History of hadron therapy accelerators

Multidisciplinary Collaboration and Novel Technological Advances in Hadron Therapy

The battle against cancer remains a top priority for society, with an urgent need to develop therapies capable of targeting challenging tumours while preserving patient's quality of life. Hadron Therapy (HT), which employs accelerated beams of protons, carbon ions, and other charged particles, represents a significant frontier in cancer treatment. This modality offers superior precision and efficacy compared to conventional methods, delivering therapeutic the dose directly to tumours while sparing healthy tissue. Even though 350,000 patients have already been treated worldwide with protons and 50,000 with carbon ions, HT is still a relatively young field and more research as well as novel, cost-effective and compact accelerator technologies are needed to make this treatment more readily available globally. Interestingly the very first patient was irradiated with protons in September 1954, the same month and year CERN was founded. Both of these endeavours are embedded in cutting edge technologies and multidisciplinary collaboration. HT is finally gaining ground and, even after 70 years, the particle therapy field continues innovating and improving for the benefits of patients globally. Developing technologies that are both affordable and easy to use is key and would allow access to more patients. Advances in accelerator-driven Boron Neutron Capture Therapy (BNCT), image-guided hadron beams delivery, clinical trials and immunotherapy, together with the recent interest and advances in FLASH therapy, which is currently an experimental treatment modality that involves ultrahigh-dose rate delivery, are just a few examples of innovation that may eventually help to provide access to a larger number of patients.

Conceptual design of sandwich walls for shielding against secondary neutrons using MC simulations with FLUKA

FLUKA Monte-Carlo transport code was employed to evaluate the secondary neutron spectra emerging from spherical sandwich shielding configurations composed of concrete and soil, similar to that used at the particle therapy facility MedAustron. This study provides a comparative analysis of neutron spectra attenuated by a concrete-soil-concrete (CSC) sandwich wall shielding configuration versus a full concrete wall design (CCC). Furthermore, we enhanced the shielding performance of the CSC configuration by adding an additional concrete layer (CCSC) to achieve results comparable to the CCC shielding. Two scenarios were tested for shielding performance: (1) primary protons at 100 MeV, and (2) primary carbon ions (C-ions) at 190 MeV/u. Our simulations with primary protons of 100 MeV showed that adding additional internal concrete wall to the CSC configuration, therefore designing the CCSC configuration, the RP performance becomes slightly improved - the HE-peak drops from (1.43 ± 0.11)10-11 to (5.62 ± 0.3)10-12, about 2.5 times. Still, the HE-peak of the exiting neutron spectrum from CCC -(6.29 ± 1.87) 10-13 is about 9 times lower than that exiting CCSC - (5.62 ± 0.3) 10-12. Our simulations with primary C-ions showed that by placing an additional internal concrete wall to the CSC configuration (CCSC) the RP performance becomes slightly improved - the exiting HE peak can be further attenuated from (6.92 ± 0.40)10-9 for CSC to (3.79 ± 0.15)10-9, becoming comparable to the one exiting the CCC configuration, (0.92 ± 0.04)10-9, only 4 times higher. Future research should be focused on improvements of the RP performance of the CCSC, by increasing the soil layer thickness and taking into consideration the humidity (water content) in the soil and concrete and also improve the number of primaries to 109 or even 1010 for better statistical outcome.

Understanding Relative Biological Effectiveness and Clinical Outcome of Prostate Cancer Therapy Using Particle Irradiation: Analysis of Tumor Control Probability With the Modified Microdosimetric Kinetic Model

PURPOSE

Recent experimental studies and clinical trial results might indicate that-at least for some indications-continued use of the mechanistic model for relative biological effectiveness (RBE) applied at carbon ion therapy facilities in Europe for several decades (LEM-I) may be unwarranted. We present a novel clinical framework for prostate cancer treatment planning and tumor control probability (TCP) prediction based on the modified microdosimetric kinetic model (mMKM) for particle therapy.

METHODS AND MATERIALS

Treatment plans of 91 patients with prostate tumors (proton: 46, carbon ions: 45) applying 66 GyRBE [RBE = 1.1 for protons and LEM-I, (α/β)x = 2.0 Gy, for carbon ions] in 20 fractions were recalculated using mMKM [(α/β)x = 3.1 Gy]). Based solely on the response data of photon-irradiated patient groups stratified according to risk and usage of androgen deprivation therapy, we derived parameters for an mMKM-based Poisson-TCP model. Subsequently, new carbon and helium ion plans, adhering to prescribed biological dose criteria, were generated. These were systematically compared with the clinical experience of Japanese centers employing an analogous fractionation scheme and existing proton plans.

