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WAVELENGTHNews and advances in precision radiation treatments and neurosurgery | www.elekta.com | Vol. 9 No. 1. | March 2005

By working together we can fight serious disease and enhance quality of life

Elekta re-energizesradiation therapy inSouthwestern India

Conferences confirm Elekta’s continuingdominance in 4D AdaptiveTM IGRT

SOLUTION CLASSIFICATIONS

nn Precision Radiation Therapy

nn Image Guided Radiation Therapy

nn Stereotactic Radiation Therapy

nn Gamma Knife® surgery

nn Stereotactic Neurosurgery

nn Functional Mapping

IN THIS ISSUE

nn Amrita Institute of Medical Sciences

and Research Centre, Cochin, India

Elekta re-energizes radiation therapy in

Southwestern India 3

nn Redding Cancer Treatment Center,

Redding, California, USA

Treatment center builds disease-

fighting capabilities while

retaining non-clinical ambience 7

nn Princess Margaret Hospital, Toronto,

Ontario, Canada

Elekta Synergy® Platform with XVI used

in first ‘solo’ case of prostate cancer

patient 11

nn Swedish Medical Center, Seattle,

Washington, USA

Acquires Elekta Synergy® and Elekta

Synergy® S 14

nn Royal Preston Hospital, Preston, UK

Elekta and the Royal Preston team up

to verify Elekta Synergy® S beam-

shaping system 15

COMPANY INFORMATION

nn ASTRO 2004

Conferences confirm Elekta’s

continuing dominance in

4D AdaptiveTM IGRT 18

nn ASTRO 2004

Elekta’s IGRT leadership on display at

ASTRO 2004 22

Elekta Synergy® S and Beam

ModulatorTM are work-in-progress

and not currently available in all

markets. Please contact your local

representative or authorized

distributor for availability.

P R E C I S I O N R A D I A T I O N T H E R A P Y

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Elekta re-energizes rad iation therapy in Southwestern India

Amrita Institute ofMedical Sciences

and ResearchCentre, Cochin

New Delhi

Mumbai(Bombay)

Although AIMS is presently aworld-class medical center withsuperspecialties in all majordepartments, it opened with noradiation therapy equipment atall. However, under the spiritualleadership of India’s MataAmritanandamayi (‘Amma,’ seepage 6), AIMS and Elektacollaborated to make radiationtherapy services a reality. AIMSbegan radiation treatments ofcancer patients in February 2004.

Until the inception of radiationoncology services at AIMS in2004, pain palliation wastypically the most that thousandsof cancer patients in Kerala couldhope for. “Nearby hospitals usecobalt units almost exclusively, sooften the intent was palliativeeven for potentially curablediseases, due to the absence ofadequate treatment modalities,”says AIMS Medical Director,Prem Nair, M.D. “Today, withtwo Precise Treatment SystemsTM

and a wealth of auxiliaryequipment, Kerala has a centerthat aggressively pursues cure as

a philosophy. Following AIMS’slead, three additional centers inKerala and several in the rest ofIndia have placed orders forlinacs in 2004, a number of themchoosing Elekta.”

AIMS started out small in1998 with just 200 beds, butsince then has growndramatically, adding 800 bedsand a medical complex consistingof a medical school, school ofnursing, school of pharmacy,school of dentistry and severalspecialty institutes under theauspices of AIMS. AmritaMedical School has super-specialties in the departments ofcardiology, nephrology andgastroenterology, with supportingservices in radiology andpathology. A cancer center was inembryonic stages in 1998, aswere plans to integrate adepartment of radiation oncologywithin the center. Final pre-construction planning for theradiation oncology departmentbegan in 2000 and culminated inequipment selection in 2002.

Elekta presents keyadvantages duringevaluation

Two of the main principals inAIMS’s equipment evaluationcommittee, Dr. Bhaskaran K.Pillai, Ph.D., Chief Physicist andRon Gottsegen, AdministrativeDirector of AIMS (pictured left),had virtually no experience withElekta equipment in 2000 whenevaluations began. In fact Dr.Pillai had worked in the USAwith the treatment machines of amajor Elekta competitor for 33years and went into theevaluation with a strongpreference for this vendor. Inaddition, another Elektacompetitor’s diagnostic imagingequipment was already in placeat AIMS. The odds weren’t greatfor a newcomer, but AIMSbrought in Elekta to ensure duediligence. During the evaluationprocess, Elekta advantages beganto mount, according to Dr. Pillai.

“Initially, I didn’t have aspecification for three photon

To meet the radiation therapy requirements of India’s population of 1.1 billion, the World HealthOrganization has recommended a ratio of one linear accelerator (linac) for every one million people.While there has been a large increase in the number of new linac orders in India in 2004, there areonly 85 linacs (installed/ordered) in the country. The state of Kerala on the southwest coast is hometo nearly 32 million people, the most of any Indian state. To better serve the healthcare needs ofthis region, the Amrita Institute of Medical Sciences and Research Centre (AIMS) was established in1997 in Kerala’s coastal city of Cochin.

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Ron Gottsegen, Administrative Director ofAIMS

“Our major concerns wereequipment reliability, themanufacturer’s commitmentto continuing research anddevelopment and itswillingness to invest itspersonal efforts andresources into our center tomake us successful and keepus at the technical edgewhere we wanted to be as ateaching institute.”

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enabling clinicians to treat aboutfive patients per hour. Two tothree hours each day are reservedfor new patient starts, whichaverage 45 minutes per slot. ByOctober 2004, with both PreciseTreatment SystemsTM operational,the combined patient volume hadclimbed to nearly 80 patients perday. At press time, daily volumeis expected to be at maximum forboth systems for a combineddaily total of about 100treatments.

“With the high dose rate (upto 600 MU/minute) of PreciseTreatment SystemsTM we have hadno problems treating our largedaily volumes,” Dr. Pillai says.“In addition, field sequencingenables us to very efficientlydeliver beams once we havecommunicated the patient plan toDesktop. And, with the built-inrecord-and-verify system – whichis standard with Elekta – we havenot had any machine set-uperrors in treatments.”

70% of AIMS’s treatments are3D conformal and employ wedgeand electron fields forapproximately 30% of allpatients. The case load comprises36% head-and-neck cases, 20%breast cancer and the remaindera variety of other disease sites.

Maintaining this brisk depart-ment workflow wasn’t simply amatter of acquiring advancedlinacs, Dr. Pillai notes. Manytechnologists in the area wereaccustomed to outdatedequipment and needed intensetraining and retraining, whichElekta helped provide. “TheElekta applications group did awonderful job of trainingtechnologists, many of whomwere not only novices, but thosewho had mostly used cobaltmachines and therefore had to un-learn some of the techniques,” hesays. “The benefit of this trainingwas that we were able to get a fewtrained technologists to serve asanchors on both the machines.”

Further supporting AIMS’smission, Elekta offered to keeptwo service engineers on-site toperform all the first-linemaintenance and trouble-shooting. “The down-time isvirtually always scheduled down-time and it is working extremelywell,” Dr. Pillai says.

