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Saudi Particle Therapy Centre (SPTC) Update 2017

Ahmed Outif

Presentation

1) Introduction to proton therapy

physics, radiobiology and technology.

2) Why invest in proton therapy.

3) SPTC project phases.

4. How far is the project?

Introduction

The aim of radiation therapyTo deliver sufficiently high dose of radiation to

tumour cells

⇒maximal tumour cell kill, = tumour control

Minimal dose to the normal surrounding tissue

⇒ minimize complications, maintain viability andfunction,

Why proton and heavy ion therapy ?

Energy loss by charged particles

• Linear energy transfer (Bethe-Bloch equ.):

• The stopping power (Energy deposition) α 1/V2

thus energy deposition increase with decreasingenergy.– It is max at lower energy E= 0.

• The stopping power (Energy deposition) α Z2 thusenergy deposition increased with charge

Bragg peak

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Advantages of proton therapy Proton stops completely within the tumor and does not cause any damage

to normal tissues beyond tumor site.

Thus proton therapy kills tumor cells with only limited damage to normal

cells before tumor and no damage to normal cells beyond tumor cells.

This allows physician to deliver higher dose to the tumor which will translate

in better cure rate.

As this kind of treatment deliver very minimum radiation dose to the normal

tissues before the tumor and no radiation dose after tumor, this kind of

treatment is considered the best treatment for pediatric patients.

This kind of treatment limit the secondary cancers that might occur as aresult of conventional photon therapy treatment.

Advantages of Proton therapy

• Low entrance dose

• Sharp distal fall off of dose

–⇒ Zero dose beyond the tumour

• Less lateral scattering

–⇒ sharper lateral penumbra

• Higher uniform dose

–⇒ better tumour control

• Lower integral dose

• Fewer complications

Photon Proton

Proton Vs Photon

Proton radiobiology

Proton Therapy: Radiobiological Aspects

• Slightly higher RBE (1.1 to 1,6 of C0-60).

• Excellent hypo-fractionation technique. As youcan give less dose to critical structure, newfractionation regiment may be implemented(Hypo-fractination).

• Heavy ions have better RBE, however no much clinical experience yet.– Very little cell cycle dependence

– Increased sensitivity to high resistance hypoxic cells

– Increased sensitivity to slowly proliferating cells

– Fewer fractions, higher doses ⇒ Reduced overall treatment time

Acceleration systems for proton therapy

Accelerator systems for proton therapy

• Cyclotron:– Fixed energy usually 230 to 250 Mev.– Thus require degrader to deliver the

dose to the site of interest.– This result in neutron, extra shielding

and isotopes production.

• Synchrotron:– Variable energy.– Magnetic field gradually increases as

energy increases– Particles accelerated in a ring, not a disk– Allows for cheaper construction.

• Currently only ProTom usessynchrotron.

1946

1996

2000

2008

Harvard

IBA

Accel

Still River

Multi gantry vs Single gantry approaches

Proton therapy (Multi gantry justify the cost)

Still River Systems treatment room concept

Proton therapy (One cyclotron per room)

Different kinds of gantries

Kinds of gantries

Hospital-based facility

Rotating Gantry

Fixed beam

• Rotating 180 and 360• Fixing with x- and y- beam

steering• Inclined

Beam spreading

Beam spreading

• A mono- energetic proton Bragg peak is not very useful for treating anything other than small tumours.

Why we need energy extraction techniques? (Beam spreading)

• Bragg peak has a finite size.• Tumours are usually present at various depths

within patients.• Patients have different sizes.• Tumours have different sizes, usually bigger than

Bragg area.• We need to deliver homogeneous dose to all

cells of the tumour, other wise we will not curethe patient.

• To make proton beam useful, one needs tospread out the beam “both” laterally andlongitudinally.

Energy extraction technique(Depth modulation = Spreading Brag

peak longitudinally)

Energy extraction techniques• Modulation of beam energy.

– Can only be done withSynchrotron.

• Range Shifter (Use tissueequivalent modifier).– Used with cyclotron (fixed

energy).– Extra material is used to bring

the dose forward to thedesired distal depth.

– This is called Scan of Braggpeak (SOBP).

SOBP increases entrance doseand integral dose to patient.