RESULTS

mMKM predictions suggested significant biological dose deviation between the proton and carbon ion arms. Patients irradiated with protons received (3.25 ± 0.08)  GyRBEmMKM/Fx, whereas patients treated with carbon ions received(2.51 ± 0.05)  GyRBEmMKM/Fx. TCP predictions were (86 ± 3)% for protons and (52 ± 4)% for carbon ions, matching the clinical outcome of 85% and 50%. Newly optimized carbon ion plans, guided by the mMKM/TCP model, effectively replicated clinical data from Japanese centers. Using mMKM, helium ions exhibited similar target coverage as proton and carbon ions and improved rectum and bladder sparing compared with proton.

CONCLUSIONS

Our mMKM-based model for prostate cancer treatment planning and TCP prediction was validated against clinical data for proton and carbon ion therapy, and its application was extended to helium ion therapy. Based on the data presented in this work, mMKM seems to be a good candidate for clinical biological calculations in carbon ion therapy for prostate cancer.

An investigation of neutron shielding and activation performances of four types of concrete for carbon ion therapy facility

Carbon ions have unique physical and biological properties that allow for precise targeting of tumors while minimizing damage to surrounding healthy tissues. The emitted neutrons dominate the radiation field in the treatment room and pose challenges for radiological shielding. Concrete is extensively utilized in the construction of radiotherapy facilities due to its good shielding characteristics, and it can be easily poured into the desired shapes and thickness. The difference in composition of concrete affects the characteristics of neutron attenuation and activation performance. Therefore, the purpose of this study is to clarify the shielding properties and activation performances of four types of concrete for carbon ion therapy facilities. The Monte Carlo method is used to analyze the neutron spectra from thick targets upon carbon ion bombardment. Furthermore, the deep attenuation efficiency of the secondary neutron in different compositions of concrete is discussed. The shielding design is developed to ensure compliance with the prescribed dose limit outside the shielding during operation. Finally, the induced radioactivity in concrete is estimated for both short-term and long-term operation. The produced radionuclides inventories and depth profiling are determined. This study reveals the shielding and radioactivity issue of carbon ion therapy facilities and is expected to aid in the design or construction of similar facilities.

The dose accumulation and the impact of deformable image registration on dose reporting parameters in a moving patient undergoing proton radiotherapy

INTRODUCTION

Potential changes in patient anatomy during proton radiotherapy may lead to a deviation of the delivered dose. A dose estimate can be computed through a deformable image registration (DIR) driven dose accumulation. The present study evaluates the accumulated dose uncertainties in a patient subject to an inadvertent breathing associated motion.

MATERIALS AND METHODS

A virtual lung tumour was inserted into a pair of single participant landmark annotated computed tomography images depicting opposite breathing phases, with the deep inspiration breath-hold the planning reference and the exhale the off-reference geometry. A novel Monte Carlo N-Particle, Version 6 (MCNP6) dose engine was developed, validated and used in treatment plan optimization. Three DIR methods were compared and used to transfer the exhale simulated dose to the reference geometry. Dose conformity and homogeneity measures from International Committee on Radioactivity Units and Measurements (ICRU) reports 78 and 83 were evaluated on simulated dose distributions registered with different DIR algorithms.

RESULTS

The MCNP6 dose engine handled patient-like geometries in reasonable dose calculation times. All registration methods were able to align image associated landmarks to distances, comparable to voxel sizes. A moderate deterioration of ICRU measures was encountered in comparing doses in on and off-reference anatomy. There were statistically significant DIR driven differences in ICRU measures, particularly a 10% difference in the relative D98% for planning tumour volume and in the 3 mm/3% gamma passing rate.

CONCLUSIONS

T he dose accumulation over two anatomies resulted in a DIR driven uncertainty, important in reporting the associated ICRU measures for quality assurance.