“We haven’t yet had a full dayof down-time on these systems,”adds Dr. T.K. Padmanabhan,M.D., Head of the Departmentof Radiation Oncology, whojoined AIMS in January 2004after working as a seniorconsultant in Apollo Hospital,Chennai for 11 years with twonon-Elekta linacs. “Our up-timehas been 98%, so I’m extremelyhappy with the equipment.”

The new Elekta radiationtreatment systems at AIMS havebegun to relieve much of thepressing load of cancer cases inthe over-burdened state ofKerala, initiating a new era oftreatment availability among the

“We were impressed by the company’s growth, its technical innovation and capacity to moveproducts to market, and reports of equipment reliability. Elekta’s commitment was evident up anddown the line.”

energies, as I was used to justtwo.” he says. “But when Ilearned that Elekta offered threephoton energies, and appreciatedthat southern India has a highincidence of head-and-neckcancers, I felt that 4MV wouldbe a very appropriate third beamfor AIMS to have. Plus, 4MVwould provide a very goodpicture for Elekta’s iViewGTTM

portal imager.”iViewGTTM itself was unique

among the other vendors’ portalimaging devices, Dr. Pillai adds.“Portal imaging and particularlyportal imaging with amorphoussilicon detection technology wasstill in its infancy in 2000.Although iViewGTTM was new toclinical use, the images I believedit could provide us would beextremely useful.”

Beyond technicalconsiderations, the mostimportant factor favoring Elektawas the level of commitmentElekta showed during theprocess. Elekta wanted a newclinical partner in India andclearly demonstrated this desire.

“Elekta invited us to itsfacility in Crawley, UK, and

showed us how intently theywanted to help us develop oursite,” he says. “Elekta struck usas a progressive company that iscommitted to creating a long-term partnership and devoted tothe customer’s preferences andsatisfaction. We had to gothrough the other vendors’corporate layers, so in the end itwas as much a gut feeling forElekta as it was appreciation ofthe technology.”

“Our major concerns wereequipment reliability, themanufacturer’s commitment tocontinuing research anddevelopment and its willingnessto invest their personal effortsand resources into our center tomake us successful and keep usat the technical edge where wewanted to be as a teachinginstitute,” says Ron Gottsegen.“Elekta scored very high in allthese areas. We were impressedby the company’s growth, itstechnical innovation and capacityto move products to market, andreports of equipment reliability.Elekta’s commitment was evidentup and down the line, from thecorporate office to the Elekta

people in India. Elekta has doneeverything, and continues to doeverything, necessary to make usas successful as we are.”

In May 2002, AIMS placedorders for two Precise TreatmentSystemsTM. The first system wasinstalled in the newly completedAIMS Radiation OncologyDepartment and accepted inNovember 2003. Patienttreatments began on February16, 2004. The second PreciseTreatment SystemTM wasdelivered in April 2004, installedand accepted in June 2004 andstarted treating patients onSeptember 20, 2004. The CMSXiO system is used for planning.

Volume builds quickly

By the end of its first week ofoperation, Amrita’s first PreciseTreatment SystemTM was treating20 patients per day, increasing to50 patients by the end of May2004. Demand for radiationtherapy services created abacklog of about 30 patients,despite initial clinic hours of 7 a.m. to 9 p.m. The averagetime slot was 12 minutes,

Pictured right:

Meeting at the Elekta exhibit at ASTRO 2004

are (left to right); Percy Schroff, Managing

Director, Elekta India; Brendan Vahey, Director,

Sales & Marketing, Asia Pacific; Bhaskaran

Pillai, Ph.D., AIMS Chief Medical Physicist;

Volker Stieber, President & CEO, Elekta, UK

and Somnath Ray, National Manager, Product

Division, Elekta India.

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state’s 32 million inhabitants, Dr.Padmanabhan adds.

“The only other cancer centertrue to this designation is theregional government-fundedcancer center in Trivandrum,where most patients receive freetreatment and which has anextremely heavy workload,” hesays. “Amrita Institute is a hugeleap forward in terms oftechnology – not only in the stateof Kerala, but also in the entirecountry, so this institution’sPrecise Treatment SystemTM reallyimproves the treatment outlookfor millions of people. Apartfrom the Regional Cancer Centrein Trivandrum, AIMS hospitalwill have a major role in themanagement of cancer patients inKerala.”

“Elekta established a regionaloffice in Cochin before theequipment installation and has ateam of engineers throughout thecountry,” says Percy Shroff,Managing Director of ElektaIndia. “Our mission is to havethe most competent serviceorganization in India to provideexcellent after-sales support toour customers in the country andthe region.”


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Mata Amritanandamayi, or ‘Amma,’ as

she is widely known in India and

worldwide, was the driving force in

AIMS’s establishment. During the last

30 years, the 51-year-old spiritual

leader has dedicated her life to

uplifting humanity through the

simplest of gestures – the embrace. In

this way, Amma has blessed and

consoled more than 21 million people

around the world. She has initiated

and inspired a vast network of

charitable activities, harnessing her

ability to transform her

compassionate vision into practical

reality. AIMS is the physical

manifestation of Amma’s vision to

create a hospital in Kerala where the

poor could receive the very best

medical care possible from highly

skilled physicians and nurses in a

compassionate, caring atmosphere.

“Amma’s message is one of love

and compassion,” says Prem Nair,

M.D., AIMS Medical Director. “There is

a strong bond that develops between

her and the people who meet her. It’s

the personal transformation that

occurs which allows people to work

selflessly toward a higher cause.”

According to AIMS Chief Medical

Physicist, Dr. Bhaskaran Pillai, AIMS

fulfills Amma’s creed of service to

fellow man in the area of medicine.

“This is a unique institution that is

one-of-a-kind in India and possibly

the whole world. AIMS’s first thrust is

to provide an opportunity for service

to humanity,” he says. “Secondly, its

goal is to provide these healthcare

services to the needy and provide

them at state-of-the-art level. A third

of our patients are treated for free,

another third is charged at

concessional rates and the last third

of patients is charged well below the

prevailing rates of other corporate

hospitals. Accordingly, after AIMS was

established many of the area

hospitals were compelled to reduce

their charges to the ultimate benefit

of all patients.”

The funds collected to create AIMS

and to finance countless other

charitable projects of Amma were

non-solicited donations and not

acquired through any fundraising at

all on Amma’s part, which testifies to

the spiritual leader’s ability to awaken

the spirit of giving among all whom

she encounters, Dr. Pillai adds.

“Private donations come not just from

a few individuals, but millions – and

yet not a single dollar is solicited. In

fact, Amma has instructed us to never

request funds. It’s her inspiration that

enables people to give selflessly.”

In relief of the victims of the

December 26, 2004 tsunami, Amma

has pledged a donation of Rs. 100

crores (US $22 million) and has

provided medical aid from AIMS as

well as aid in rebuilding homes for

the poor.

Amma, the ‘Hugging Saint of India,’drives development of AIMS throughmessage of love


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“Our up-time has been 98%,so I’m extremely happy with

the equipment.”

