monte Carlo dose calculation algorithm, with 4 workstations connected to one database.
Challenge
A synoptical review of available clinical data suggests that at least 50% of patients would benefit from intensity modulated radiation therapy (IMRT)1-3.
However, it is important that any new technique must fit into the current departmental infrastructure. Therefore, in order to provide modulated treatment for this many patients in our clinic, it is necessary to reduce treatment times of modulated therapy.
Our experience has shown that volumetric intensity modulated arc therapy (VMAT) can be used to deliver high quality modulated treatment plans in very short treatment times.
Clinical evidence suggests that most indications can be treated using VMAT, including head and neck, rectal, anal prostate and many other cancers. The impetus for increasing the use of VMAT in our department is theclinical benefit for patients using modulated treatments.
Solution Implementation
The combination of Integrity digital control system, Monaco with VMAT and MLCi2 has the potential to reduce treatment times in the delivery of VMAT by allowing complex plans that incorporate continuous variable dose rate (CVDR) and interdigitation. We were, therefore, very keen to evaluate this combination in order to meet our patient demands for modulated treatments - so that more patients could benefit from modulated treatments in a resource neutral way.
Figure 3. Advantages of Continuously Variable Dose Rate (CVDR).
Delivery Time (seconds)
Dos
e R
ate
(MU
)
20 40 60 80 100 1200
0
50
100
150
250
200
300
350
400
450
In order to speed up the VMAT treatment process, we created new pre-sets in MOSAIQ and XVI (X-ray volume imaging) for image guided radiation therapy (IGRT). This allowed cone beam image acquisition in a counter clockwise rotation of the gantry, prior to initiation of VMAT treatment in a clockwise rotation of the gantry, thus further minimizing total imaging and treatment time.
ResultsThe result of the new pre-sets in MOSAIQ, in combination with the benefits of Integrity, Monaco with VMAT and the Elekta MLCi2, meant that, in a typical one hour period during the treatment day on one linac, the total VMAT treatment time (including cone beam CT) was reduced to 27 minutes, with beam-on times of between only 2-7 minutes (Figure 5), with the remaining 33 minutes incurred by patient logistics.
Figure 5. One hour routine treatment. Patient logistics vs. treatment time (IGRT + VMAT): 50% / 50%. Beam-on times between 2 and 7 minutes.
5 min 4 min
10 min 8 min
Interdigitation allows accurate planning and beam shaping of multiple target islands during all treatment techniques, including static, arc, IMRT, Omniwedge, dynamic, dynamic arc and VMAT. This precise, beam-shaping capability ensures maximum conformance to target volumes, improved efficiency of dose delivery, and reduced radiation to both normal tissue and critical structures
•
• CVDR allows the dose rate to be adjusted to its ideal value during delivery of VMAT prescriptions. This option makes the delivery of the prescribed dose smoother and faster, when compared to previous discrete dose rates, and can reduce delivery time by 30% (Figure 3).
Professor Frank Lohr, Oncologist Professor Frederik Wenz, OncologistBrigitte Hermann, OncologistYasser Abo-Madyan, OncologistVolker Steil, PhysicistFlorian Stieler, PhysicistLennart Janke, PhysicistJens Fleckenstein, PhysicistFrank Schneider, PhysicistKerstin Siebenlist, Dosimetrist
Authors:
Elekta - Case in pointMonaco® with VMAT, Elekta Integrity™ and Elekta MLCi2
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Art. No. 018939.00 ©2011 Elekta AB (publ). All mentioned trademarks and registered trademarks are the property of the Elekta Group.
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DiscussionThe combination of Elekta Integrity, Monaco with VMAT and Elekta MLCi2 resulted in 20-30% faster treatment times consistently. This was achieved, primarily, through CVDR (allowing 50% higher dose rates than before) and interdigitation. This meant that, in a one hour time slot, a high degree of modulation could be achieved with significantly faster treatment times (Figure 6).