Modulator wheel(placed farther from patient = less neutron dose

Range (energy) modulator is usually made of lowatomic number material

Spread-Out

Bragg Peak

(SOBP)

RM

Wheel rotates @ 10 / sec

Spread-Out

Bragg Peak

(SOBP)

RM

Wheel rotates @ 10 / sec

Spread-Out

Bragg Peak

(SOBP)

RM

Wheel rotates @ 10 / sec

Extending the beam laterallyTreatment techniques

• Scattering• Scanning

Extending the beam laterally (single scattering technique)

• Use single scatter to spread thebeam.

• Place the patient further from thescatter to get larger field.

• Only flattening part of the beam isused.

• Disadvantage: less number ofproton reach the patient (poorefficiency).

• Single scatter technique is usedfor eye treatment.

• High Z material is used asscattering material.

Passive scattering technique

Brass Collimator Lexan

Modulator wheelAperture

Bolus Inhomogeneity

Beam

• Require moulding system.• High neutron dose to patient.• Storage of the material for decay.

limitation of Passive scattering technique

Active scanningtreatment technique

Scanning techniques

• Proton beam is usually produced withdiameter of 2 to 3 mm.

• Proton beam is charged particle and can becontrolled via magnet.

There are two scanning techniques:

Spot (step and shoot) scanning.Continuous scanning.

Demonstration of scanning technique

Tumor

Brainstem

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SPTC Project background

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Why proton therapy Currently no other proton therapy center is available in

Middle East and Africa.

Number of diagnosed cancer cases increase yearly.

According to the 2012 Saudi cancer registry: Total of:

703 new pediatric (age 0 to 14 years old) cases were

registered.

Total of 1012 new (age 15 to 25 ) cancer cases were

registered.

For adult a total of 14336 new adult cases were registered.

These numbers are expected to increase with adoption of

new diagnostic tools.

All pediatric patients and large number of adult patients areexpected to need proton therapy.

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Project background• Cancer is one of the most killers in Saudi Arabia.

• Early detection of cancer increases the survival chance.

• The government of Saudi Arabia encourage private investor to invest in

different health related sectors.

• Currently no Saudi Arabian center offer proton therapy treatment for

cancer patients.

• To fill this gap Abdulmohesen Almohaisin Company submitted a proposal

to build and operate the first Saudi Arabian proton therapy center in Saudi

Arabia.

• This proposal accepted first by ministry of health and eventually received

the blessing of King Abdullah bin Abdulaziz on 26th of Dhul-Qa’dah1431 H

• King Fahad Medical City (KFMC) was then chosen by ministry of health to

houses this national project.

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Project background• It was chosen to build the project on a rented land from KFMC

such that the project complete the multicomponent of health

excellent centers in KFMC which include National neuroscience

center, cancer center, research center and proton therapy

center.

• It was also agreed that ministry of health will refer “exclusively”

all potential proton therapy patients to the Saudi proton

therapy center (SPTC).

• In return SPTC agreed to charge “ministry of health” a fixed

price for each patient treated by the center.

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Overview of the project• SPTC projects consists of:

• 250 Mev cyclotron feeding 3 rotating rooms, one fixed beam and one eye andresearch room.

• A dedicated Energy selection system with dedicated beamline to feed the fivetreatment rooms.

• One PET/CT for PETCT simulation. PET will also be used for dosimetricverification.

• Large number of Eclipse Treatment Planning.

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Overview of the project• The full center will also be managed by ARIA® oncology information system.

• Number of clinics offices for physician, physicists and administration.

• The center was developed and equipped such that it will use the latest protontherapy treatment delivery technique “Scanning Technique”.

• A big room was also dedicated for research.

• The weekend will be dedicated for selected scientific research.

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Overview of the project• The center is designed to treat up to 2200 patients /year.

• However the feasibility study was done base on 1233 patients /year.

SPTC Project Phases

Phase I Equipment RFP, bid, decision and

contracting

SPTC history

• On 16/9/1432 H (16 August 2011); KFMC (andministry of health) signed contract withAlmohisen group (Saudi Proton therapycompany) to establish and operate (for 24years) Saudi Proton therapy center.