In the early 1990s, radiationoncologist Vidya Bobba’s visionwas to create a cancer treatmentcenter that was as unlike thestandard example as possible – atleast from appearances. Dr. Bobba’s own ideas, and thoseobtained through patientquestionnaires, resulted in a free-standing outpatient treatmentcenter that looks like a homefrom the outside with a warm,inviting and decidedly non-clinical feel inside. However, thetechnological capabilities atRedding Cancer TreatmentCenter (RCTC), Redding,California, USA are anything but

quaint. Through the years, Dr. Bobba has been quietlybuilding an arsenal of advancedcancer-fighting technology.Redding’s most recent acquisitionincludes a Precise TreatmentSystemTM with iViewGTTM andPreciseBEAMTM IMRT, whichexecutes IMRT plans developedon the NOMOS CORVUSplanning system.

Vidya Bobba, M.D., RadiationOncologist and founder ofRCTC, didn’t want to evoke‘hospital’ among patients visitinghis site. While hospitals areplaces where sick people go fortreatment, patients and visitorsoften perceive the architecture,ambience, décor and even sterilesmells as negatives.

“The goal was to make thecenter as unlike a hospital aspossible,” Dr. Bobba recalls.“I’ve worked and trained inseveral hospitals and theirdrabness can be verydiscouraging for patients. So, Ihad the center built to look like ahouse. On the inside we chosecolors, pictures and furnishingsthat would put patients andfamily members at ease.Interestingly, we did not put inthings such as an aquarium orprovide jigsaw puzzles to help

Redding CancerTreatment Center builds disease-fightingcapabilities whileretaining non-clinicalambience


patients pass time, because wewanted them in and out quicklyfor their convenience.”

Since its opening in 1994,RCTC has been very popularwith patients, he says. “Theyreally love it, and remark on hownice it looks and how pleasedand comfortable they feel in thisplace.”

Practice grows steadily Starting with an Elekta SL18treatment system (upgraded toan SL19) and SLS9 simulator,and himself as the sole radiationoncologist, Dr. Bobba begantreating patients from Redding’s

population of 85,000. Mostpatients still come from Reddingtoday, but within a 15-mileradius are approximately150,000 residents, increasing to350,000 inhabitants in thegreater region. “That doesn’tsound like a lot, but there are alot of retired folks that tilt thepopulation for our specialty quitea bit,” he says.

RCTC’s principal indicationshave always been lung and breastcancer, but prostate cancerpatients began flooding in overthe last three years when Dr.Bobba and his associate WayneKoll, M.D., who joined thepractice in 1999, beganconducting real-time ultrasound-guided brachytherapyimplantations. “We’re the onlycenter that does this in co-operation with the urologists inthe community,” he says. “So,now we see nearly 100% of theprostate patients in Redding.”

Today, half of RCTC’s prostatepatients receive real-timebrachytherapy, while the otherhalf is treated exclusively withexternal beam radiation therapy.Approximately one third of theseed implantations also receive afive-week course of externalbeam radiation therapy to treatthe prostate, seminal vesicles andadjacent lymph nodes. At anyone time, eight prostate cancerpatients are on the treatmentschedule. For all indications,RCTC treats approximately 40patients a day.

Soon after the inception of the

brachytherapy program, thetreatment center continued toimprove its cancer treatmentservices for prostate and head-and-neck cancers with the 2001acquisition of the NOMOSPeacock MIMiC (highlyconformal MLC) system withNOMOS Corvus IMRT software.RCTC also acquired theNOMOS BAT ultrasound systemfor localization of the prostate.

Precise Treatment SystemTM isnewest technology centerpiece in Redding Although RCTC inaugurated itstreatment services with Elektatreatment and simulation equip-ment, acquiring additionalradiation therapy equipment tomeet Redding’s burgeoningdemand wouldn’t be driven bysentimentality for its first system.

“In 2002, we re-did the wholeprocess of evaluation, and invitedboth Varian and Elekta to makesales presentations,” Dr. Bobbasays.

In the end, several keyadvantages convinced Dr. Bobba,Dr. Koll, Chief RadiationOncology Physicist, StevenWallace, Ph.D (hired in 2002),the dosimetrist and radiationtherapists that Precise TreatmentSystemTM would be the rightchoice.

“The therapists and thedosimetrist really liked theoperator-friendliness of theexisting Elekta system,” he says.“Actually, when I evaluated thatsystem in 1993, I interviewed

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many therapists in various Elektacenters and they unanimouslyexpressed their enthusiasm forthe user interface. We researchedportal imaging and realized afterevaluating several EPIDs thatiViewGTTM was the best on themarket, and indeed, the onlyamorphous silicon detector. Theimage quality is excellent.”

“I was very impressed withiViewGTTM and continue to be,”Dr. Wallace observes. “TheEPID’s superb image quality isthe reason we were able to startusing gold markers for dailyprostate localization. TheiViewGTTM software makes itextraordinarily easy to calculatethe shifts patients need to makein order to correct set-up errors.The therapists can implement theshifts very quickly and that was abig plus for us.”

Perhaps the most importantdeal-maker was Elekta’s promiseto assign a senior service engineerto RCTC if they purchasedPrecise Treatment SystemTM.“Before we installed our secondElekta system, Tom Belchambecame our service engineer,” hesays. “We really liked him and

told Elekta we would purchasePrecise Treatment SystemTM if thecompany could convince him tomove to Northern Californiafrom Los Angeles. Since then, hehas done a wonderful job.”

In May 2003, RCTCcompleted acceptance testing onPrecise Treatment SystemTM,equipped with MLCi, iViewGTTM

and PreciseBEAM® IMRT. In July2003, commissioning wascompleted and the system begantreating patients. Concurrentwith the Precise TreatmentSystemTM purchase, RCTC alsoacquired a GE CT-simulator.

RCTC is first to use NOMOS CorvusIMRT software with MLC-equippedElekta system In the summer of 2003, Reddingcontinued its technologyacquisitions with the purchase ofthe NOMOS Corvus IMRTpackage for Precise TreatmentSystemTM. Integration of Corvuswith Precise Treatment SystemTM

would mark the very first MLCi-equipped Elekta treatment systemto have this IMRT software. Thiswasn’t just by chance; RCTC’sPhysicist, Dr. Wallace, worked

for a year at NOMOS focusingon IMRT commissioning and QAon a number of vendors’ MLCmodules, including Elekta’s.

“In 2002, I began working atRCTC, which less than a yearlater would have PreciseTreatment SystemTM with MLC,just as NOMOS was releasingthe new Corvus version, so thecards just fell into place,” Dr.Wallace recalls.

Around the time cliniciansbegan using Precise TreatmentSystemTM to treat patients in July2003, Dr. Wallace began thecommissioning process forCorvus. “We did a fairlysubstantial QA procedure,” hesays. “For our first 10 patients, Idid film dosimetry in axial,sagittal and coronal planes –which is far above requirements,but since this was the first onewe really wanted to make surethe QA was comprehensive. Wethen did a very thoroughindividual patient QA, deliveringeach plan four times, one to anion chamber and then to threeorthogonal films, before we putthe patient on the couch.”

In October 2003, RCTC began

Images of gold seed markers, front and

lateral views from iViewGTTM, both

simulation (top) and portal images

Vidya Bobba, (fourth from left, back row),M.D., Radiation Oncologist and founder of RCTC

“The goal was to make the center as unlike a hospital as possible,”

Dr. Bobba recalls. “I’ve worked and trained in several hospitals and

their drabness can be very discouraging for patients. So, I had the

center built to look like a house.”

