1. Agility™ shines
on clinical front
PAGE 4
25 years of
Gamma Knife®
surgery at UPMC
PAGE 8
Brachytherapy
for gynecological
treatment
PAGE 16
The future
of cancer care
PAGE 21
Vol.16 | No.2 | October 2012
PIONEERING SIGNIFICANT INNOVATIONS IN CLINICAL SOLUTIONS
FOR TREATING CANCER AND BRAIN DISORDERS
2. Vision without action
is a dream. Action without
vision is simply passing time.
Action with vision is making
a positive difference.
Professor Lars Leksell (1907–1986)
Inventor of radiosurgery and founder of Elekta
Elekta has been a company for four decades, and the gem that symbolizes
this 40th anniversary is the ruby. Appropriately, Elekta launched its Rubicon™
technology this year, in which rubies tip the multileaf collimator leaves of Agility™.
4. 4
2012 – “THE YEAR OF AGILITY”
Elekta’s ground-breaking new MLC
sweeping the globe
Since receiving us 510(k), achieving European ce marking and
other medical device clearances in the first half of 2012, Elekta has
shipped Agility™ 160-leaf mlc to more than 20 countries. Clinicians
at these sites are reporting remarkable gains in beam-shaping ability
and delivery speed with Agility. Shorter treatment times have
resulted in increased patient comfort and convenience, as well as
an improved ability for caregivers to treat more patients each day.
“According to the World Health Organization,
cancer is a leading cause of death worldwide, and
the incidence is expected to continue rising signifi-
cantly,” says Tomas Puusepp, President and ceo of
Elekta. “To meet this increasing need, we have col-
laborated closely with leading hospitals and research
institutions to develop a solution that can increase
patient throughput while delivering exceptional
precision. Agility is designed to meet these demands.
As Agility use continues to spread globally, hundreds
of thousands of patients will benefit from this
unique solution every year.” l
ONCOLOGY SOLUTIONS
Read more about Agility at
www.elekta.com/agility
5. 5
Agility shines on clinical front
St. James’s University Hospital
– Leeds, U.K.
“We can schedule treatments
to more patients per day.”
l In April 2012, St. James’s became the first in the
world to use Agility™ clinically, following up this
success with the first combined Agility/vmat
treatment only weeks later. The combination of the
two innovations reduced the time it takes to deliver
the treatment from five minutes down to just two
minutes. Elekta’s Monaco® treatment planning system
also contributed to the patient’s treatment by enabling
much lower doses to nearby critical structures than
traditional plans the Leeds team had been producing.
“The combination of planning with Monaco,
vmat and Agility means that treatment times are
significantly reduced,” says John Lilley, physicist at
St. James’s, part of The Leeds Teaching Hospitals nhs
Trust. “For this patient, the vmat delivery was three
minutes quicker than the regular conformal plan.
This is very important because the immobilization
mask the patient wears for treatment can be uncom-
fortable and reduced treatment times mean less risk
of patient movement. Quicker treatment times make
a big difference for us as well, as it means we can
schedule treatments to more patients per day.” l
The James Cook University Hospital
– Middlesbrough, U.K.
“Treatment speed reduces
the likelihood that the
patient moves.”
l Soon after St. James’s treated its first patients
with Agility, The James Cook University Hospital
became clinically operational with the new beam-
shaping innovation. Three months later, physicians
here achieved another benchmark – their first use
of Agility to deliver radiation therapy employing
Elekta’s Volumetric Modulated Arc Therapy (vmat).
The ability to accelerate both beam shaping and
beam delivery with Agility and vmat shaved
57 seconds off the beam delivery time of the first
patient.
“This was our first experience with vmat and
it went very well,” says Christopher Walker, phd,
Head of Radiotherapy Physics at The James Cook
University Hospital. “The treatment speed not only
reduces the likelihood that the patient will move
and that the internal organs will shift position,
but it also contributes to faster patient throughput,
which is key. With Agility/vmat we expect to be
able to treat five patients per hour.” l
Agility – now shipped to over 20 countries
6. 6
ONCOLOGY SOLUTIONS
SALK and Paracelsus Medical
University – Salzburg, Austria
“Greater precision improves
our ability to focus radiation
to the tumor.”
l As the first center to field-upgrade to Agility™,
salk and Paracelsus Medical University treated
its first patient using Agility on May 14, increas-
ing its daily patient volume to 50 on its Agility-
equipped Elekta Synergy® system after only a
month. Based on their experiences, clinicians at
the Salzburg clinic report that the Agility mlc’s
new design provides them with more precise dose
sculpting capabilities and remarkably lower non-
therapeutic radiation dose delivered to the patient.
“Looking closely at several cases, we’ve calcu-
lated a measureable improvement in dose shaping
precision with the five millimeter leaves of Agility,”
says Felix Sedlmayer, md, Professor and Chairman,
Department of Radiotherapy and Radio-Oncology.
“This greater precision improves our ability to
focus radiation to the tumor, while strictly limiting
exposure to surrounding critical structures, such
as the rectum and bladder. We were astonished at
the amount of healthy tissue dose reduction we
could achieve. This capacity theoretically enables
us to improve outcomes and reduce the potential
for complications.” l
Riverina Cancer Care Centre
– Wagga Wagga, NSW, Australia
“Interdigitation enables
far fewer segments for
complex plans.”
l Transitioning from its two Siemens treatment
machines to, eventually, two Elekta Synergy
radiotherapy systems equipped with Agility 160-leaf
multi-leaf collimator (mlc) – physicians at Riverina
Cancer Care Centre, have been able to decrease
beam delivery time by up to seven minutes for a
variety of cancers. Riverina treated its first patients
using its first Agility-equipped Synergy system on
July 30, making the New South Wales facility first
in the southern hemisphere to go clinical with the
beam-shaping device.
“We have been very pleasantly surprised with
the delivery speed of Agility, in addition to its beam-
shaping accuracy,” says Damien Williams, Riverina
Cancer Care Centre Managing Director. “Reducing
beam delivery time for complex imrt treatments by
up to seven minutes – from around 16 or 17 minutes
with our previous system to 9 or 10 minutes with
the Agility-equipped Synergy – is a very significant
efficiency and clinical benefit. The interdigitation
capabilities of Agility enable far fewer segments for
complex plans. We also have observed a marked
difference in the precision we can achieve.” l
7. 7
Intelligent beam shaping
Agility, compared to other multi-leaf collimators,
is in class by itself – combining leaf speeds that
are twice as fast as conventional beam-shaping
devices.
The 160 leaves of Agility are 5 mm in width
at isocenter and are capable of interdigitation
to enable treatment of island fields and multiple
targets in a single session.
Rubicon optical leaf positioning technology
improves accuracy and increases the reliability and
seamlessness of beam-shaping, and the exception-
ally low leaf transmission of less than 0.5 percent
enhances treatment delivery while reducing
integral dose.
The integrated whole results in a sophisticated
multi-functional beam-shaping solution.
8. 8
Elekta interviewed Dr. L. Dade Lunsford,
md, co-director of the upmc Center for Image-
Guided Neurosurgery and Lars Leksell Professor
and Distinguished Professor, Department of
Neurological Surgery, University of Pittsburgh
School of Medicine, recently about upmc’s
experience with stereotactic radiosurgery.
What radiosurgery technology has UPMC
used over the years?
‘‘
At one time we had three Gamma Knife sys-
tems, the original unit, a 4c and then Perfexion.
Today, we continue to use the Leksell Gamma
Knife 4c and Leksell Gamma Knife® Perfexion™.
What are your thoughts about the growth
of radiosurgery over the last 25 years?
‘‘
Gamma Knife fits the paradigm of ‘disrup-
tive innovation’. When it first arrived in the
United States after a six-year effort – culminat-
ing in 1987 when we treated the first patient –
Gamma Knife was totally unknown in terms of
its role, potential and outcomes. However, after
just 25 years, Gamma Knife, as opposed to many
other technologies, has evolved, has continually
been applied and is continuing to grow. While to
some extent this form of radiosurgery may be con-
sidered to be more esoteric because of its focus
on the brain only, that is what Gamma Knife is
designed for. Its growth in applications, patients
treated and centers has been almost logarithmic.