Ultrasound-assisted carbon ion dosimetry and range measurement using injectable polymer-shelled phase-change nanodroplets: in vitro study

Methods allowing for in situ dosimetry and range verification are essential in radiotherapy to reduce the safety margins required to account for uncertainties introduced in the entire treatment workflow. This study suggests a non-invasive dosimetry concept for carbon ion radiotherapy based on phase-change ultrasound contrast agents. Injectable nanodroplets made of a metastable perfluorobutane (PFB) liquid core, stabilized with a crosslinked poly(vinylalcohol) shell, are vaporized at physiological temperature when exposed to carbon ion radiation (C-ions), converting them into echogenic microbubbles. Nanodroplets, embedded in tissue-mimicking phantoms, are exposed at 37 °C to a 312 MeV/u clinical C-ions beam at different doses between 0.1 and 4 Gy. The evaluation of the contrast enhancement from ultrasound imaging of the phantoms, pre- and post-irradiation, reveals a significant radiation-triggered nanodroplets vaporization occurring at the C-ions Bragg peak with sub-millimeter shift reproducibility and dose dependency. The specific response of the nanodroplets to C-ions is further confirmed by varying the phantom position, the beam range, and by performing spread-out Bragg peak irradiation. The nanodroplets' response to C-ions is influenced by their concentration and is dose rate independent. These early findings show the ground-breaking potential of polymer-shelled PFB nanodroplets to enable in vivo carbon ion dosimetry and range verification.

Ultra‐High dose rate radiation production and delivery systems intended for FLASH

Higher dose rates, a trend for radiotherapy machines, can be beneficial in shortening treatment times for radiosurgery and mitigating the effects of motion. Recently, even higher doses (e.g., 100 times greater) have become targeted because of their potential to generate the FLASH effect (FE). We refer to these physical dose rates as ultra‐high (UHDR). The complete relationship between UHDR and the FE is unknown. But UHDR systems are needed to explore the relationship further and to deliver clinical UHDR treatments, where indicated. Despite the challenging set of unknowns, the authors seek to make reasonable assumptions to probe how existing and developing technology can address the UHDR conditions needed to provide beam generation capable of producing the FE in preclinical and clinical applications. As a preface, this paper discusses the known and unknown relationships between UHDR and the FE. Based on these, different accelerator and ionizing radiation types are then discussed regarding the relevant UHDR needs. The details of UHDR beam production are discussed for existing and potential future systems such as linacs, cyclotrons, synchrotrons, synchrocyclotrons, and laser accelerators. In addition, various UHDR delivery mechanisms are discussed, along with required developments in beam diagnostics and dose control systems.

Remotely Activated Nanoparticles for Anticancer Therapy

Cancer has nowadays become one of the leading causes of death worldwide. Conventional anticancer approaches are associated with different limitations. Therefore, innovative methodologies are being investigated, and several researchers propose the use of remotely activated nanoparticles to trigger cancer cell death. The idea is to conjugate two different components, i.e., an external physical input and nanoparticles. Both are given in a harmless dose that once combined together act synergistically to therapeutically treat the cell or tissue of interest, thus also limiting the negative outcomes for the surrounding tissues. Tuning both the properties of the nanomaterial and the involved triggering stimulus, it is possible furthermore to achieve not only a therapeutic effect, but also a powerful platform for imaging at the same time, obtaining a nano-theranostic application. In the present review, we highlight the role of nanoparticles as therapeutic or theranostic tools, thus excluding the cases where a molecular drug is activated. We thus present many examples where the highly cytotoxic power only derives from the active interaction between different physical inputs and nanoparticles. We perform a special focus on mechanical waves responding nanoparticles, in which remotely activated nanoparticles directly become therapeutic agents without the need of the administration of chemotherapeutics or sonosensitizing drugs.

Particle therapy in the future of precision therapy

The first hospital-based treatment facilities for particle therapy started operation about thirty years ago. Since then, the clinical experience with protons and carbon ions has grown continuously and more than 200,000 patients have been treated to date. The promising clinical results led to a rapidly increasing number of treatment facilities and many new facilities are planned or under construction all over the world. An inverted depth-dose profile combined with potential radiobiological advantages make charged particles a precious tool for the treatment of tumours that are particularly radioresistant or located nearby sensitive structures. A rising number of trials have already confirmed the benefits of particle therapy in selected clinical situations and further improvements in beam delivery, image guidance and treatment planning are expected. This review summarises some physical and biological characteristics of accelerated charged particles and gives some examples of their clinical application. Furthermore, challenges and future perspectives of particle therapy will be discussed.