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its prostate IMRT program onPrecise Treatment SystemTM. Thetypical case specifies a 5-field,75-segment treatment in a 15-minute time slot.

“Precise Treatment SystemTM

delivers 600MUs per minute,which is a very fast dose rate, butsince we’re using a step-and-shoot technique I was concernedabout our dose accuracy andflatness and symmetry for smallMU segments,” Dr. Wallace says.“I tested it with the ProfilerTM

and the ion chambermeasurements all the way downto 1MU and it was veryacceptable, with dose accuracywithin 1% and flatness andsymmetry within 2%. And thiswas for just a 1 or 2MU beam. Iwas astonished with that.”

In addition to prostate IMRT,RCTC also conducts IMRT forhead-and-neck cancer, and upperabdominal and pelvicmalignancies.

Upgrades, acquisitions continueto better serve communityIn November 2004, RCTCreceived the new Desktop ProTM

control system for PreciseTreatment SystemTM, which Dr.Wallace predicts will shave fiveminutes from IMRT deliverytimes. “Beam loading will thenbe virtually instantaneous, so wewill gain almost a minute perfield,” he says.

In addition, at press time, thetreatment center was upgrading theSL18’s control system to Desktop,Dr. Bobba says.

“Presently, we’re also justabout ready to start HDRbrachytherapy with the Gamma-Med Plus, and we’re going tostart doing MammoSite breastimplants,” he adds. “Our hope isthat – just like with prostate –technology will attract andbenefit many breast cancerpatients.”

Since its founding in 1994,RCTC’s staff has growndramatically as well. MaheshPant, M.D., joined the center inAugust 2004 and now the staffincludes three physicians, twophysicists, a dosimetrist, fivetherapists, an administrator, amedical assistant and twoadministrative assistants.

“The whole story of ReddingCancer Treatment Center is oneof growth,” Dr. Bobba continues.“The community is growing, thepopulation that will need ourservices is also growing fast. So,we’ll continue to acquire thelatest technology to meet theneeds of the residents of Reddingand this region.”

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Princess Margaret Hospital usesElekta Synergy® Platform withXVI, in first ‘solo’ case of prostatecancer patient

On September 29, 2004, Princess Margaret Hospital (PMH), Toronto,Ontario, Canada became the second of four Elekta Synergy®

Platform with XVI, clinical installations to use 4D AdaptiveTM IGRTVolumeViewTM.

The volumetric (cone beam) scanning capability was used tolocalize patient anatomy, with the patient in the treatmentposition just before treatment. The prostate case occurred severalmonths after PMH researchers initiated an investigation comparingElekta Synergy® Platform XVI soft tissue matching with PMH’sbenchmark seed matching program for prostate cancer.

PMH will conduct similar XVI treatments in additional patients whoare contraindicated for fiducial marker implantation, and intendsto expand clinical applications as work progresses.

I M A G E G U I D E D R A D I A T I O N T H E R A P Y

Charles Catton, M.D., RadiationOncologist, Princess MargaretHospital, a member of the ElektaSynergy® Research Group


100. The results showed that, ingeneral, both XVI and seedmatching techniques achievedsimilar accuracy, with MV seedmatching and kV seed matchingbeing virtually equivalent.

“Using the cone beam to matchseeds versus the portal imager tomatch seeds, there is very littledifference,” he reports. “From leftto right (L/R), there’s a 0.7mmspread, from front to back (A/P), a1.5mm spread and from top tobottom (S/I), a 1.1mm spread.”

There was a slightly largerdivergence when comparing MVseed matching with soft-tissuematching. In this case the resultswere: L/R, A/P, S/I = 1.0mm,2.5mm and 2.3mm, respectively.

A statistical comparison (R-coefficient) yielded good toexcellent agreement between thetwo techniques. MV and kV seedmatching showed high correlations(R2 = 0.98, 0.95, 0.89 [L/R, S/I,A/P]). There were lower, but still

good, correlations for shifts basedon soft tissue targeting (R2 = 0.97,0.73, 0.71 [L/R, S/I, A/P]).

Interobserver variability testedreal-world conditions, in whichdifferent individuals would beevaluating images (see below).

Interobserver variability:MV seed matching vs. soft-tissuematching (contoured CTV)

(mm) L/R A/P S/IMV Seeds 0.3 0.9 0.5Soft tissue 1.1 2.8 3.0

Average SD for 5 observers over 5patients

“In MV versus kV seedmatching, different observersagreed virtually all the time, towithin a millimeter,” Dr. Cattonnotes. “With soft tissue, it’s notquite as good, but still prettyacceptable. The top/bottom planeseems to be the most difficult todeal with.”

Although at press time, PMHhad analyzed only a portion of the

acquired VolumeViewTM images,Dr. Catton expects no surprises.

“The XVI images we acquiredwere excellent and were allperfectly useable for the purposesof the study,” he says. “The twomatching techniques are notidentical, but they are comparable.One possible reason that seed andsoft tissue matching onreconstructions in the coronal andsagittal planes are not identical isbecause of the learning curve toaddress. We have analyzed only100 images so far, and it likelytook the therapists about 30images to become accustomed tothe soft tissue matching process.Secondly, the image quality isn’tidentical in all three planes – it’sbest in the axial plane, and youcan’t see the edge of the prostatequite as well in the coronal andsagittal planes.”

Next steps

The next logical evolution ofPMH’s new soft tissue matchingtechnique is to implement thetechnique in real-time.

“Once we limit the therapist to20 minutes to do the match, theirchallenge will be to acquire theimages, do the match and treat thepatient while still maintaining thesame level of accuracy that theyachieved when working quietly inthe evening, and I think we arevery likely to achieve that with thissystem,” he says.


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Since 1997, PMH clinicians haverefined a strategy to addressprostate motion in an effort toimprove the radiation therapyaccuracy. PMH’s benchmarktechnique uses fiducial markersimplanted in the prostate for targetlocalization and to serve asreference points to improve theaccuracy of MR image fusion.

“The use of implanted goldmarkers is a robust method thatenables daily on-line imaging ofthe target, but it does havedisadvantages,” according toCharles Catton, M.D., RadiationOncologist at PMH. “It is invasive,adds time to the planning processand requires an expertinverventionalist to implant theseeds. The markers can alsodegrade planning CT images andthis method can only be used on-line with an amorphous-siliconimager.”

An ongoing study that began inFebruary 2004 comparing PMH’sseed matching technique and softtissue matching using ElektaSynergy Platform® XVIdemonstrated that the two imagematching techniques yieldcomparable accuracy. Accordingly,on September 29, 2004, PMHconducted its first Elekta Synergy®

Platform treatment unaided byportal imaging in a patient forwhich seed implantation wascontraindicated.

“We’re flying solo with thisgentleman,” Dr. Catton says. “Inother words, we’re using ElektaSynergy® Platform’s XVIvolumetric kV imaging capability

(VolumeViewTM) as the soletechnique for image matching. He’shalfway through his 42 fractionsand it’s going great.”

Study demonstratesexcellent image quality with XVI

Because PMH’s study populationwas comprised entirely of patientswith previously implanted fiducialmarkers, investigators had to firstaddress issues of image degrada-tion and observer bias, Dr. Cattonsays.