Gamma Knife surgery for the treatment of
metastatic disease continues to grow.
To what do you attribute this trend?
‘‘
In the past, when a patient’s cancer spread to the
brain, it was regarded as a very fatalistic event.
They would receive a very substandard treatment
– whole brain radiation therapy [wbrt] – which
was all that was available. That started the clock;
outcome data showed that the average patient lived
only five or six months. So, both the oncologist and
the patient essentially gave up, and most of these
patients ended up dying of spread of the tumor to
the brain. That’s not the case anymore. We replaced
wbrt with radiosurgery one or more times if new
disease shows up in the future. We can control the
spread of cancer to the brain in more than 85-90
percent of patients. That pushes the oncologist to
develop and use more effective tools to control the
systemic disease, rather than throwing in the towel.
And there have been many successes over the last
25 years. Patients have presented with brain disease
– essentially Stage 4 of their cancer – who respond to
systemic treatment and Gamma Knife. They end up
with no active disease at this time and are living
normal lives.
EXPERT QA
A quarter century
of Gamma Knife excellence at UPMC
The University of Pittsburgh Medical Center (upmc) marked
its 25th year of Gamma Knife® surgery on August 14, 2012, and
is on track to treating its 12,000th patient in that quarter century
period by December 12, 2012 (12/12/12).
Dr. L. Dade Lunsford, md,
co-director of the upmc
Center for Image-Guided
Neurosurgery
NEUROSCIENCE SOLUTIONS
9. 9
Given this shift to radiosurgery, what is your opin-
ion of the future of WBRT as a treatment option?
‘‘
Gamma Knife is changing the treatment para-
digm in metastatic cancer to the brain away from
reflexively using wbrt to only selectively using it in
patients with miliary disease or carcinomatous men-
ingitis. Since their survival has increased, there is a
higher risk over many years that patients can develop
that late problem related to cancer. If you initially
held off on using wbrt, you can at least use it then.
The shift away from wbrt has already begun.
We are seeing that more and more patients are
being diagnosed early because they are getting an
mri scan as part of staging. They receive stereo-
tactic radio surgery early – when the tumors are
smaller and there is a very high tumor control rate.
Gamma Knife surgery is increasingly used to
treat multiple metastases in a single session.
How do you see this trend evolving?
‘‘
The number of mets is not the issue. Many
insurance companies don’t understand this
either. The volume of the treated tumors is impor-
tant. So, a patient with a single, large volume brain
met may have more difficulties that a patient with
20 mets all of which are small. The issue is, if you
treat all existing disease, then you simply have to
wait and see whether anything shows up in the
future – but Gamma Knife is effective in more than
90 percent of every treatable tumor. So, we gener-
ally use Gamma Knife not by the total number of
brain metastases but by the volume that is there.
And, we don’t find that there is a significant change
in benefit between one or four or ten or even 20 as
long as you are treating everything that exists.
What is the future of Gamma Knife radiosurgery?
‘‘
Radiosurgery has evolved
in the United States and is
very much a team effort in
which there is participation
from neurosurgeons, radia-
tion oncologists, medical
physicists and nurses.
First UPMC Gamma Knife
surgery patient marks 25-year
milestone with gratitude
John Lynch, UPMC’s first Gamma Knife surgery
patient – the first in North America and only the
world’s fifth – has celebrated 27 birthdays since his
surgery. On August 14, 1987, Lynch – then 25 years-old
– received radiosurgery to
treat an AVM that every
surgeon he spoke with had
said was inoperable. Just
12 months later, the AVM had
shrank and his symptoms –
severe migraine headaches
and seizures – began to disappear. Since then, every
follow up appointment that the Pittsburgh resident
has had has indicated that the AVM is gone for good.
“I had an MRI just six months ago and the
AVM is still gone – I’m fine,” Lynch, now 52, reports.
“I’m very grateful to have had the chance to have
Gamma Knife surgery. Surgery wasn’t an option
because the AVM was located too deeply inside my
brain, and I was having some micro-hemorrhaging
so it wasn’t looking good until I found Dr. Lunsford.
I have a lot of gratitude.”
And, it is this team management that parallels how
medical care in general has evolved in the United
States. Rather than a ‘lone wolf’ doing everything,
it is a team of people with expertise that is providing
a high level of care to people with complex medical
problems.
Gamma Knife is here to stay. I think it is going to
continue to evolve, but it is being focused more on
high volume needs. That is to say, if we look across
the world, it is dealing with metastatic cancer that
has spread to the brain. Gamma Knife clearly has
revolutionized the management of patients when
cancer spreads to the brain. l
‘‘
The shift
away from
whole brain
radiation therapy
has already
begun.”
10. 10
DEEP BRAIN STIMULATION THERAPY WITH LEKSELL STEREOTACTIC SYSTEM
DBS – stimulating a
more normal life
NEUROSCIENCE SOLUTIONS
What began in 2006 as some slight trembling in her left knee and
arm, evolved in six months to increasingly debilitating left leg
stiffness that made her gait seem hardly like walking at all.
Mrs. Christine Barker, now a 64-year-old retired school teacher
from Crowthorne, Berkshire, u.k., was diagnosed with Parkinson’s
disease*, her leg stiffness – dystonia – a symptom of the disorder.
“Instead of bending my foot properly, I was
sort of putting my foot down flat and I was becom-
ing increasingly aware that I couldn’t get my heel
down on the ground properly,” she recounts.
“The dystonia got much worse, and after about
18 months I was walking in a very bizarre man-
ner, and walking any distance at all was completely
exhausting. I ended up being in a wheelchair for
most of the time if I was going out of the house.”
Medications (e.g., levodopa) made no impact at
all, which prompted her neurologist in 2010 to refer
her to the National Hospital for Neurology and
Neurosurgery’s Unit of Functional Neurosurgery in
London. There, she met Ludvic Zrinzo, md, phd, a
neurosurgeon and specialist in Deep Brain Stimula
tion (dbs) therapy (see sidebar). Dr. Zrinzo told her
that while Mrs. Barker’s case was unusual, he thought
there was a chance that dbs could help her.
“It would be a leap of faith, really,” she remarks.
“They said dbs might have no effect, or it might
provide a 10 percent improvement or 20 percent or
30 percent. They said that it was very difficult to tell
because they couldn’t compare my situation with
anyone else’s.”
A second chance
Mrs. Barker was scheduled for surgery on February
15, 2011. The Unit’s dbs experience spans a decade
and over 300 patients – 40 implants from January
to July 2012 alone – allowing Mrs. Barker to benefit
from the refinement of the technique over the years.
Shaving the patient’s entire head is now a thing of
the past as scientific evidence doesn’t support the
premise that it reduces infection. In addition,
Mrs. Christine Barker
*To learn more about the equipment
used to perform DBS for the treatment
of Parkinson’s disease, see page 11.
11. 11
instead of conducting the procedure using micro-
electrode recording (mer) under local anesthesia,
the Unit ensures accurate anatomical placement of
electrodes using post-implantation mri.1
“Our surgical protocol maximizes the use of
imaging to minimize the number of brain passes
and reduce the risk of hemorrhage and its poten-
tially severe sequalae,” Dr. Zrinzo says. “Instead of
relying on subjective intraoperative observations,
we place increasing emphasis on mri. Among other
things, this allows us to perform surgery under
general anesthetic without having to totally with-
draw pd medication – something many patients
are grateful for. It also means that we have reduced
the procedure time such that we regularly per-
form two dbs procedures in one day. Moreover,
we haven’t noticed any decline in efficacy.”
Mrs. Barker didn’t have to wait long before
knowing her surgery had been successful.
“I could tell even a couple of days after the
operation that my walking was slightly better,”
she recalls. “To cut a long story short, the doctors
gradually increased the simulation and my walking
improved tremendously over the next several months.
