In radiation therapy, planning precise treatments continues to be the goal. With that in mind, manufacturers are moving forward with equipment and software improvements to make cancer treatment more targeted.

Companies are also continuing to research Flash therapy, which delivers ultrahigh doses of radiation in less than a second in order to spare healthy surrounding tissue.

Here's a look at what's new and what’s next in both proton therapy and radiation therapy.

PROTON THERAPY

Hitachi Proton
In June, University of Wisconsin Health (UW Health) selected Hitachi to provide the infrastructure to support proton therapy at the new UW Health Eastpark Medical Center in Madison, Wisconsin. The system is equipped with advanced technologies such as spot scanning irradiation technology, which allows the proton beam to be delivered according to the shape of the cancer, a 360-degree rotating gantry with cone-beam CT for high-precision positioning and Real-time image Gated Proton Therapy (RGPT).

Hitachi will also provide an upright proton therapy solution in collaboration with Leo Cancer Care. With the upright treatment approach, the patient is in a natural, seated position on a specially-designed chair that moves the patient in front of a static proton beam. This approach may also break down many traditional barriers to proton treatment.

In November 2021, Hitachi Proton announced that it been selected by the University of Tsukuba in Japan to design, construct and maintain a new proton therapy center. The new center will be equipped with Hitachi's compact design proton therapy system, including one accelerator and two rotating gantry treatment rooms.

This is the first time in Japan that a particle therapy system provider received a second unit order from an existing facility, according to the company. After 20 years of operation of the original University of Tsukuba proton therapy center, Hitachi will continue its relationship with the university with a further 20-year period of operations and maintenance support after the expected start of patient treatment around the summer of 2025.

Also in Japan, Shonan Kamakura Advanced Medical Center at Shonan Kamakura General Hospital of Tokushukai Medical Group, began treating patients with Hitachi's compact proton therapy system in January 2022. Hitachi developed the system, which reduces its footprint to about 70% of the room of a conventional solution, in response to a growing demand for smaller proton therapy systems.

The system’s smaller size makes it possible to install in compact urban areas at a reduced cost and with a shorter installation time, according to the company.

IBA
Last September, IBA and SCK CEN, the Belgian Nuclear Research Centre, announced a strategic partnership to enable large-scale production of Actinium-225, a novel radioisotope that has potential cancer treatment applications. Research is underway for its use in treating prostate, lung, colon, breast, pancreatic, blood and kidney cancers, as well as glioblastomas.

Actinium-225 has a high cytotoxic potency within a very short range, meaning it targets cancer cells while sparing surrounding healthy tissue, according to the company. IBA and SCK CEN are currently evaluating the project’s technical and economic feasibility.

IBA continues to develop its Proteus proton therapy product line, and has been delivering 45 treatment fractions per day on its ProteusONE compact open gantry solution, said Nicolas Denef, global marketing director at IBA.

“The open gantry allows for treatment of all proton therapy indications, both simple and complex, and has shown average treatment times of under 20 minutes at several treatment sites,” Denef said. “(The) combination of oblique and CBCT imaging allows practitioners to tailor the imaging needed for the patient.”

In 2022, IBA delivered its ProteusONE and ProteusPLUS systems to facilities in the U.S., China, Taiwan and India.

Leo Cancer Care
Over a year ago, the Centre Leon Berard in France began using Leo Cancer Care’s proton therapy upright patient positioning system for preclinical research, which they plan to publish in the next six months.

“They've been assessing things like patient acceptance to being positioned upright rather than laying down, said Stephen Towe, the chief executive officer of Leo Cancer Care. “The resounding result is that — no surprise to us, but it’s great that it's been validated by them — the patients do prefer being positioned upright rather than laying down on a solid table. And they've also shown that patients can be set up two to three times faster in the upright position compared to laying down, so patient throughput is improved and overall patient experience is improved.”

The company recently secured two more partnerships in the U.S., with the McLaren Proton Therapy Center in Flint, Michigan, and UW Health, the integrated health system of the University of Wisconsin-Madison, installing the company’s upright treatment technology for proton therapy.

Mevion
Since July 2021, Mevion has continued to advance its FLASH development program for the MEVION S250i Proton Therapy System through both research and technological innovations.

FLASH delivers radiation therapy with protons at ultrahigh dose rates. Last year, the company conducted a series of mouse studies in an effort to develop and validate a “merged-field” technique that delivers FLASH radiation by combining small fields into a large, common irradiation volume.