“The gold seeds right in themiddle of the prostate wereinterfering with the kV imagequality and also causing observersto inadvertently focus on the seedsrather than on the soft tissue,” heobserves. “To deal with theseissues for the purposes of ourstudy, our physicist devised aprogram to electronically delete theseeds from the images.”

Over the next few months,clinicians acquired – and stored forfuture analysis – a volumetric dataset of each patient beforeproceeding with the customaryseed matching protocol usingElekta iViewGTTM electronic portalimager. Any necessary adjustmentswere made to the patient’s set-upbefore treatment. Later in theevening, the therapist would pullup the VolumeViewTM images andperform two retrospective matches.

“They matched MV seedmatching versus kV seed matching,then erased the seeds andcompared MV seed matching tosoft tissue matching,” Dr. Cattonexplains. “This latter match wasdone by moving the cone beamimage to match the target asclosely as possible to determine thedegree of agreement with seedmatching.”

At press time, of the 600VolumeViewTM images acquired,PMH researchers had analyzed


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“We conducted an exhaustivesearch of linear acceleratorvendors specifically looking forIGRT capability, and based onthat search criterion we choseElekta,” says Todd Barnett,M.D., Radiation Oncologist andMedical Director at the Swedish

Cancer Institute, the largestcancer treatment provider in theNorthwest USA. “In the end wereally sensed that Elekta is aheadof the curve technologically andthat Elekta Synergy® is actuallytreating patients clinically. Addi-tionally, we very much wanted astrong partner to team up withus on research, and we believedElekta also strongly valued sucha relationship.”

Another key differentiator, Dr. Barnett points out, is that allElekta products, including Elekta Synergy®, are networkable withthe treatment planning andrecord-and-verify products ofmultiple vendors. “SwedishMedical Center is a largecomplex network that hasinvested significantly in manyvendors’ products,” he says.“Going with our current vendorfor IGRT would have compelledus to use most of its ancillaryproducts as well, which wouldhave been a lengthy, complex andexpensive project.”

Lung cancer program to benefitwith Elekta Synergy®Elekta Synergy® system’s abilityto image patients at the point oftreatment will profit the SwedishMedical Center’s lung cancer

program, Dr. Barnett observes.“We don’t know what’s

happening in these lung cancerpatients, in terms of both inter-and intrafraction target motion,”he says. “Consequently, we’rereluctant to make our marginsmuch tighter due to thisuncertainty. Elekta will beworking with us to develop aprotocol and image registrationtools for Elekta Synergy® thatshould improve these treatmentsand give us greater clinicalconfidence.”

Elekta Synergy® S will completestereotactic center of excellence With the later addition of ElektaSynergy® S, Swedish MedicalCenter will have the toolsnecessary to become a stereotacticcenter of excellence – ElektaSynergy® S for extracranialradiosurgery and Leksell GammaKnife® for intracranial radio-surgery.

“Our medical oncologists andsurgeons want better treatmentoptions for patients with livermetastases, paraspinal metastasesand even pancreatic primarytumors – targets where surround-ing structures are very sensitive,and where we could performsome highly focused treatments.”


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Swedish Medical Center toacquire Elekta Synergy® andElekta Synergy® S systems

The first of three Elekta Synergy®

systems will arrive at the Swedish

Cancer Institute (part of the

Swedish Medical Center, Seattle,

Washington, USA) in early 2005.

Two additional Elekta Synergy®

systems and an Elekta Synergy® S

will be installed in the third and

fourth quarters of next year. The

Elekta acquisitions represent

Swedish Medical Center officials’

realization that Elekta is capable –

today – of supplying the image-

guided radiation therapy (IGRT)

equipment the center would need

to enter a new phase of advanced

radiation therapy.

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N Elekta and Royal Preston Hospital team up to fine tune the physics and clinical aspects of the Beam ModulatorTM

Medical equipment manufacturers always get the most useful assessments of a new product when the device has spenttime operating in the real-world laboratory of the clinic or hospital. These assessments are even more valuable whenobtained before the product is commercially introduced. In 2003, Elekta had the opportunity to test the pre-market versionof Beam ModulatorTM (Elekta’s fine resolution beam-shaping system) at the Royal Preston Hospital (RPH), Rosemere CancerCentre, Preston, Northern England, in collaboration with an Elekta team. The project resulted in many improvements thatare now integrated in the commercial Beam ModulatorTM, a key component of Elekta Synergy® S, Elekta’s platform foradvanced stereotactic radiation therapy.

In the spring of 2003, RPH wasin negotations for a sixth linearaccelerator, one equipped with afine-leaf MLC capable ofstereotactic treatments. Elektawas among the finalists in theevaluation, although Elekta’sBeam ModulatorTM – the beam-shaping component of ElektaSynergy® S – was still in pre-verification development.

“We wanted an integratedMLC, not an add-on device,”says Dr. Michael Kirby,Consultant Physicist, DeputyHead of Radiotherapy Physics atRPH. “Plus, we have a longhistory with Elekta. All our linacsand simulators are from Elektaand it was desirable to maintainour good working relationship.Although we didn’t know thenthat we would be the BeamModulatorTM test site, there stillwas the attraction of beingamong the first centers globallyto have this new technology.Royal Preston has always prideditself on using novel technology

to its fullest and on being at theforefront of routine use of, state-of-the-art radiation therapydelivery for as many patients aspossible. Selecting BeamModulatorTM was a way of beingat the forefront with a newproduct and evaluating it in aclinical environment.”

Royal Preston Hospitalagrees to testingpartnership

What would change thecomplexion of this BeamModuatorTM acquisition,ironically, was a resource issue,Dr. Kirby says. “Royal Prestondidn’t have enough radiographersto operate its complement oflinacs, thus leaving one treatmentmachine underutilized.” AtElekta, meanwhile, BeamModulatorTM was undergoingextensive engineering. In April2003, Elekta took a prototypeBeam ModulatorTM to Brightonand Sussex University Hospitals

to re-evaluate the penumbrafollowing leaf tip modificationsusing the center’s non-commissioned linac. Becausefurther testing was desirable on aclinical machine, Elekta issued afield request to locate a clinicalsite capable of conducting thesetests. In May 2003, PaddyGreally, the Elekta representativefor RPH, notified headquartersthat the Elekta SL15 at RPHcould be modified to incorporateBeam ModulatorTM for testing.

“Paddy told us we would havea shelter available from Juneuntil at least September,” saysBeam ModulatorTM ProjectManager, Mark Knowles. “It waslike gold – we jumped at thechance. We know from vastexperience that when we go to ahospital, especially with a newMLC during pre-verification –when the door is open to acceptdesign changes andimprovements – we can improvethe product.”

On June 17, 2003, a meeting


between Elekta and RPHrepresentatives generated aproposal for a ‘testing in partner-ship’ venture. The agreementcovered installation of the pilotBeam ModulatorTM hardware andsoftware, upgrade to DesktopProTM, set-to-work andcalibration. Additionally, theproject specified a comprehensiverange of tests, including physicsdata collection, safety andperformance, clinical workflowsfrom planning to treatmentdelivery, and verification test casedry runs.