Monte Carlo characterization and benchmarking of extended range REM meters for its application in shielding and radiation area monitoring in Compact Proton Therapy Centers (CPTC)

Compact Proton Therapy Centers, CPTC, have a single treatment room, and are technologically more affordable, smaller, advanced and easier to use. From a radiological protection point of view, the leading concern in CPTC are interactions of protons with components of the facility and patients that yield a broad emission of secondary particles, mainly high-energy neutrons, up to 230 MeV, and photons. Optimal design of shielding involves theoretical assumptions in the design phase and, consequently, experimental measurements with extended range neutron detectors must be carried out in the facility during the commissioning period to verify the design, assumptions and building of the enclosures. There are almost 50 CPTC under construction and planning around the world, hence the improvement of methodologies to verify the shielding and to evaluate the dose to workers and general public in CPTC is a trending issue. The aim of this work was to evaluate and compare the response of two commercial extended range REM meters, WENDI-II and LUPIN-II, for their application in shielding verification and radiation area monitoring in CPTC facilities, by estimating the ambient dose equivalent, H*(10), through the Monte Carlo code MCNP6. The results have been compared with previous works. Likewise, the performance evaluation of these devices in continuous energy neutron field have been carried out, using the AmBe/241 neutron source of the Neutronics Hall (NH) of the Neutron Measurements Laboratory of the Energy Engineering Department of Universidad Politecnica de Madrid (LMN-UPM), through Monte Carlo simulation with the MCNP6 code and experimental measurements. The work is framed into the project Contributions to Shielding and Dosimetry of Neutrons in CPTC.

Monte Carlo investigation of the characteristics of radioactive beams for heavy ion therapy

This work presents a simulation study evaluating relative biological effectiveness at 10% survival fraction (RBE10) of several different positron-emitting radionuclides in heavy ion treatment systems, and comparing these to the RBE10s of their non-radioactive counterparts. RBE10 is evaluated as a function of depth for three positron-emitting radioactive ion beams (¹⁰C, ¹¹C and ¹⁵O) and two stable ion beams (¹²C and ¹⁶O) using the modified microdosimetric kinetic model (MKM) in a heterogeneous skull phantom subject to a rectangular 50 mm × 50 mm × 60 mm spread out Bragg peak. We demonstrate that the RBE10 of the positron-emitting radioactive beams is almost identical to the corresponding stable isotopes. The potential improvement in PET quality assurance image quality which is obtained when using radioactive beams is evaluated by comparing the signal to background ratios of positron annihilations at different intra- and post-irradiation time points. Finally, the incidental dose to the patient resulting from the use of radioactive beams is also quantified and shown to be negligible.

Beam parameters optimization and characterization for a TUrning LInac for Protontherapy

TULIP (TUrning LInac for Protontherapy) is a novel compact accelerator system for protontherapy mounted on a rotating gantry (Amaldi et al., 2013, 2010, 2009). Its high-energy Linac has the unique property of being able to modulate the beam energy from one pulse to the next, in only a couple of milliseconds. The main purpose of this study is to optimize the properties of the beam exiting the Linac to make them compatible to medical therapy and to characterize their medical physics properties for later implementation in a Treatment Planning System. For this purpose, multi-particle tracking and Monte Carlo (MC) simulations are used to follow the particles through their path up to the treatment isocenter, following the so-called phase-space method. The data compiled includes particle fluences in air and depth-dose curves and provides the basis for a specific model of the TULIP beam.

[Radiotherapy and radiosurgery in treatment of craniopharyngiomas]

Craniopharyngiomas are benign epithelial tumors having a dysembryogenetic origin, which are usually located in the sellar/parasellar and/or third ventricle regions. Gross total resection is the modern standard of treatment for these tumors because of a low recurrence rate. However, this surgery in some patients with craniopharyngioma often leads to the development or worsening of diencephalic disorders poorly responding to treatment. Perhaps, in these cases, subtotal or partial tumor resection or implantation of an Ommaya reservoir into the tumor cyst followed by stereotactic radiotherapy/radiosurgery may provide better functional outcomes and higher life quality in patients, with tumor growth control being reasonable (according to the published data, the mean 10-year disease-free survival is 66.9% after total tumor resection and 79.6% after combined treatment). The paper presents a review of the literature on radiological treatment of craniopharyngiomas. We discuss the issues of indications, optimal timing of radiotherapy/radiosurgery, its efficacy, and treatment outcomes in terms of complications and quality of life. Particular attention is paid to enlargement of craniopharyngioma cysts during and after radiological treatment.