Figure 6. DVH-parameters and treatment efficiency for different treatment modalities (mean + SD). The two values for the treatment time of VMAT display the old (a) and the most recent (b) linac control system.
MIMIC (Corvus)
IMRT 7F (Hyperion)
IMRT 9F (Hyperion
VMAT (Monaco)
DmeanPTV1
[Gy] 59.9 + 0.1 60 + 0.4 60.1 + 0.5 60.6 + 0.3
DmeanPTV2
[Gy] 55.7 + 0.7 56.4 + 0.4 56.5 + 0.4 56.7 + 0.7
D99%PTV1
[Gy] 56.0 + 0.4 51.7 + 1.5 52.0 + 1.6 53.3 + 0.6
D99%PTV2
[Gy] 53.0 + 0.7 50.3 + 0.8 50.6 + 0.8 51.6 + 1.7
DmeanParotis
[Gy] 19.5 + 0.9 14.1 + 1.1 13.9 + 1.5 14.9 + 0.6
CI 2.5 + 0.6 1.8 + 0.2 1.9 + 0.2 1.6 + 0.4
HIPTV1
1.9 + 0.5 1.7 + 0.2 1.7 + 0.2 1.6 + 0.1
HIPTV2
1.5 + 0.3 1.4 + 0.1 1.4 + 0.0 1.3 + 0.1
MU 2551 + 349 945.2 + 201 925 + 234 521.5 + 53
Treatment Time [min] 12.8 + 1.7 7.6 + 0.3 8.5 + 0.4 6.2 + 1.0a
4.3 + 0.6b
Since imaging (for IGRT) and VMAT treatment times were reduced significantly, more patients could receive modulated treatments per day.
Currently, the two Elekta Synergy Linacs in the department are used exclusively for modulated treatments, allowing the clinic to treat around 70 patients with modulated radiation therapy every day.
Not only do these efficiencies enable more patients to receive the clinical benefits of modulated therapy, but the shorter treatment time is easier and more comfortable for patients, particularly if they have painful lesions or severe discomfort. In addition, position insecurities are reduced to ensure more accurate treatment delivery. The center will soon be able to treat around 1000 patients per year with modulated radiation therapy, approaching 50% of the total treatments performed. Already, 60% of the modulated treatments are VMAT but it is anticipated that this will increase to 80% VMAT in mid-2011, with the remainder receiving static gantry IMRT with dynamic MLC sequencing.
Significantly, the use of Monaco with VMAT for treatment planning has been beneficial in a number of ways:
• The Monte Carlo dose calculation algorithm gives extremely precise dose calculation.
• It is very easy to commission additional machines, especially if they have the same set up, which saves time.
• Both static and VMAT treatment plans can be planned on the same interface.
• The system is very robust, intuitive and easy to use, delivering good quality plans consistently, thus, the high number of modulated plans can be handled efficiently.
Leaf speed is currently the rate limiting factor. The next generation Elekta MLC* will have double the leaf speed compared to the current MLC, which will allow the beam-on time to be reduced by a further 50%. This will take the delivery of normofractionated modulated treatments consistently to <3 minutes and therefore to an extremely low percentage of total slot time.
* The next generation Elekta MLC is a works in progress and is not available for sale or distribution in all markets. Note: Specifications are provisional.
References[1] VeldemanL,MadaniI,HulstaertF,etal(2008)Evidencebehinduseofintensity-modulatedradiotherapy:
asystematicreviewofcomparativeclinicalstudies..LancetOncol.9(4):367-75.[2] MaylesWP:RadiotherapyDevelopmentBoard(2010)Surveyoftheavailabilityanduseofadvancedradiotherapy
technologyintheUK.ClinOncol(RCollRadiol)22(8):636-42.Epub2010Jul27.[3] StaffurthJ;RadiotherapyDevelopmentBoard(2010)Areviewoftheclinicalevidenceforintensity-modulated
radiotherapy.ClinOncol(RCollRadiol)22(8):643-57.Epub2010Jul31.
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