“It was truly a collaborativeventure. The project involvedengineering, clinical and physicsstaff from both Elekta and theRoyal Preston,” Dr. Kirby notes.“Elekta staff installed theDesktop ProTM upgrade and diddata collection, set up theconnection between Precise-PLAN® and Beam ModulatorTM

and tested the optics.Concurrently, Preston staffevaluated the technical ability ofBeam ModulatorTM, examiningleakage characteristics, leafposition accuracy andreproducibility, stability of BeamModulatorTM optical assemblyand MLC camera image, leafpenumbra, connectivity to acommercial TPS, improvementsin isodose shaping anddistributions and analyzed itsability to deliver IMRT.Ultimately, a joint team of Elektaand Preston clinical staff, led bySuperintendent RadiographerHelen Clements, evaluated actual

clinical delivery and workflowaspects by running through anumber of test cases.”

The Beam ModulatorTM andDesktop ProTM upgrades to RPH’sSL linear accelerator, andcalibration and set-to-workactivities occurred in August andSeptember 2003, followed by thestart of the main test period inSeptember.

Testing revealssophisticationof Beam ModulatorTM

The RPH-Elekta team discoveredsome key areas in which BeamModulatorTM could be improved,and was pleased with theintegrity of the device.

“Our overall impression wasthat technically everything lookedvery good,” Dr. Kirby recalls. “Wewere perfectly happy with beamoutputs, wedge factors, leafpositioning reproducibility andstability and how BeamModulatorTM was set up. We wereeven able to deliver an IMRT plan(on a phantom) in the first week.”

On December 2, 2003, theRPH team presented its BeamModulatorTM test results to allElekta users in NorthwesternEngland. With their Elektacolleagues present, RPHrepresentatives discussed engi-neering, radiation therapyphysics, clinical workflow andIMRT verification aspects, andgave Elekta clinical users ahands-on tour of the testingconfiguration.

“We wanted other customersto witness the benefits of BeamModulatorTM in a clinical settingand hear about them fromclinical professionals,” Dr. Kirbysays. Numerous otherpresentations by RPH stafffollowed including; – February 2004, internal

seminars at Elekta, Crawley,UK

– June 2004, presentation aspart of Elekta’s ‘A clinical andproduct review for UK Elektacustomers,’ Crawley, UK

– September 2004, presentationat the IPEM ASM, Universityof York, York, UK

– October 2004, posterpresentation at ESTRO,Amsterdam, the Netherlands.As a result of RPH’s successful

verification testing of BeamModulatorTM, Elekta asked thehospital to help conduct formalvalidation of the technologybeginning in March 2004. RPHalso performed IEC 60976 testingfrom July to September 2004.This improved version of BeamModulatorTM was installed on oneof RPH’s newest Elekta linacs inDecember 2004.

“Validation went exactlyaccording to schedule, becausewe had ironed out virtually alltechnical issues,” Knowles adds.

Testing in partnershipbenefits all parties

RPH professionals take greatpride not only in using advancedtechnology, but also in learning

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enough about it to providedevelopment input. Accordingly,testing Beam ModulatorTM was avery appealing prospect.

“We were deeply interested inknowing exactly what BeamModulatorTM could do and alsoto be involved at a stage wherewe could possibly influence itsdevelopment. To see thatfeedback reflected in the finalclinical product is immenselysatisfying,” Dr. Kirby says.

“The testing in partnershipventure with the Royal Prestonmade Beam ModulatorTM what itis today – a reliable, clinicallyuseable, installable safecomponent, a component thatwill enable Elekta Synergy® S tosatisfy the customer’s advancedstereotactic needs,” Knowlesadds. “Plain and simple, if wehadn’t gone to the Royal Prestonlast autumn, Beam ModulatorTM

would not be as good as it istoday.”

In December 2004, RPHbegan commissioning aproduction Beam ModulatorTM

on its Elekta Synergy® Platform.The system will be used toevaluate the field shapingcapabilities of BeamModulatorTM.

“We will begin using BeamModulatorTM at the end of March2005, focusing on prostate cases,and in time, head-and-neck cases.We believe we will obtainextremely good field shaping forprostate fields due to the finerresolution. The planning studieswe did, led by Glyn Shentall,

Head of Radiotherapy Physics atRosemere showed dramaticimprovements in isodose shapingfor prostate and head-and-necktargets,” Dr. Kirby notes. “Wewill be doing further tests onBeam ModulatorTM robustnessand reproducibility and datacollection. Other UK sites arealso acquiring BeamModulatorTM, and we are goingto keep open channels with themso we can effectively commissionthem in parallel.”

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With the 46th annual meetingof the American Society ofTherapeutic Radiology andOncology (ASTRO, October,Atlanta, Georgia, USA) as thebackdrop, Elekta continued toassert itself as the undisputedleader in image-guidedradiation therapy (IGRT) withtwo major IGRT meetings: thefirst meeting of the ElektaSynergy® Research Group andan IGRT educationalsymposium, each of whichdrew hundreds of attendees.

“These conferences staked outElekta’s clear leadership positionin 4D AdaptiveTM IGRT offeredby Elekta Synergy®, an imageguided robotic linearaccelerator,” says Rajinder SinghDhada, Director, GlobalMarketing at Elekta. “Thesemeetings emphasized theimportant role of IGRT inproviding the most effectiveradiation therapy treatments andthat Elekta is at the forefront inthis field with a 4D AdaptiveTM

IGRT solution in clinics treatingpatients today.”

The Elekta Synergy® ResearchGroup (the first global usersmeeting of Elekta Synergy®

customers) was held October 2,2004 at Atlanta’s Fox Theatre.More than 100 customers, whohave purchased Elekta Synergy®,Elekta Synergy® Platform andElekta Synergy® S, attended theevent, along with Elekta officialsand key members of the ElektaSynergy® Research Group.

The Elekta educationalsymposium on 4D AdaptiveTM

IGRT in the clinic convened onOctober 2, 2004 at the 755 Clubat Turner Field, Home of theAtlanta Braves. This meetingattracted over 450 radiationoncologists, physicists, therapists,dosimetrists and administrators.

Elekta Synergy® ResearchGroup emphasizes clinicalbreakout of world’s first IGRTsystem

To highlight the first global usersmeeting of Elekta Synergy®

customers, talks were given byrepresentatives of the ElektaSynergy® Research Group, thefounding members of which are:William Beaumont Hospital(WBH), Royal Oak, Michigan,USA, the Netherlands CancerInstitute (NKI/AvL), Amsterdam,the Netherlands, ChristieHospital (Christie), Manchester,UK and Princess MargaretHospital (PMH), Toronto,Ontario, Canada).

After confirming ElektaSynergy® system’s ability toacquire single volumetric imageswith VolumeViewTM – to verifytreatment delivery in a widevariety of disease sites – Christiebegan acquiring multiple serialimages, according to Christie’sAnn Henry, M.D.

“We acquired VolumeViewTM

images of patients with bladdercancer for the first five treatmentdays, and then once weeklyduring treatment,” she said. “Thecoronal images were very goodfor verification in 3D treatmentdelivery to the CTV. In 93% ofthe images, the CTV was withinthe PTV and the GTV wasalways within the PTV.”