Neutron shielding for a new projected proton therapy facility: A Geant4 simulation study

In this work, we used the Monte Carlo-based Geant4 simulation toolkit to calculate the ambient dose equivalents due to the secondary neutron field produced in a new projected proton therapy facility. In particular the facility geometry was modeled in Geant4 based on the CAD design. Proton beams were originated with an energy of 250MeV in the gantry rooms with different angles with respect to the patient; a fixed 250MeV proton beam was also modeled. The ambient dose equivalent was calculated in several locations of interest inside and outside the facility, for different scenarios. The simulation results were compared qualitatively to previous work on an existing facility bearing some similarities with the design under study, showing that the ambient dose equivalent ranges obtained are reasonable. The ambient dose equivalents, calculated by means of the Geant4 simulation, were compared to the Australian regulatory limits and showed that the new facility will not pose health risks for the public or staff, with a maximum equivalent dose rate equal to 7.9mSv/y in the control rooms and maze exit areas and 1.3·10^-1mSv/y close to the walls, outside the facility, under very conservative assumptions. This work represents the first neutron shielding verification analysis of a new projected proton therapy facility and, as such, it may serve as a new source of comparison and validation for the international community, besides confirming the viability of the project from a radioprotection point of view.

Antiproton stopping power data for radiation therapy simulations

Stopping powers of H, He, H₂, and H₂O targets for antiprotons have been calculated using a convergent close-coupling method. For He and H₂ targets electron-electron correlations are fully accounted for using a multiconfiguration approximation. Two-electron processes are included using an independent-event model. The water molecule is described using a neon-like structure model with a pseudo-spherical potential. Results are tabulated for the purpose of Monte Carlo simulations to model antiproton transport through matter for radiation therapy.

Production of the PET isotope 11C in hadron therapy via neutron knockout

PURPOSE

Positron emitting isotopes such as ¹¹C and ¹⁰C can be used for vital dose verification in hadron therapy. These isotopes are produced when the high energy ¹²C primary beam particles undergo nuclear reactions within the patient.

METHODS

We discuss a model for calculating cross sections for the production ¹¹C in ¹²C+¹²C collisions, applicable at hadron therapy energies.

RESULTS

Good agreement with the available cross section measurements is found for ¹²C(-1n), though more detailed, systematic measurements would be very valuable.

CONCLUSIONS

Nuclear structure plays a crucial role in the reactions of light nuclei, particularly when those reactions are peripheral and involve only a few nucleons. For such reactions, nuclear structure has a strong influence on the energy and angular distribution of the cross section, and is an important consideration for reliable dose verification using ¹¹C in hadron therapy.

Higher Initial DNA Damage and Persistent Cell Cycle Arrest after Carbon Ion Irradiation Compared to X-irradiation in Prostate and Colon Cancer Cells

The use of charged-particle beams, such as carbon ions, is becoming a more and more attractive treatment option for cancer therapy. Given the precise absorbed dose-localization and an increased biological effectiveness, this form of therapy is much more advantageous compared to conventional radiotherapy, and is currently being used for treatment of specific cancer types. The high ballistic accuracy of particle beams deposits the maximal dose to the tumor, while damage to the surrounding healthy tissue is limited. In order to better understand the underlying mechanisms responsible for the increased biological effectiveness, we investigated the DNA damage and repair kinetics and cell cycle progression in two p53 mutant cell lines, more specifically a prostate (PC3) and colon (Caco-2) cancer cell line, after exposure to different radiation qualities. Cells were irradiated with various absorbed doses (0, 0.5, and 2 Gy) of accelerated ¹³C-ions at the Grand Accélérateur National d’Ions Lourds facility (Caen, France) or with X-rays (0, 0.1, 0.5, 1, 2, and 5 Gy). Microscopic analysis of DNA double-strand breaks showed dose-dependent increases in γ-H2AX foci numbers and foci occupancy after exposure to both types of irradiation, in both cell lines. However, 24 h after exposure, residual damage was more pronounced after lower doses of carbon ion irradiation compared to X-irradiation. Flow cytometric analysis showed that carbon ion irradiation induced a permanent G2/M arrest in PC3 cells at lower doses (2 Gy) compared to X-rays (5 Gy), while in Caco-2 cells the G2/M arrest was transient after irradiation with X-rays (2 and 5 Gy) but persistent after exposure to carbon ions (2 Gy).