In April 2022, Mevion introduced its FLASH Research Kit that enables Mevion users to quickly and safely switch their HYPERSCAN clinical system into FLASH-research mode.

“While this internal research and development effort has proved extraordinarily valuable in understanding the specific technical and clinical requirements needed to deliver FLASH treatments, Mevion believes that supplying Mevion users and researchers with the ability to perform their own FLASH research experiments will even further accelerate the growth of this exciting irradiation technique,” said Rocky Owen, clinical R&D engineer and relationship manager at Mevion. “All of us at Mevion believe that FLASH technology can provide the most advanced and cost-effective platform for proton FLASH irradiations.”

In the second half of 2021, Huntsman Cancer Institute at the University of Utah in Salt Lake City started treatment with the MEVION S250i Proton Therapy System. The center is the only National Cancer Institute-designated Comprehensive Cancer Center in the area, and serves both adult and pediatric patients in Utah, Idaho, Montana, Nevada and Wyoming.

Mercy Hospital in St. Louis started proton therapy treatment with the MEVION S250i system in July of this year.

In addition, Mevion was selected to equip centers in the U.S. and around the world, including the Kansas City Proton Institute and Tongji Hospital in China. Barnes-Jewish Hospital in St. Louis upgraded its first system and expanded its partnership with Mevion on FLASH therapy research.

P-Cure
In May 6, P-Cure opened a clinical research and training site within its headquarters in Israel, located 20 minutes from both Tel Aviv and Jerusalem. The site includes a fully operational proton therapy system, which is composed of a compact linear accelerator, a 360-degree, gantryless treatment room and access to treatment and delivery planning.

The site is designed to deliver and develop proton therapy protocols for patients and to train existing and new customers.

The company’s system, which treats patients in a seated position, can be installed in an existing linac vault, eliminating the expense of construction.

“We are excited to open our operational proton therapy site for clinical research and training, as well as for demonstrating the opportunity for oncology centers to expand their cancer fighting potential to include proton therapy,” said Michael Marash, P-Cure’s chief executive officer, in a statement announcing the opening of the center. “P-Cure is proud to become a member of the world-wide research community expanding the clinical benefits of proton therapy and demonstrating what is the most cost-effective system available to existing oncology centers.”

ProTom International
ProTom International is moving forward with installation of a Radiance 330 proton therapy system at the new Australian Bragg Centre in Adelaide, which is expected to begin operating in early 2024 as the first proton therapy center in Australia and the Southern Hemisphere.

The Australian center will incorporate new enhancements that the company has been making to its Radiance 330 proton therapy system over the past few years, said Stephen Spotts, chief executive officer of ProTom International.

The system has a new nozzle with a more precise beam and reduced size for more maneuverability around the patient. The gantry has also been completely redesigned to make installation easier and faster, Spotts said.

The company has also made software upgrades to improve patient automation and usability.

“One of the things that we're very proud of [about] our system is that it was designed by our RTs and clinicians to make the user experience much more user friendly,” Spotts said. “The recently-installed software upgrade has made that user experience better for the RTs.”

RaySearch
RaySearch recently launched deep learning-based automatic treatment planning for photon and proton therapy. The new solution, which is included in the RayStation treatment planning system, reduces the time to create a deliverable treatment plan significantly, said Martin Janson, senior product manager for proton therapy at RaySearch. In addition, the deep learning automatic treatment planning ensures an even quality and reduces dependency on the skill of the individual treatment planner.

RaySearch has also invested heavily in making use of the computer’s graphics card for heavy calculations.

“At RaySearch, we know that the quality of a treatment plan is highly dependent on the speed of the planning tools and have therefore worked hard on supporting GPU-accelerated algorithms,” Janson said. “A great example of this is last year’s migration of our proton Monte Carlo dose engine to the GPU, which makes it possible to compute the dose using the most accurate algorithm in just a few seconds. A few years ago, a computation like this was expected to run for several hours.”

A recent study showed that RaySearch’s proton dose algorithm is 50 to 100 times faster than the competition, according to Janson.

In addition to the typical indications for protons, RayStation has recently been used for creating ocular proton therapy plans using the new RayOcular module, as well as proton stereo tactical treatments.

Varian, a Siemens Healthineers company
In December 2021, Varian launched the FLEX treatment planning system (TPS) research solution, a nonclinical, research-use-only, cloud-hosted version of the Eclipse planning tool for advanced cancer care.