Conferences confirm Elekta’s continuin g dominance in 4D AdaptiveTM IGRT Christie clinicians alsoobtained promising results inElekta Synergy® lung tumorstudies

“For several patients, we’reacquiring AP and lateral Planar-ViewTM kV static and Motion-ViewTM fluoroscopic qulaityimages over two to threebreathing cycles and evaluatingsystematic and random set-uperrors and lung tumor motion,”she said. “The PlanarViewTM kVstatic images give us much betterbony anatomy definition and softtissue resolution than electronicportal imaging.”

Christie’s prostate studiesentail daily tracking of prostatemotion. Elekta Synergy® is usedfor off-line analysis of CTVcoverage to correct for systematicerrors (translations). Investigatorsare also conducting on-boardplanning studies that employElekta Synergy® VolumeViewTM

volumetric imaging to assess theimpact of deformation.

Di Yan, Ph.D., WBH,discussed ongoing projects inAdaptive Radiation Therapy(ART) utilizing Elekta Synergy®.These include hypofractionationof prostate cancer, acceleratedradiation therapy for lung cancerand partial breast treatment.“These treatment processes alluse Elekta Synergy® for either on-line navigation to correct for

patient position and/or as an off-line tool for adaptive planningmodification to account for thepatient’s temporal changes duringthe treatment course,” Dr. Yansaid.

WBH’s applications afford theopportunity to evaluate ElektaSynergy® system’s variousimaging modes. For example,Motion-ViewTM is used tomonitor breathing motion in lungtreatments. “We can generate adigitally reconstructed imagefrom 4D adaptive planning thatis used to compare with portalMotionViewTM before treatmentto verify how the breathingpattern affects tumor motion andmake treatment correctionsaccordingly,” he says.

The concept is similar forpartial breast treatments, exceptthat implanted markers aretracked. “There’s a surgicalmarker around the tumor bed,”Dr. Yan says. “When we treat thepatient, we use VolumeViewTM

and MotionViewTM to monitormarker position, and determinewhat kind of modification isneeded.”

Additional Elekta Synergy®

updates were given by HarryBartelink, M.D. (NKI/AvL) andDavid Jaffray, Ph.D. (PMH).Elekta Strategic ProgramManager, Elekta, Robert Pitt,provided an update on Elekta’sstereotactic body radiation

therapy IGRT program featuringElekta Synergy® S.

Elekta Research Director,Kevin Brown, shared his viewthat the technical developmentphase of Elekta Synergy® isofficially over. “We are at the endof a period of significant productengineering and moving into anera of very broad clinicaldeployment and development.”

He observed that the ElektaSynergy® Research Consortiumwill enable Elekta Synergy® usersto share best practices and willserve as a clearing house for thecollection of clinical data thatwill sustain funding andreimbursement for 4D AdaptiveTM

IGRT. Jill Stief, Product Manager,

Imaging and Positioning, Elekta,provided product updateinformation on Elekta Synergy®

and imaging software tools,which detailed a number of newsoftware options and packages.Most significant are softwareoptions for three imaging modes:MotionViewTM, PlanarViewTM andVolumeViewTM.

Symposium demonstratesElekta’s leadership positionin IGRT

Clinicians at the four ElektaSynergy® Research Group insti-tutions provided compellingtestimony on the practical imple-


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Synergy®) respiratory-correlatedscan, we have fairly goodvisualization of the tumorthroughout the breathing cycle. Arespiratory curve can be used tocreate a probability densityfunction for tumor motion, todetermine the mean position ofthe tumor based on the breathingcycle position.”

WBH’s 4D union technique(GTV = union of all GTVsacquired during 4D imagescans), incorporates respiratorymotion, enabling accuratedefinition of tumor position overtime, Dr. Kestin notes. “Their4D adaptive technique builds onthis concept, incorporatingfurther information, includingthe probability density functionof tumor location, to reduce themargin while still assuringaccurate coverage of the tumorin all phases of the breathingcycle.”

Laura Dawson, M.D. (PMH),discussed the use of imageguidance in a stereotactic hypo-fractionated radiation treatmentprotocol for primary andmetastatic liver cancer. “Whenfeasible, patients are treated withtheir liver immobilized usingActive Breathing CoordinatorTM.Using daily orthogonal MVportal imaging, PMH therapistsreposition the patient for any

offset in diaphragm position of3mm or more.”

“This has enabled us toimprove the accuracy of set-up,but MV orthogonal imaging haslimits,” Dr. Dawson observed.“The image quality for bone isnot as good as that of kV, andthe process is based on 2Dalignment of vertebral bodies andthe diaphragm, which is asurrogate for the liver.”

Using Elekta Synergy® Platformwith XVI, PMH acquired 53orthogonal sequence mode(MotionViewTM) sessions and 53cone beam images in 15 patientswith liver cancer. “kV imaging offluoroscopic quality allowsconfirmation of the liver positionand range of liver motion due tobreathing immediately beforeeach radiation fraction,” she said.“We recently used ElektaSynergy® with XVI to obtainvolumetric imaging of the liver,immobilized using ActiveBreathing CoordinatorTM. This

3D verification imaging isproviding us with far moreinformation than we had withmegavoltage imaging and we arelooking forward to using ElektaSynergy® Platform with XVI forimage guidance of future livercancer patients.”

Additional presentations onearly experience with IGRT inthe clinic were given by AlvaroMartinez, M.D. (WBH), CharlesCatton, M.D. (PMH, see articlepage 11) and Marcel van Herk,Ph.D. (NKI/AvL).

mentation of Elekta Synergy®

today, at the Elekta EducationalSymposium on 4D AdaptiveTM

IGRT in the Clinic. Christie’s Jonathan Sykes

discussed two possible futureapplications of Elekta Synergy®,Intensity Modulated Arc Therapy(IMAT) and kV fluoroscopy. “InIMAT, Elekta Synergy® could beemployed in an off-line adaptiveprotocol for auditing patientposition during treatment,” hesaid. “Performing the gantryrotations for both imaging andtreatment simultaneously wouldsave time, but we would have todetermine how much MV scatteris encountered at the kV panel.”

Utilizing a Farmer chamber,Sykes measured MV scatter to be0.14Gy/min. or less than 0.2% ofthe dose at dmax. “MV scatterdeteriorates image quality interms of contrast-to-noise, but itmay be possible to improveimage quality by using scatterreduction techniques,” heobserved. “The reconstructionimage quality is sufficient forautomated 3D registration ofhigh-contrast anatomicalinterfaces, such as bone-tissueand tissue-air interfaces.”

Sykes also discussed thepotential of Elekta Synergy®

using either or both kV and MVimaging systems for real-time

tracking of tumor motion in theupper abdomen and lung. “Itmay be possible in some cases totrack the movement of features inthe image and use these to infertumor motion,” he said. “Analternative is to track the motionof radiographic markersimplanted in the tumor. Bothstrategies focus on finding a wayto gate treatment based on tumorposition.”