“It has just been a very positive experience,” she
continues. “If anyone would ever ask me if I recom-
mend it, I would say: ‘Yes, go for it all the way.’ It
has made a difference in my life – I have a future I
can look forward to. Having dbs therapy was a life
changing experience.” l
References
1. Foltynie T, Zrinzo L, Martinez-Torres I, Tripoliti E, Petersen E, Holl
E, Aviles-Olmos I, Jahanshahi M, Hariz M, Limousin P. MRI-guided STN
DBS in Parkinson’s disease without microelectrode recording: effi-
cacy and safety. J Neurol Neurosurg Psychiatry. 2011;82:358-363.
Ludvic Zrinzo, md, phd,
at London’s National
Hospital for Neurology
and Neurosurgery
Leksell Stereotactic System®
a key to DBS accuracy
The sophistication of the center-of-arc principle of
Leksell Stereotactic System enables physicians at the
Unit of Functional Neurosurgery to ensure an accurate
trajectory to the brain target, in Christine Barker’s
case, the globus pallidus internus (GPi).
“A trajectory that avoids the sulci and ventricle of
the brain will also avoid the vessels enclosed within
these structures and will greatly reduce the risk of
bleeding,” Dr. Zrinzo explains. “Leksell Stereotactic
System has a long heritage and there are many reasons
that make it an excellent choice when performing
precision stereotactic surgery. It is an MRI compatible
frame and the fiducials are close to the head, minimiz-
ing MRI distortion.”
He continues, “In addition, the principles are
easy to understand and the surgeon can calculate
target coordinates manually, removing blind reliance
on software. Phantom experiments have shown that it
performs favorably in comparison to other stereotactic
frames in terms of accuracy. Importantly, Elekta is
responsive and has produced custom made RF probes
and taken our advice for product improvements, such
as a counter scale on the x coordinate.”
What is DBS therapy?
DBS is a surgical procedure
in which an electrode** the
thickness of an uncooked
spaghetti noodle is
implanted in the subthalamic
nucleus (STN) or globus
pallidus internus (Gpi), brain
regions that are responsible
for controlling movement.
To navigate to the pre-
cise brain region accurately,
the team at the Unit of
Functional Neurosurgery
uses Leksell Stereotactic
System (see above).
The electrode is con-
nected to a pulse generator
that is implanted subcutane-
ously below the clavicle.
When the generator is
activated, it transmits mild
electrical pulses through the
electrode to the brain. These
electrical pulses modulate
the brain’s electrical signals
to help control or stop
abnormal movements.
Deep brain stimula-
tion is both adjustable and
reversible. Patients can use
a remote control to modify
the stimulation level neces-
sary to afford the greatest
symptom relief with the least
amount of side effects.
**The electrode and associated equipment are manufactured by Medtronic, Inc. and are indicated for unilateral thalamic stimulation
for the suppression of tremor in the upper extremity in patients who are diagnosed with essential tremor or Parkinsonian tremor
not adequately controlled by medications and where the tremor constitutes a significant functional disability.
12. 12
The progenitor of MEG was an induction-coil
magnetometer with two million turns of copper wire
wound around a ferrite core. In 1968, Dr. David
Cohen used the device to perform the first successful
recording of a magnetic field emanating from the
living human brain.
“You couldn’t use it clinically – it was too weird
and cumbersome,” recalls Dr. Cohen, then a physics
professor at Chicago’s University of Illinois. “The
coil was just proof of principle that the brain’s mag-
netic field existed.”
Four years later as a researcher at mit, Dr. Cohen
used a Superconducting Quantum Interference
Device (squid) invented by James Zimmerman to
attempt to refine the measurement of these fields.
“Once I had the squid, I could revisit this idea
and try it again,” he says. “And this time it was glori-
ous, because the noise was a thousand times less, and
you could see the brain’s magnetic field just as easily
as you could see the eeg. That is when the field took
off, and when the word ‘meg’ really had meaning.”
Dr. Cohen published this success in Science in
19721
, the magazine bestowing upon him the title of
the “Father of meg.”
MEG finds its place
The evolution of meg since 1972 entailed the incor-
poration of hundreds of squids, analogous to eeg
with its numerous electrodes placed on the scalp.
“With many eeg electrodes, you can make a
map of the whole head as a function of time – like a
movie happening over the whole head,” Dr. Cohen
explains. “The same applies to meg. If you just mea-
sure the magnetic field as I did in the early 1970’s – at
one place – it was, at most, interesting, but it doesn’t
lead to any application. Once companies such as
Neuromag began making whole head systems that
enabled mapping the magnetic field over the entire
head, then it really got fascinating.”
Whole head arrays enabled researchers to detect
the source of the magnetic fields in a way not
possible before.
First, meg detected auditory evoked responses.
Around 1990, clinical meg work began, involving
the measurement of the interictal spikes of epilepsy.
“Sometimes the spikes in epileptic kids could
not be seen on eeg, but could be seen on meg –
that made a lot of neurologists sit up and take
notice,” he remarks. “Now, meg could be used
to help the surgeon decide if they need to oper-
ate on epilepsy, where to go and where to cut.”
In research, meg is providing valuable insight
into brain connectivity – how different parts of
the brain communicate with each other – and is
NEUROSCIENCE SOLUTIONS
MAGNETOENCEPHALOGRAPHY
MEG – valuable insight into
brain connectivity
Dr. David Cohen
Dr. David Cohen, often referred to as “The Father of meg”,
reflects on the technique he brought to life 40 years ago.
13. 13
used increasingly in multimodal imaging, in which
meg measurements are combined with functional
and morphologic mri and other modalities.
Forty years after his seminal work on meg,
Dr. Cohen, 84 and a professor at Harvard Medical
School, mentors students on the use of meg.
“I believe we’ve only scratched the surface of
meg’s potential,” he says. l
References
1. Cohen D., 1972. Magnetoencephalography: detection of the
brain’s electrical activity with a superconducting magnetometer.
Science 175, 664-666.
What is MEG?
Magnetoencephalography (MEG) is a non- invasive
technique for measuring neuronal activity in the
human brain. Electrical currents flowing through
neurons generate weak magnetic fields that can be
recorded at the head’s surface using very sensitive
magnetic detectors known as superconducting
quantum interference devices (SQUIDs).
MEG can detect the timing of magnetic signals
with millisecond precision. Because this is the
timescale on which neurons communicate, MEG can
measure the rapid signals that reflect communication
between different parts of the human brain.
MEG is complementary to other brain imaging
modalities such as functional magnetic resonance
imaging (fMRI) and positron emission tomography
(PET), which depend on changes in blood flow, and
which have higher spatial resolution but much lower
temporal resolution than MEG.
Elekta is the leading player
within meg technology.
Elekta Neuromag® triux
represents the latest
development.
14. 14
What do you believe we will see in the next
40 years in radiation therapy or in radiosurgery?
We asked
several Elekta
customers
to predict
advances in
their field
over the next
four decades.
‘‘
Radiosurgery will be more and more widely used
for functional neurological disorders in 40 years.
With refinement of imaging and neurophysiological
techniques, non-invasive physiological confirmation
of functional targets in the brain will be possible,
which makes radiosurgery for functional disorders
more feasible.”
Takaomi Taira, MD, PhD • Professor of Neurosurgery
Tokyo Women’s Medical University • Tokyo, Japan
‘‘
Radiation oncology will continue to maintain
an important role in treating cancer beyond
2050. Robotic-assisted treatment, based on molecular
imaging, cancer nanotechnology, and the genomic
profile of every patient, will allow optimal individualized
patient care, both in delivering radiation alone and
in combining radiation with smart drugs. Radiation
schedules will be strongly hypofractionated in the
majority of cancer sites.”
Umberto Ricardi, MD, PhD • Full Professor
Radiation Oncology University of Turin • Turin, Italy
‘‘
Citius, altius, fortius: radiotherapy of the next
decades will strongly act upon the Olympic maxim.
Faster treatments, higher doses, stronger effects.