The FLEX TPS research solution enables researchers to explore Flash proton planning and provides access to proprietary features that enable dose-rate calculation and visualization, unique to Flash. This expands the ability of multiple sites to conduct research of Flash therapy from a treatment planning perspective.

“The cloud-based format also means customers are able to receive new treatment planning tools as they become available, with the ultimate goal of helping create a smoother transition from bench to bed,” said Adam Earwicker, director of market development for Flash at Varian.

The FLEX portfolio includes products for existing Clinac and ProBeam customers to conduct electron Flash research, in addition to the research planning capabilities of FLEX TPS.

“Flash is one of the most discussed topics in radiation therapy today and we’re proud to contribute to advancing important research in this area” said Ty Boruff, FLEX business manager at Varian.

Additionally, the Penn Medicine Lancaster General Health Ann B. Barshinger Cancer Institute recently hosted a ribbon-cutting ceremony for its new Proton Therapy Center. The Lancaster site is the first proton therapy center in Central Pennsylvania and the first ever to be equipped with a Varian ProBeam 360° system, which is 510(k) pending.

“As Pennsylvania’s only proton therapy center outside of Philadelphia, home to Penn Medicine’s Roberts Proton Therapy Center, the new Lancaster site will enable Penn Medicine to treat more patients close to home,” said Jean-Paul Sier, senior product manager at Varian.

The ProBeam 360° system is currently being installed at three cancer centers in the U.S., including one multiroom system for The Ohio State University Comprehensive Cancer Center- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.

In December 2021, the Hefei Ion Medical Center in China started patient treatment on Varian’s ProBeam system, representing the first patient ever treated with this technology in China. Other centers in China which have recently received ProBeam systems include the Shandong Proton Center and Guangzhou Concord Cancer Center.

In February 2021, Her Royal Highness Princess Maha Chakri Sirindhorn Proton Center in Thailand began treating patients on a ProBeam system. Additionally, the University College Hospital in central London officially launched a center in March that will treat patients using the ProBeam system.

RADIATION THERAPY

Accuray
Accuray recently added new features within the Accuray Precision/iDMS Treatment Planning System for the CyberKnife radiosurgery platform, including workflow enhancements to group multiple brain metastases, an anterior commissure/posterior commissure coordinate system and upgrades of the gradient and conformality indexes.

The company also introduced its new Accuray Connect feature, which facilitates the direct import of external images, including CT and MR images, RT structure sets and spatial registrations, from Brainlab Elements into the Accuray Precision/iDMS System without user interaction.

Accuray is continuing to enhance its Radixact radiation therapy system with new functionality supporting adaptive therapy. This includes ClearRT helical fan-beam kVCT imaging, now commercially available worldwide, which provides diagnostic-like quality CT images in a more affordable way.

“High-quality imaging has previously been cost prohibitive and complex,” said Corey Lawson, vice president of product strategy at Accuray. “The introduction of ClearRT for the Radixact System addresses this unmet medical need. The technology delivers enhanced imaging capabilities compared to conventional linear accelerators that rely on CBCT imaging and offers an alternative to MR-based radiotherapy systems that are contraindicated for some patients, such as those with metal implants, and cost prohibitive to use.”

The company also released VOLO Ultra for its TomoTherapy platform, including the next-generation Radixact System, which uses automated tools to help speed up treatment plans and allow clinicians to treat more patients.

Additionally, Accuray recently announced the development of an integrated and automated solution for Deep Inspiration Breath Hold (DIBH) using Surface Guided Radiation Therapy (SGRT) with hardware provided by C-RAD Catalyst+ HD for the Radixact System. With this addition, the Radixact System will be able to be used to treat the full range of breast cancer cases while minimizing the radiation dose to the heart and lungs.

Brainlab
In January 2022, Brainlab released a new version of ExacTrac Dynamic. The release includes a dedicated Deep Inspiration Breath Hold (DIBH) workflow for breast cancer treatment.

“This solution delivers correlation between internal and external anatomy in one shot, revealing any misalignment that would otherwise remain undetected and could result in delivering excess dose to the heart,” said Lukas Kompatscher, manager of product management and marketing for ExacTrac Positioning at Brainlab.

UZ Brussel in Belgium treated the first patients with the ExacTrac Dynamic DIBH workflow and the team found that it streamlined the treatment process and increased positioning confidence through “on-the-fly” X-ray confirmation of the patient´s breath hold level.