• This center is to be established within KFMCland.

• This contract was then approved by the king.

SPTC history

• Immediately after signing this contract, KFMCteam was established to plan for this projectunder the leadership of Dr. Abdullah Alamro(Radiation oncologist and KFMC CEO) andmembership of Dr. Moshabab Assiri (Chairmanof Radiation oncology Dept) and Dr. AhmedOutif (Head of medical Physics Dept).

• The committee was charged with the task toprepare RFP.

• The RFP was ready within one month.

SPTC history

• List of the potential bidder was accumulated.

• RFP was emailed to all potential bidders withintent form for them to fill incase they wouldlike to participate in this bid.

• Softcopies of the RFP were emailed toaccepted bidders.

• February 10, 2011 was given as a deadline forreceiving intent form.

• April 1, 2011 was given as the deadline forreceiving responses to the RFP.

SPTC history

• 5 companies submitted there bid.

• Tender analysis.

• Two companies were short listed (Varian andSumitomo).

• Negotiation (Varian win).

• Draft of contract (about 3 months).

• Contract signed on 14/1/2012.

Phase II Shield design and Equipment building

interface

Shield calculation

• Shield documents:

– NCRP 144.

– DIN 25413

– PTCOG

– BULK

• Technical document (Varian).

• Clinical assumptions and workload.

• Building Layout.

Shield calculation

• Two physicists calculated shield independently.– Dr. Wilhelm Goldstein (hired by Varian), used DIN.– Dr. Outif; used DIN and BULK for banker, Cyclotron and

beam line. NCRP and PTCOG for maze (see example Excelsheet).

• Comparison of results.• Correction and finalization of shield calculation (end

of Apr 2012).• Penetration was left to be assessed after engineers

finalize various penetration (air duct, water pips . . .Etc)

Phase III BID

This is an architecture and engineering design of the building and interface of

proton equipment to the building.

Time line

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Current status of the projectThe building was made ready for equipment rigging on

October 2016.

Cyclotron installation, cabling and power supply installationfinalized on Nov 2016.

Beamline installation finalized on Dec 2016.

Gantry 1 installation finalized on August 2016.

Gantry 2 installation finalized on August 2016.

Gantry 3 installation finalized on Sept 2016.

Beamline and fixed beam room on Nov 2016

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Current status of the project

Acceptance test of G1 expected on Sept 2017. Delayed by 5

to 6 months.

Acceptance test of G2 expected on Nov 2017. Delayed by 5

to 6 months.

Acceptance test of G3 expected on Feb 2018.

Acceptance test of G4 expected on Jun 2018

Acceptance test of fixed beam expected on June 2018

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Project Plan

Pictures from the site

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Oct 2016, Site ready for equipment installation BRIEF:

• Concrete works are

completed.

• MEP works, finishing works

and T&C are completed

for the RFE.

• De-snagging is in progress.

• MEP works and finishing

works are in progress in the

proton offices.

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Gantry Room.

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

MEP WORKS. SHELL STEEL STRCUTRE PLATES.

STAIRS SLAB OPEINIG

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Electrical Substations .

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Electrical Substations .

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Electrical Substations .

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Magnetic Substations .

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Pump rooms.

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

BRIEF:

• Concrete works are completed.

• MEP works, finishing works

and T&C are completed for

the RFE.• De-snagging is in progress.

• MEP works and finishing works

are in progress in the proton

offices.

Services Tunnels.

OCT 2016, SITE READY FOR EQUIPMENT INSTALLATION

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NOV 2016; CYCLOTRON INSTALLATION

• Video 1

• Video 2

• Video 3

• Video 4

• Video 5

• Video 6

• Video 7

• Video 8

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NOV 2016; CYCLOTRON RIGGING

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NOV 2016; BEAMLINE INSTALLATION

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AUGUST 2016; GANTRY INSTALLATION

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AUGUST 2016; GANTRY INSTALLATION

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NOV 2016; FIXED BEAM INSTALLATION

Today 7/11/2017

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NOV 2017

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NOV 2017

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NOV 2017

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NOV 2017

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NOV 2017

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FINAL PROJECT PICTURE

Others

• Research.

• Management.

. . . . etc

ThanksSPTC in 2017