Continuous progress in adaptive dose conformation
in all terms of on-time tracking a tumor’s position and
its biology will intensify radiation response while
dramatically reducing normal tissue exposure. Major
solutions in cancer cure are to be expected from physics
and hence, radiation oncology.”
Felix Sedlmayer, MD • Professor and Chairman
Dept. of Radiotherapy and Radio-Oncology • SALK and Paracelsus
Medical University • Salzburg, Austria
‘‘
All treatments will be image guided to accurately
target the radiation based on surface anatomy,
internal anatomy and molecular characteristics of the
tumor with real time feedback.”
Ruth Heimann, MD, PhD • Professor, Radiation Oncology • Vermont
Cancer Center • University of Vermont/Fletcher Allen Health Care, USA
‘‘
In the next 40 years I think we will be able to
locate the genetic loci responsible for a few or
many of the cancer-causing genomes and will have
developed radiation delivery systems with adequate
verification tools to be able to knock out the malignant
loci with preservation of the basic codes for normal
tissue structures and functions. The EMR would have
grown to record all these changes and reflect them in
the clinical follow up and patient profiling.”
Tejinder Kataria, MD • Chairperson Radiation Oncology
Medanta-the Medicity, Gurgaon, India
‘‘
The next 40 years is sure to be our professions’
most exciting. As we gain greater understanding of
tumor and normal tissue biology, we will individualize
radiation treatments and optimally combine radiation
with molecular targeted treatments and immuno
therapy to increase cure rates.”
Thomas A. Buchholz, MD, FACR • Head, Division of Radiation Oncology
The University of Texas M. D. Anderson Cancer Center, USA
‘‘
Technological innovation will remain the primary
driver of radiotherapy. Comparative effectiveness
research will prove the high value of radiotherapy
hopefully leading to more funding for biological
innovation, allowing us to do more with less dose.
Population constraints we will be replaced by patient
specific constraints. Patients with metastatic disease
being treated for cure or prolongation of life, not just
palliation, will ultimately be the most common patient
in the radiotherapy clinic.”
Robert Timmerman, MD • Professor of Radiation Oncology and
Neurosurgery • University of Texas Southwestern Medical Center, USA
‘‘
With the ability to dose escalate while sparing
normal tissue combined with better imaging
capabilities – including real-time imaging – radiosur-
gery will become more widely adopted as a minimally
invasive surgically ablative procedure. The new specialty
of “Radiosurgeon” will treat both malignant and benign
tumors, as well as perform functional treatments,
to many different organ systems.”
Peter C. Gerszten, MD, MPH • Associate Professor, Neurological Surgery
and Radiation Oncology • University of Pittsburgh Medical Center, USA
‘‘
Imaging will continue to push the frontiers in
radiotherapy for the foreseeable future. Clinical
trials will be aimed at understanding the relationship
between biological imaging metrics and treatment
outcome that will lead to individualized prescriptions
with targeted dose escalation. High precision targeted
radiotherapy will be further aided by radiation activated
cytotoxic agents, and treatment planning will be based
on probabilistic dose distributions, which account for
treatment uncertainties and radiation responsiveness.”
John Simpson, PhD • Director of Medical Physics
Radiation Oncology Institute, Sydney, Australia
‘‘
Radiotherapy will continue to be an important
tool to fight disease locally with ever decreasing
side effects and it will help to unlock the full potential
of systemic treatments such as immunotherapy.”
Frank Lohr, MD • Vice Chairman
University Medical Center (UMC) Mannheim, Germany
15. 15
‘‘
Patients will have worldwide access to the same
high quality of care, in which information and pro-
cess flow will be completely integrated from diagnosis,
treatment, and long-term follow up, It also will involve
complex algorithms for decision-making through the
continuum of care and for resources utilization.”
Marie-Andrée Fortin, MD, FRCPC • Head of Radiation Oncology
Centre intégré de cancérologie de Laval, Québec, Canada
‘‘
Radiosurgery will continue to grow and become
a main trend of treatment for most vascular
lesions, such as AVMs and DAVFs, deep-seated benign
brain tumors, and certain functional disorders,
such as trigeminal neuralgia.”
Prof. David Hung-Chi Pan, MD • Professor, Functional
Neurosurgery • Taipei Veterans General Hospital, Taiwan
And from some of our Elekta experts:
‘‘
Radiation Medicine will be one of if not the
safest therapy for managing cancer beyond 2050.
Automation, instant feedback, and multi-modality
imaging will help cure cancers in their early stages. Global
aggregation of patient follow-up and treatment outcomes
facilitated by the Oncology EMR will enable clinicians to
find and deliver the best treatments to every cancer
patient no matter where on the globe they live.”
Timothy J. Prosser, MBA • Director, Oncology Business Line
Management, Elekta • Crawley, West Sussex UK
‘‘
In the next 40 years, I believe Radiosurgery technol-
ogy will develop to the point where a therapeutic
radiation dose will be precisely and safely delivered
in a single session, to fully control medium and even
larger targets, anywhere in the body, regardless of target
movement during imaging or treatment. And with this
advancement, Radiosurgery will also expand clinically,
to treat new indications and diseases that can be well
localized with anatomic or functional imaging.”
Ray Rau • Vice President, Gamma Knife Sales, Elekta
Latin America, Middle East, and Eastern Europe
‘‘
Radiosurgery will become standard of care for
treatment of brain metastases in combination
with drug therapies for a lifelong disease management
and thus proliferate into every comprehensive cancer
care facility. SRS in combination with sophisticated
biological modifiers will open a new field of modulating
neurological activity for functional indications.”
Per Nylund, MSc • Vice President, Product Management, Elekta
Neuroscience Solutions
‘‘
Radiotherapy will play an essential role in highly
diversified and individualized multi-disciplinary
concepts. Strict boundaries between curative and pal-
liative treatment will be lost, rendering many cancers
a chronic disease due to integrated systemic and local
treatments. Software solutions will actively assist in all
decision-making processes and radiotherapy steps by
combined analyses of clinical evidence and institutional
outcome data.”
Prof. Dr. Matthias Guckenberger, MD • Vice Chairman, Dept. of
Radiation Oncology • University Hospital Würzburg, Germany
‘‘
Stereotactic radiosurgery should see significant
advances with the integration of sophisticated
neuro-imaging modalities to patient selection, targeting,
dose planning, and post-treatment assessment.”
Jason Sheehan, MD, PhD, FACS • Alumni Professor, Department
of Neurological Surgery • University of Virginia, USA
‘‘
Large cancer registries, established from EMR data
transfers, will allow Radiation Oncology to become
transformed based on predictive analytics that establish
best care models and directives that are personalized
and evidence-based. Likewise, the process of delivering
radiation therapy will become predictable and safer due
to novel management processes.”
Louis Potters, MD, FACR, FASTRO • Prof Chair,
Dept of Radiation Medicine • North Shore - LIJ Health System, USA
‘‘
Even with the huge expenditure on cancer drug
research, in 40 years time, therapy with radiation
is still likely to be one of the most cost-effective and
curative of cancer treatments. This will no doubt be
supported by more accurate tumor cell localization,
right down to microscopic levels, so that we can do
away with the concept of CTV!”
Vivian Cosgrove, PhD • Head of Radiotherapy Physics
St. James’s Institute of Oncology, Leeds, UK
‘‘
Rooted in the 1950’s, the radiosurgical revolution
is still ongoing and will continue to transform the
practice of neurosurgery in the coming decades for the
greatest benefit of patients. Functional neurosurgery
indications will continue to expand and we will come
to a better understanding of the benefit of low non-
necrotizing dose on the cerebral parenchyma. These two
factors are expected to play major roles in the future
development of radiosurgery.”