“Challenges arise in real-timemeasurement since both MV andkV beams are needed; the tumormay fall outside dose tolerance,necessitating turning off the MVbeam and losing a keymeasurement dimension,” hesaid. “Similarly, if the MV beamwere an IMRT prescription, theMLC would inevitably obscurethe marker of the feature beingtracked. Therefore, the future ofreal-time measurement usingElekta Synergy® would be forvalidating indirect methods ofmonitoring tumor motion, such

as tracking the surface of thelung or validating using ActiveBreathing CoordinatorTM.”

To test the effects of MVscatter on contrast detail, Sykesimaged a contrast detail testobject and gold seeds sandwichedbetween two slabs of solid water,with and without the MV scatter.“MV scatter reduces the visibilityof all sizes of contrast detail,which will make automaticdetection of small objects, suchas radiographic markers, moredifficult,” he explained.“Solutions include eitherincreasing the exposure orincreasing marker size. Apromising alternative could beusing synchronous interlacing ofMV and kV exposures.”

Larry Kestin, MD (WBH),discussed the difficulties in free-breathing slice-based CT of lungtumors and how Elekta Synergy®

was used to address thesechallenges.

“Unlike conventional CT,respiratory-correlated cone beamCT doesn’t require an externalsignal – you can just use thediaphragm from the images,” hesaid. “As long as we know inwhich breathing cycle phase eachprojection was obtained, we canreconstruct these images in a CTdata set in that position of thebreathing cycle. In the (Elekta

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TopKevin Brown, Elekta Research Director,

and David Jaffray, PhD., PMH, at the

seminal meeting of the Elekta Synergy®

Research Group, October 2nd, 2004Bottom Marcel van Herk and Harry

Bartelink, M.D., NKI/AvL, presenting at

the Elekta Educational Symposium on 4D

AdaptiveTM IGRT, October 2nd, 2004

“The PlanarViewTM

kV static images give usmuch better bony

anatomy definition andsoft tissue resolution thanelectronic portal imaging.”

“In the (Elekta Synergy®)respiratory-correlated

scan, we have fairly goodvisualization of the tumorthroughout the breathing

cycle.”


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n In the breast cancer area,

demonstrators showed how

Active Breathing CoordinatorTM

can help shield the heart from

radiation, while OmniWedgeTM

software creates virtual wedges

in any direction, that help obtain

greater dose conformality to the

treatment area.

n The lung cancer area featured

Stereotactic Body Frame®, a tool

for enabling increased dose

delivery to the target in a

reduced number of fractions –

one clinic is ensuring high

conformality for lung tumors

using real-time MotionViewTM

during patient set-up on Elekta

Synergy®

n Elekta Synergy® VolumeViewTM

dramatically increases targeting

accuracy by enabling the

visualization of soft tissue shape

and position, according to one

clinic’s experience, as highlighted

in the prostate cancer area.

Another clinic uses

VolumeViewTM in an off-line

adaptive manner to measure

systematic errors, enabling PTV

reductions.

n Lastly, the metastatic disease

area highlighted the use of

Leksell Gamma Knife® 4C to treat

multiple brain metastases on an

out-patient basis. In addition,

one clinic is considering the use

of Elekta Synergy® to rapidly

image, verify and palliatively

treat a patient suffering pain

from a spinal metastasis.

An estimated 10,000 radiationoncology professionals attendedthe 46th ASTRO in Atlanta,Georgia, USA, October 3-7, 2004at the Georgia World CongressCenter.

Elekta Synergy®, ElektaSynergy® S and 4D AdaptiveTM

IGRT formed the centerpiece ofElekta’s offering. Around thisunequaled IGRT portfolio, Elektaalso built a forceful case for itscontinuing pre-eminence inneurosurgery and radiationoncology solutions with its broad

arsenal of disease-fightingweapons, including PreciseTreatment SystemTM, LeksellGamma Knife® 4C, Precise-PLAN®, PreciseBEAM® IMRT,Stereotactic Body Frame®, andActive Breathing CoordinatorTM.

At ASTRO 2004, Elektapresented IGRT, neurosurgeryand radiation oncology, underthe theme of “Disease-focusedSolutions,” clinical solutions thatphysicians can harness to treatbreast, lung, prostate andmetastatic disease. Elekta’s

sophisticated stereotactic toolsand accurate disease targetingtechnology become potentweapons in the hands ofclinicians, giving them the powerto fight cancer more aggressivelythan ever before withoutendangering healthy tissue.

“Only Elekta gives cliniciansthe power to treat their patientswith unmatched accuracy usingIGRT or disease-focusedsolutions,” says Anthony DeCarolis, President and CEO ofElekta North America, Inc.

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“Elekta remains at the forefrontof technology, business solutionsand treatment solutions. Ourcommitment to research anddevelopment, and to expandingour solutions will continue tofuel Elekta’s growth, as well asthe growth of centers using ourtechnologies.”

Elekta Synergy® still drawingthousands

The ASTRO 2004 Elekta Synergy®

exhibit continued to attract intensecuriosity and attention, even a fullyear since Elekta Synergy®, theworld’s first IGRT system, waslaunched at ASTRO 2003.Continuous Elekta Synergy®

demonstrations were given at theElekta exhibit during the five-daymeeting, attracting large audiences.Attendees learned that ElektaSynergy® systems in clinical sitesworldwide have acquired nearly2,000 images among 200 patientsand across a broad spectrum ofclinical indications.

This year’s conferencehighlighted new softwareoptions; single image mode(PlanarViewTM), sequence imagemode (MotionViewTM) andvolume mode (VolumeViewTM),part of Elekta Synergy® X-rayvolume imaging technology. Alsoat ASTRO 2004, a total of 15presentations and 16 postersfeatured Elekta 4D AdaptiveTM

IGRT, adding to an Elekta IGRTbibliography that currently lists127 presentations and papers in2004 alone.

Elekta Synergy® has made suchtremendous progress in the lastyear that Elekta had the criticalmass of interest in the radiationoncology community and wealthof clinical experience within theElekta Synergy® Research Groupto host two IGRT meetings atASTRO 2004: the very firstmeeting of the Elekta Synergy®

Consortium and an IGRTeducational symposium, each ofwhich drew hundreds ofattendees.

“In the arena of IGRT,ASTRO 2004 was a stunningsuccess for Elekta,” says RajinderSingh Dhada, Director, GlobalMarketing at Elekta. “Elektaclearly demonstrated itscommittment and the leadershipposition with clinically working4D AdaptiveTM IGRT solutionsthat we can offer doctors today.This was reflected in theattention Elekta Synergy®

received at the exhibit, thenumber of papers and posters onElekta 4D AdaptiveTM IGRT andthe incredible attendance at ourIGRT events.”

A weapon for all common clinical challenges

At the four corners of Elekta’sASTRO 2004 exhibit weredisease-based clinical solutions,featuring sophisticated Elektastereotactic tools and disease-targeting technologies.

Backed by:

n Scientific papersn The Elekta Synergy® consortiumn The Elekta IGRT educational

symposiumn A visitor-packed Elekta IGRT

demonstrations and n Ample evidence of Elekta 4D

AdaptiveTM IGRT in clinicalpractice today

Elekta made apowerful statement atASTRO 2004 that itleads the world inIGRT


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Elekta’s IGRT leadership on display at ASTRO 2004

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Corporate Head OfficeStockholm, SwedenTel +46 8 587 254 00Fax +46 8 587 255 [email protected]

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