“Internal anatomy verification at the breath hold level may increase confidence in dose-sparing of critical structures like the heart,” Kompatscher said. “The incorporation of ‘on-the-fly’ X-ray confirmation streamlines the process and delivers the confidence that the heart is outside of the treatment beam.”

The new version of the ExacTrac Dynamic also incorporates an updated workflow for positioning and monitoring implanted markers for prostate and other soft-tissue treatments. Quick verification allows clinicians to detect internal movement during the treatment of organs with implanted markers, without interrupting the treatment, and allowing radiation therapists to reduce margins and improve outcomes for stereotactic body radiotherapy treatments, Kompatscher said.

ExacTrac Dynamic was recently also used to successfully treat a neurological condition called trigeminal neuralgia in combination with the Brainlab frameless mask system.

“This condition can be treated with radiosurgery and is often done with rigid frames fixated directly to the patients head, as it requires a very high level of accuracy, even higher than for stereotactic treatments of multiple brain metastases, or for cranial lesions,” Kompatscher said. “Some of our customers have used ExacTrac Dynamic and our noninvasive immobilization system to perform these types of high accuracy treatments.”

Brainlab also launched a new program called Brainlab Novalis Knowledge to train, connect and certify radiosurgery professionals.

This includes Brainlab Academy, which offers in-person and digital training courses on Brainlab radiosurgery treatment planning software, and Brainlab Novalis Circle, where clinicians share new treatment approaches.

The Novalis Certified program allows hospitals providing stereotactic radiosurgery and stereotactic body radiotherapy to obtain certification with an external audit conducted by the independent and multidisciplinary Novalis Circle expert group.

The Brainlab Novalis SRS Registry will help professionals share best practices from their clinics.

“At Brainlab we believe that every treatment should be based on a holistic view of each patient’s situation and clinical history,” said Gabi Geiselmann, manager of product management and marketing for Novalis Knowledge at Brainlab. “With the Brainlab Novalis SRS Registry we want to support all clinical specialties involved in radiosurgical diagnoses and treatments with tools for reporting, intelligently structuring, and visualizing clinical data from different sources to advance patient-specific treatment decisions.”

Elekta
In May 2022, Elekta unveiled Elekta Esprit, a new Leksell Gamma Knife radiosurgery platform. This includes the new headframe, Vantage, which was released in late 2021.

Improved workflow and operator experience is at the heart of the redesigned onboard monitor and makes patient setup and positioning easier, said Verena Schiller, executive vice president of Elekta’s Neuro business line. This new operator experience is extended to the control area through a reduced control system footprint and ergonomic design of the control panel.

“With Elekta Esprit, we’ve worked to build a kinder, gentler patient experience,” Schiller said. “The Vantage headframe is designed to improve targeting through improved imaging, while the open-face design is more patient friendly, allowing eating and drinking while in the frame.”

Esprit also offers high-resolution digital video and clear audio for improved communication between the patient and their care team, with improved sound, including an input where patients can listen to music or podcasts.

Elekta Esprit also offers submillimeter — down to 0.3 millimeters — precision and treatment planning that can be completed by the end user in less than 60 seconds, compared to the 0.8- to 1-millimeter precision associated with most competitive systems, according to the company. In addition, Elekta Esprit offers two to 21 times lower dose outside the target than competing systems.

MagnetTx
On May 4, 2022, Canada-based MagnetTx received clearance from the FDA for Aurora-RT, an innovative radiation therapy system that combines MR and linear accelerator to help cancer patients. Now, the MR-LINAC can be sold throughout the U.S.

“Aurora-RT offers all of the radiation positioning advantages of conventional linear acccelerators with CBCT while adding on board MR during irradiation,” said Mike Cogswell, president and CEO of MagnetTx. “Its unique open (110 x 60 cm bore) bi-planar rotating parallel MR field design avoids dose-perturbation (electron-return effects) allowing the use of conventional treatment planning systems, offers placement of the patient to the optimal position improving set-up and throughput time, offers larger number of indications, such as tangential fields, while minimizing claustrophobia.”

The system utilizes a 0.5 T magnet and does not require any liquid helium, therefore, there is no need for a quench pipe. The unique magnet can also be turned off for ease of servicing.

“Any radiation therapy department with multiple treatment machines will be interested in purchasing the Aurora-RT because of how it would integrate seamlessly into all these RT departments, allowing all conventional techniques with the advantage of on-line MR guidance,” said Cogswell.

MagnetTx premiered the Aurora-RT MR-LINAC at the 2021 ASTRO meeting.