Prof. Jean Régis • Head of Functional Neurosurgery
Timone Hospital, Marseilles, France
16. 16
GYNECOLOGICAL TREATMENT
MRI sharpens vision of
cervical tumors
National Cancer Centre Singapore clinicians harness
magnetic resonance imaging (mri) to better tailor brachytherapy
radiation dose to the tumor, sparing normal tissues
The ability of MRI to create exquisite images
of the body’s soft tissues – and the tumors that
arise amid them – is helping physicians at National
Cancer Centre Singapore (nccs) to precisely shape
brachytherapy doses to cervical tumors, while at
the same time avoiding exposure to critical healthy
organs and tissues. Since November 2011, nccs
clinicians have used mri to characterize soft tissues,
organs-at-risk and lesions before successive brachy-
therapy treatments using the microSelectron®
Digital remote afterloader and Oncentra® 3d
Brachy Image Guided Treatment Planning system,
both manufactured by Nucletron, an Elekta
company. Nucletron is a pioneer in image-guided
brachytherapy.
Brachytherapy is an advanced, highly targeted
cancer treatment in which radiotherapeutic sources
are placed in or near a tumor, giving a high radia-
tion dose to the tumor while reducing the radia-
tion exposure in the surrounding healthy tissues.
nccs uses the microSelectron Digital high dose rate
(hdr) brachytherapy, which introduces the radiation
source for a certain time using a special applicator.
“After our first year using ct based planning for
3d brachytherapy, we felt confident enough to take
the next step: mri guided adaptive brachytherapy,”
says Richard Yeo, md, Senior Consultant Radiation
Oncologist at nccs. “The ability to visualize the
tumor on mri and plan the treatment ‘live’ is
nothing short of amazing.”
Better images, better treatment
mri provides information about the tumor’s volume
(3d) and how the volume and shape change between
treatment sessions (4d). Performing an mri scan
before each brachy session enables clinicians to
adapt the dose to the unique anatomy of each
patient, accounting for not only the position of
organs-at-risk, but also tumor regression or move-
ment, which may have occurred during preceding
external beam radiotherapy and/or chemotherapy
and between brachy sessions themselves.
Conforming brachytherapy doses closely to
the tumor’s shape and position is important in
order to apply the highest possible dose to the
tumor while limiting the dose to critical structures
such as the bladder and rectum, thereby decreas-
ing the likelihood of treatment side effects.
“The Oncentra Treatment Planning (otp) sys-
tem is very user friendly, with its intuitive inter-
face and flexible workflow for managing ct and mr
images,” says Lawrence Ng, Consultant Physicist at
BRACHYTHERAPY SOLUTIONS
17. 17
nccs. “The recently upgraded otp version 4.1 incor-
porates a very useful 3d modeling library for accu-
rate applicator placement during planning. This
results in enhanced accuracy in source dwell posi-
tion reconstruction and dose calculation which
hopefully will translate into better treatment result.”
Various publications from leading hospitals
around the world have shown that use of this
advanced technology allows health care teams
to treat even the most complex cervical cancers,
expected to result in lower recurrence rates and
higher survival. Intensive multi-center research is
ongoing with the aim to provide more data to
confirm these treatment benefits over traditional
methods. This will allow experts to address unmet
medical needs for this common cancer.1
World-class training
A group of nccs experts received training on
mri guided adaptive therapy at the University
Hospital of Vienna, a leading center pioneering
the development of this technique for the treat-
ment of cervical cancer. The advanced work done
in medical centers in Austria, and across Europe
will now gradually be adopted in a growing num-
ber of hospitals in the Asia Pacific region.
“Building a network of regional expertise will
help other Asian hospitals adopt this new technol-
ogy and provide state-of-the-art treatments to their
patients,” says Ulrich Krumme, Regional Director
for Sales and Marketing Elekta Brachytherapy Far
East. “This will be especially important, as technolo-
gies that have been developed in Europe will need
to be adapted to local infrastructures and patient
demographics. The potential clinical benefit of
3d gynecological planning and treatment over the
conventional 2d approach makes it attractive for
us to help hospitals with the adoption.” l
To better fulfill the needs of customers in Southeast Asian
markets, Elekta will launch a smaller version of its
well-known applicator this autumn. The Fletcher CT/MR
Applicator Set XS is designed to better meet the needs
of women in countries such as China, India, Japan, and
Malaysia who tend to be more slightly built.
The new applicator is a scaled-down version of the
standard Fletcher Applicator Set. It has the same features
and options, but in a smaller size. For example, the set’s
adjustable intrauterine tube has a four-millimeter radius
rather than the standard six millimeters.
“The introduction of this new brachytherapy solution is
a great example of personalizing medical technology for a
certain group of patients,” says Maurits Wolleswinkel, VP,
Elekta Brachytherapy Solutions. “This is important not only
regionally – because smaller female anatomies are found
most commonly in Asian countries – but also clinically,
because up to now there hasn’t been a good brachytherapy
applicator for smaller patients regardless of where they live.”
According to the World Health Organization, cervical
cancer is the second most common cancer in women
worldwide, with about 500,000 new cases and 250,000
deaths each year.
Adapted brachytherapy applicator for Asian markets
The new applicator will also enable an easier change process
for customers who want to make the transition from 2D to
3D treatment planning. In developed countries, many
customers have made the transition to 3D, but that requires
computed tomography (CT) and magnetic resonance (MR)
capabilities – the imaging modalities that generate 3D data
sets. Since this applicator is CT- and MR-compatible, these
customers will have the opportunity to upgrade over time.
The XS applicator is
integrated in Oncentra®
Brachy treatment planning.
The software recognizes
the applicator stored in an
applicator library, which
allows the clinical team to
reconstruct the applicator
with just a couple of
mouse-clicks. Applicator
Modeling in Oncentra
Brachy offers better
visibility, accuracy and
reproducibility for
physicians and physicists.
‘‘
The ability
to visualize
the tumor
on MRI and plan
the treatment ‘live’
is nothing short
of amazing.”
References
1. Radiotherapy and Oncology 94
(2010) 173–180, Int. J. Radiation
Oncology Biol. Phys., Vol. 65,
No. 2, pp. 624–630, 2006, Clinical
Oncology 22 (2010) 602-604.
18. 18
The resolve to put the patient’s needs first in
every decision they made regarding the establish-
ment of a new cancer center drove officials at
Quebec’s Centre de Santé et de Services Sociaux de
Laval (csssl) to unite both radiation oncology and
medical oncology departments under mosaiq®.
The new facility, Centre Intégré de Cancérologie
de Laval (cicl), officially opened on February 21,
2012. cicl is Quebec’s first center to implement
mosaiq for both oncology departments.
“When we initiated the cicl project, our first
objective was to define the cancer centre’s vision,” says
Marie-Andrée Fortin, md, Chief Radiation Oncologist
at csssl. “The goal was to facilitate cancer care deliv-
ery around the patient’s needs. We concluded that to
achieve that goal we needed to implement an ois.”
Dr. Fortin and her colleagues dedicated time to
visit u.s. and u.k. medical centers that operated
mosaiq and another vendor’s Oncology Information
System (ois) to evaluate their respective strengths.
According to Dr. Fortin, mosaiq offered more
flexibility to configure the ois according to cicl’s
unique processes than did another vendor’s ois.
“It was important that the ois adapt to our pro-
cesses instead of us adapting to the ois,” she says.
“From our perspective, mosaiq would best meet that
requirement, enabling us to create the workflow we
wanted from referral to follow up. The overriding
goal was to streamline and automate our processes.
This is one of the reasons why the mosaiq iq
Scripts™ functionality was so important to us.”
Throughout the mosaiq implementation pro-
cess, Elekta worked closely with cicl staff to ensure
a successful outcome.
“We had extremely high standards and worked
hard to develop our processes and workflow,” Dr.
Fortin remarks. “We had to get very creative to use
all the mosaiq functionality we could to meet those
standards. To that end, we had a great collaboration
with Elekta and the ro and mo staffs to find ways to
make it work. Elekta’s team was quite flexible in
accommodating our needs.”
MOSAIQ IN CANADA
A patient-centered
workflow
Thanks to mosaiq®, a new Quebec center’s radiation oncology
and medical oncology departments are paperless from day one.
Initial diagnosis/
Doctor referral
CT/MR
image capture
Quality control/
Treatment
preparation
Patient
fixation
Imaging
in situation
Treatment
MOSAIQ® Oncology Information System
Universal database for archived plans
Treatment
planning
Administration
Billing
Statistics
Analysis
Image archive
• Notes
• Scheduling
• Documents
• Images
Elekta’s software solutions are vendor neutral,
meaning that clinics using equipment from another
vendor can seamlessly integrate their systems and
databases with Elekta’s open source products.
Treatment planning is
performed either with
an Elekta product (e.g.
Monaco®, XiO®, Focal4D®
or ERGO++™) or with
a software solution
from another vendor.
Internal workflow processes at the
clinic are eased by comprehensive
modules for administration and
analysis of patient data and statistics.
Marie-Andrée Fortin, md,
Chief Radiation
Oncologist, Centre Intégré
de Cancérologie de Laval
MOSAIQ ENCOMPASSES THE COMPLETE FLOW OF PATIENT INFORMATION
ONCOLOGY INFORMATION SOFTWARE
19. 19
Real-time data access
While both medical oncology departments at cicl
were paperless with mosaiq from their first day, for
cicl the most critical benefit is real-time data access.
At cicl, access is even more convenient with an IT
infrastructure that sites 200 mosaiq client worksta-
tions throughout the facility.
“We want the workflow to be around the patient,
not the physician or caregiver,” Dr. Fortin says.
“With mosaiq workstations in multiple locations, I
can log in anywhere to see the patient’s chart. It’s
very efficient and it gives us mobility.”
Diverse data
mosaiq is compatible with virtually any treatment or
planning system, giving cicl clinicians access to a wide
variety of information. mosaiq has interfaces with
cicl’s his, adt and lab results systems, all modalities
in the imaging department, and the hospital’s pacs
and emr systems and metriq® cancer registry.
Adhering to provincial standards that seek to
ensure patients receive equitable and timely care,
cicl has implemented a patient priority system inte-
grated within mosaiq.
“Based on the seriousness of their case, patients
can be prioritized to be seen and/or treated earlier,
which avoids a simple ‘first-come-first-served’ policy
that is not medically rational,” Dr. Fortin explains.
“In addition, at cicl we can be even more precise
and systematic in patient care through standardized
care plans, which are integrated in mosaiq.”
Standardized care plans provide evidence-based
guidelines for a given diagnosis, including recom-
mended consultations, medical regimens, tests, rt
planning and patient-specific quality control.
“Standardizing case management helps us pro-
vide the same high quality to patients regardless of
who they see – it’s not physician dependent,” Dr.
Fortin says. “This reduces the chance of error. Also,
the mosaiq iq Scripts functionality reinforces the
standardized care plan by specifying a sequence of
tasks that have to be done by different care managers.
Once each task is completed, it is automatically
pushed to the next caregiver in the sequence, making
the process quite efficient. It also helps us see where
bottlenecks are and determine where you need to put
more resources.”
The mosaiq implementation has brought pre-
dictability and order to the workflow, adds cicl
Chief of Physics Fadi Hobeila.
“The patient’s emr will have all the information
necessary to plan for cases,” he says. “For example, if
the emr shows the patient has a pacemaker and her
first treatment is on May 15th, I know I have to be
there and need to prepare my in vivo dosimetry tools.
“In this way, the ois helps the physics team be
more an integrated part of the clinical team,”
Hobeila continues. “We’re not just doing machine
and patient qa, we’re always working in the patient
record, and have ongoing, close contact with the
dosimetrists, therapists and doctors, because all
communication goes through the patient record.”
Patient-centered OIS
Communicating and accessing information in real
time has streamlined cicl operations noticeably,
mainly to the benefit of patients.
“Patient wait times are shorter,” she says. “They
were used to waiting for chemotherapy. Now, because
medication orders are done through mosaiq, the
nurse can consult the emr anytime to see when the
pharmacy has completed the preparation. They don’t
have to call or walk to the pharmacy to check.”
In addition, since cicl’s first day, there also has
been an absence of the clutter and physical transpor-
tation of paper charts and documents in both radia-
tion oncology and medical oncology departments.
This has made these clinical environments more
tranquil places, Dr. Fortin adds.
“I’ve had experience in paper-based depart-
ments, with people bustling around carrying charts
or hunting for misplaced charts,” she says. “This
environment is so peaceful and much tidier without
all that paper.” l
FACTS
Centre Intégré de Cancérologie de Laval (CICL):
F Uses MOSAIQ (v.2.4) in the French Canadian Language
F Operates two Elekta Infinity treatment systems.
Two additional Elekta Infinity systems will be up and running in 2013.
F Has 30 infusion rooms, two CT systems, laboratory, and
patient information center.
F In its first year, will treat approximately 1,000 patients with radiation therapy.
F Gives approximately 10,000 chemotherapy treatments per year.
Cancer is the leading cause of death in Quebec (and Canada),
surpassing cardiovascular disease.1
1. Canadian Cancer Statistics 2010 (www.cancer.ca)
‘‘
We had
extremely
high stan-
dards and worked
hard to develop
our processes
and workflow.”
20. New software developments in
planning scanning
20
SOFTWARE SOLUTIONS
Monaco 3.20
The launch of the most recent release of Monaco®
Treatment Planning System, version 3.20 offers
customers improved vmat planning and delivery
support, in addition to support for Elekta’s Agility™
160 multileaf collimator. The release promises to
create new workflow efficiencies through inte-
grated plan approval and enhanced integration
with mosaiq® Oncology Information System.
The new Segment Shape Optimization™ is driving
better dose conformity, plan quality and delivery effi-
ciency through its proprietary approach to smoothing
and clustering segments, then optimizing beam
weights and shapes. Powered by the renowned Monte
Carlo algorithm, the results are plans that improve
sparing of organs-at-risk and dose conformality.
In addition, the release’s new contouring tool,
ez Sketch, and Room’s Eye View increase workflow
efficiency. Support for Agility means that Monaco
3.20 users can achieve a new level of beam-shaping
precision and delivery speed. l
Clarity with Autoscan
Clarity® soft tissue visualization system now
provides an Autoscan option for automated ultra-
sound scanning from outside of the treatment room,
employing a motorized probe positioned at the
patient’s perineum. The transperineal approach
also benefits planning by providing a clear view
of the prostate and surrounding critical areas.
Clearly visualizing these critical structures could
enable physicians to create plans with tighter
margins around intended targets, thus avoiding
exposure to uninvolved tissues.
Clarity with Autoscan provides a flexible
alternative to traditional hand-held scanning and
is the ideal platform on which to build future
live (i.e., real time) imaging applications that will
track the prostate and surrounding anatomy during
treatment*. Live imaging has become increasingly
important for physicians wanting to pursue
reduced margin hypofractionated therapy. l
* Works in progress and not available for sale or distribution.
21. THE FUTURE OF
CANCER TREATMENT
21
Everyone agrees that there will be radical changes
in how to treat cancer in the next decade. This
applies to everything from the devices used and
locating and eliminating tumors, to the role of soft-
ware and data. Obviously, no crystal ball can show
us what lies ahead, but Elekta has a few experts
willing to make an educated guess.
Kevin Brown, Global Vice President, Scientific
Research, says he expects the value and effectiveness
of rt will continue to develop with better diagnos-
tics and improved imaging.
“I believe improved targeting through image
guidance will be the biggest breakthrough for rt,”
Brown says. “Elekta is already a trailblazer with
Clarity® soft tissue visualization, Elekta Synergy®
with 3d and 4d image guidance, and our research
program into using magnetic resonance imag-
ing [mri] for image guidance. It’s inevitable that
all rt devices will have integral image guidance.
“Better imaging means we will be able to
treat much smaller fields with much higher
doses. We’ll have functional imaging that will
tell us which parts are already dead and which
are still active or have metastatic potential.”
Brown says the real intellectual breakthrough
in treating cancer, though, will be in software.
This view is shared by Dr. John Christodouleas,
Vice President of Clinical Affairs at Elekta, and
Adjunct Assistant Professor of Radiation Oncology
at the Hospital of the University of Pennsylvania.
“The biggest change in the next ten years will be
a result of improvements in information technol-
ogy,” Christodouleas says. “The widespread use of
data registries – perhaps Elekta’s – will give us the
potential to learn from literally everyone we treat.”
Today, every hospital in the usa is required to have
a separate cancer-registry department, and Elekta’s
Oncology Data Alliance (oda) helps them aggre-
gate oncology data. Christodouleas believes that in
the future there will be registries in every country,
in every hospital. This, he says, will open oncology
to the world of big data (data that exceeds the pro-
cessing capacity of conventional database systems).
“Big data opens the door to substantially differ-
ent kinds of analyses and enables running experi-
ments within the data,” he says. “It will allow us to
appreciate very small differences between treatments
and procedures, and to identify small subgroups that
may benefit more or less than the average person.”
Joel Goldwein, Senior Vice President, Medical
Affairs, believes the future of oncology and cancer
care will be the use of specifically targeted thera-
pies, not just focusing on a particular lesion, but
targeting particular cells and particular patients.
“We will have much more granular under-
standing of the genetic basis of cancer and the
genetic makeup of patients who are more likely
at risk of recurrence after surgery or chemo-
therapy. We will be able to select patients much
more intelligently and irradiate them much more
deliberately to a much more focused area.”
Goldwein says rt treatment will be more
than just pointing and focusing a beam at a par-
ticular tumor. “We’ll be able to point the beam
at the right place, but then have something
administered to the patient that will enhance
the effects of the radiation on the cancer cells
while protecting the normal cells,” he says.
All three agree that this is an exciting time for
radiosurgery and radiotherapy, and that the future
holds amazing and untold developments. l
Elekta’s Kevin Brown, Global
VP, Scientific Research;
Dr. John Christodouleas,
VP, Clinical Affairs;
and Joel Goldwein, Senior VP,
Medical Affairs
22. Elekta around the world
AMSTERDAM, THE NETHERLANDS
In 2011, Elekta acquired Nucletron BV. Headquartered in
Veenendaal, The Netherlands, Nucletron is the undisputed
global leader in brachytherapy, a very precise, highly effective
and well-tolerated treatment option that is tailored to the
needs of individual patients. By joining forces with Elekta,
Nucletron became part of a world-leading provider of
therapy for many types of cancers.
ATLANTA, GEORGIA, USA
September 22-25, 2013 the American Society for Radiation
Oncology will hold its 55th Annual Meeting at the Georgia World
Congress Center in Atlanta. Home of Elekta’s newly-relocated
North America headquarters, the company’s first foreign
subsidiary opened in the United States in 1983. Today, North
America remains the single largest market for Elekta, as well as
the world’s largest market for radiotherapy.
BEIJING, CHINA
In the last five years, Elekta has concentrated resources to
support China’s initiatives to modernize and improve access
to cancer care. This has resulted in a number of firsts and
milestones, including Elekta BMEI shipping its 100th Elekta
Compact™, the release of MOSAIQ® in the Chinese Language
and installation of China’s first Leksell Gamma Knife®
Perfexion™ and Elekta Axesse™ treatment systems.
DUBAI, UNITED ARAB EMIRATES
In recent years, Elekta has increased its focus and resources
on the Middle East, establishing new offices or improving its
distribution network, education and training, users meetings,
clinical collaborations, equipment service infrastructure, spare
parts management and regional offices. In October 2010, Elekta
opened an office in Dubai, where all Elekta key technologies
and functions are individually represented.
LONDON, ENGLAND
Acknowledging its contribution to the discovery and delivery of
new technology, Elekta’s Crawley facility is known as “home of
the world’s first digital linac.” Since the company’s 1997
acquisition of Philips’ radiotherapy division, the finest scientific
talent has collaborated with clinicians to pioneer advancements
such as the new Agility™ MLC – an innovation that precisely
shapes radiation beams to tumor targets.
MONTREAL, CANADA
Following the 2010 acquisition of Canada-based Resonant
Medical Inc., Montreal became home to Elekta’s Clarity®
research and development team. Earlier this year, Elekta held
its first European Clarity User Meeting, where users from
Germany, Denmark, Ireland, Italy and France convened to learn
more about the Clarity product roadmap and breakthrough
studies that suit the clinical needs of the European market.
SINGAPORE
In March 2011, the inaugural meeting of Elekta’s trans-Asia
consortium met in Singapore to focus on the study of
nasopharyngeal carcinoma (NPC). The group reviewed their
respective experiences in treating NPC and deliberated research
topics. In September 2012, Gleneagles Hospital became the first
in Singapore to begin radiotherapy treatments with the center’s
new Agility™ 160-leaf multi-leaf collimator.
Elekta Instrument AB
founded by Professor
Lars Leksell
First foreign
subsidiary
established
in the USA
First fully digital
accelerator
introduced
First commercial
Leksell Gamma
Knife® delivered
Leksell Gamma
Knife® Society
formed
Elekta AB
listed on the
Stockholm
Stock Exchange
IMRT
Consortium
established
Stereotactic
Body Frame®
22
Year 1972 1985 1990 1995
23. SAN FRANCISCO, CALIFORNIA, USA
Following the 2005 acquisition of California-based IMPAC
Medical Systems Inc., Elekta became the world’s largest
supplier of oncology software. In 2012, U.S. News World
Report issued its annual list of America’s best hospitals,
including the top-ranked hospitals for cancer. Out of the
top 50 cancer hospitals listed, more than half are users of
Elekta’s MOSAIQ® Oncology Information System.
SÃO PAULO, BRAZIL
In recent years, Elekta has strengthened its presence in Latin
America. To support the region’s growing cancer management
requirements; Elekta relocated its office to São Paulo, as well
as acquired Radon Ltda., the leading linear accelerator service
company in Brazil. Through the acquisition, Elekta’s customer
base increased 25 percent regionally. In 2012, the first TPS User
Meeting took place in Salvador.
NUREMBERG, GERMANY
In July 2012, IBA opened its International Competence Center
(ICC).The ICC provides high-level practical training to promote
safer radiation therapy to healthcare professionals. The training
courses will include topics such as efficient and effective Elekta
linac and RTPS commissioning. The goal is to provide high-end
dosimetry training on how to plan and safely use the latest
techniques, such as Elekta VMAT.
ST. LOUIS, MISSOURI, USA
In 2008, Elekta acquired St. Louis-based CMS Inc., adding a suite
of advanced RTP systems, a large and growing installed base
and a well-established RTP infrastructure. Most recently, an
updated version of Elekta’s Monaco® treatment planning system
was launched, offering customers better VMAT and workflow,
in addition to support for Elekta’s Agility™ MLC, and enhanced
integration with MOSAIQ®.
STOCKHOLM, SWEDEN
Before Elekta became a company in 1972, Swedish neurosur-
geon Prof. Lars Leksell invented Leksell Gamma Knife® and
Gamma Knife® radiosurgery in 1968 for treating a variety of
intracranial disorders. Since then, more than 600,000 patients
have been treated, and this gold-standard technique has been
validated by over 3,000 publications documenting the results.
In 2012, the company marked its 40th year.
SYDNEY, AUSTRALIA
A well-established market for Elekta, an estimated 300
clinicians from 12 countries gathered in Sydney in 2012 for
Elekta’s 16th International Gamma Knife Society Meeting.
The continent’s first Leksell Gamma Knife® Perfexion™ was
installed in 2010 and most recently, sites throughout Australasia
– including clinics in New South Wales and Melbourne – have
begun treating patients with Elekta’s Agility™ MLC.
TOKYO, JAPAN
Elekta and Toshiba Medical Systems Corporation opened a
420m2
radiation therapy training center in Nasu (about 150km
north of Tokyo) on July 16, 2012. With full scale operation
expected by April 2013, the facility provides customers from
both companies access to a training environment that includes
a fully-functional Elekta linear accelerator, including supporting
imaging and software systems.
Digital
linear accel-
erator with
integrated
MLC (MLCi)
Philips Radiation
Therapy Division,
acquired
Leksell
Gamma
Knife® C with
Automatic
Positioning
System™
iViewGT™
and Active
Breathing
Coordinator™
Manufacturing
facility estab-
lished in China
Elekta
IntelliMax™
Medical
Intelligence
Medizin-
technik
GmbH
acquired
IMPAC
Medical
Systems Inc
acquired
Leksell
Gamma
Knife®
Perfexion™
Elekta
Axesse™
80% of
BMEI in
China
acquired
Elekta
Infinity™
Elekta
Compact™
3D Line
Research
and Develop-
ment Srl acquired
XiO® with
Electron
Montecarlo
FDA clearance
for VMAT
with Monaco®
Elekta
Agility™
Radon Ltda
acquired
PrecisePLAN®
Leksell
Gamma
Knife® 4 C
FDA
clearance
for VMAT
CMS Inc
acquired
Elekta
Synergy® for
clinical use
Neuromag
Oy acquired
Resonant
Medical Inc
acquired
Nucletron
BV acquired
23
2000 2005 2010 2012
24. 24
What makes your center unique?
We share the passion of our customers in advancing the frontiers of cancer care,
and we enjoy news from clinics that are treating patients more effectively, precisely and
efficiently with the help of Elekta technology. Here are a few stories from across the globe.
In April, the Prime Minister of India, Dr.
Manmohan Singh, honored the Dr. Bhubaneswar
Borooah Cancer Institute (bbci) by presiding over
the inauguration of its Elekta Synergy® linear accel-
erator. Established in 1973, bbci is among the leading
cancer institutes in east India, and was recognized as
a Regional Cancer Centre in 1980.
In the state of Assam – as it is across India –
head-and-neck cancer and tobacco-related cancers
(mainly lung cancer) comprise 15-20 percent of the
total cancers. Among males, the top three cancer
incidences are oral cavity, larynx and lung cancer,
while in women, cervical and breast cancer are the
most common. In metro areas, prostate and breast
cancer incidences are rising. At any given time in
India, about three million individuals have cancer,
with approximately 960,000 new cases identified
per year, and rising rapidly. A national task force
estimates that two-thirds of those diagnosed with
cancer will need radiation therapy.
Elekta and other healthcare providers have collab-
orated with medical centers and clinics across India to
address a shortage of radiation therapy equipment.
bbci’s new Synergy system is fully equipped with the
most advanced radiation therapy techniques in use
today, including imrt, igrt, srs and sbrt. l
Prime Minister of India Inaugurates Elekta Linear Accelerator
‘‘
In metro
areas,
prostate
and breast cancer
incidences are
rising.”
ELEKTA CUSTOMERS IN FOCUS
25. 25
In June, Vejle Hospital, Region of Southern
Denmark, and Elekta collaborated to host a sympo-
sium on advanced treatment of breast cancer.
Bringing together 117 participants from 18 countries,
including more than a dozen European countries
and participants from the us and Canada, the sym-
posium focused on topics such as target delineation,
3d conformal, imrt and vmat planning, sparing of
the heart using breath hold or gated techniques and
patient positioning protocols.
Together, with Elekta, Vejle Hospital donated
the registration fee for the symposium to the
Danish Cancer Society, totaling nearly dkk 83,800
(usd 14,200). Closely aligned with Elekta’s mis-
sion to improve, prolong and save lives, the Danish
Cancer Society – the largest organization of its kind
in Denmark – is very active in fighting cancer.
In his closing remarks, Martin Berg, msc, Head
of Medical Physics at Vejle Hospital and symposium
chair, said: “The meeting was a great success and
hopefully laid the groundwork for a second such
symposium.”
At Vejle Hospital, all left-sided breast cancer
patients receiving radiotherapy after surgery are
treated with Elekta Active Breathing Coordinator™,
which assists patients in maintaining a deep-breath
hold while irradiating the breast. This separates the
breast tissue from the heart, which helps irradiate
more breast tissue while sparing the heart and its
critical blood vessels at the same time.
The clinical focus at Vejle Hospital – apart
from breast cancer treatments – includes lung
cancer, prostate cancer and rectal and anal
cancers. The department is currently developing an
mri compatible shielded applicator for conformal
hdr brachytherapy boosts given to rectal and
anal cancer patients receiving intensity modulated
external beam treatment. l
Danish Hospital Donates Proceeds
from Breast Cancer Symposium to Local Cancer Society
‘‘
The meeting
was a great
success and
hopefully laid
the groundwork
for a second such
symposium.”
26. 26
What makes your center unique?
Do you have some special treatment or compelling patient story from your center that you want to share? Tell us!
Send us your story and we may feature your clinic in an upcoming issue of Wavelength. Write a brief description
of your story, include photographs (high-resolution jpgs) and your name, clinic or hospital name and email address.
Send it, marked “Unique Center”, to media@elekta.com. We look forward to hearing from you!
Tell us what’s happening where you are!
Among the largest public hospitals in Brazil,
Barretos Cancer Hospital recently made a major
commitment to the healthcare of the country’s
citizens by acquiring a range of advanced Elekta
cancer management solutions. The technology,
including Elekta Synergy® Platform, Monaco® and
XiO® treatment planning systems and Clarity®
3d ultrasound-assisted image guided radiation
therapy (igrt) were delivered in August 2012.
“As a teaching hospital, it was important for us
to broaden our range of cancer treatment systems
beyond our existing equipment – to enable us to
evaluate how Elekta’s solutions might improve the
provision of healthcare,” says Rodrigo Gadia, md,
Head of the Department of Radiotherapy.
“In Brazil, this is critical, as access to advanced
treatment technology is limited. In particular, we
hope that use of Elekta Synergy Platform – once
it is upgraded with igrt capabilities – may rep-
resent a practical demonstration of a good cost-
benefit ratio for the use of igrt in Brazil.”
Barretos will use its two Clarity systems – the
first in Latin America – to provide image guidance
for soft tissue targets. The center also intends to
pursue clinical studies on the planning benefits of
integrating 3d ultrasound with ct based planning.
This work will help explore the local applicability
of a relatively low-cost imaging modality that could
be retrofitted on existing equipment in the region.
“Clarity will be another way to obtain fast, accu-
rate soft tissue igrt that we can integrate with any
of our linear accelerators, with the added benefit of
non-invasiveness,” he says. l
Brazilian Hospital First in Latin America to
Acquire Clarity Soft Tissue Visualization Software
‘‘
Clarity
will be
another
way to obtain
fast, accurate
soft tissue IGRT
that we can
integrate with
any of our linear
accelerators.”
ELEKTA CUSTOMERS IN FOCUS
27. imagine
...twice the leaves at twice the speed
With Agility™
, it’s reality.
As the ultimate device for advancing modern radiotherapy,
Elekta’s Agility MLC precisely sculpts radiation with 160 high-
resolution leaves across a 40 cm x 40 cm field. Capable of
managing the broadest spectrum of therapies, Agility also
boasts ultra-fast leaf movements with extraordinarily low
leakage to maximize the potential for advanced techniques
such as SRS, SRT and VMAT.
Human care makes the future possible.
More at elekta.com/imagine
4513371099303:12
Agility is not licensed for sale in all markets.
Please contact your local Elekta representative for details.
28. Corporate Head Office:
Elekta AB (publ)
Box 7593, SE-103 93 Stockholm, Sweden
Tel +46 8 587 254 00
Fax +46 8 587 255 00
info@elekta.com
Regional Sales, Marketing and Service:
North America
Tel +1 770 300 9725
Fax +1 770 448 6338
info.america@elekta.com
Europe, Latin America,
Africa, Middle East India
Tel +46 8 587 254 00
Fax +46 8 587 255 00
info.europe@elekta.com
Asia Pacific
Tel +852 2891 2208
Fax +852 2575 7133
info.asia@elekta.com
www.elekta.com
Human Care Makes the Future Possible
