The document is a newsletter from Elekta that discusses: 1) Elekta's vision to provide the best technology and service in the industry with a commitment to open systems. 2) Elekta plans to consolidate trusted brands it has acquired under a single Elekta brand to provide a cohesive identity for customers. 3) The newsletter highlights two case studies of cancer centers that have implemented comprehensive Elekta solutions, including the Instituto do Cancer do Estado de Sao Paulo in Brazil and The Roy and Patricia Disney Family Cancer Center in the US.

1. VOL. 14 NO.1 | FEBRUARY 2011
4
The “all-Elekta” route to
exceptional cancer care
Dutch partner improves
stereotactic capabilities
12
Opera star Zheng Cao
battles brain mets
16
Advanced cancer care
streams into India
20
NEWS AND ADVANCES IN THE MANAGEMENT
AND TREATMENT OF SERIOUS DISEASE
Global cancer rates
could increase 50%
by 2020
Treatments aim to
cure, prolong life and
improve quality of life
Cancer emerges as
major health problem
in developing countries
Clear evidence
that 1/3 of cancers
can be cured

2. CONTENTS
ofTable
Dear friends,
Since its inception, Elekta has worked diligently to
provide products and services that bring the highest
value to you and your patients. Our vision is simple:
we want to provide the best technology and service
in the industry, with an ongoing commitment to
open systems that you need and expect.
Elekta has continuously strengthened its marketplace
reputation by not only developing world-class solutions,
but also by acquiring companies with complementary
best-in-class technology. These were careful, strategic
additions to the Elekta family – based not only on how
their offerings enhanced our portfolio, but also on how
you, their customers at the time, perceived their
respective brands.
In 2011 and beyond, Elekta will begin to consolidate
these trusted brands under a single, unified Elekta
brand. These efforts will help you identify the myriad
cancer care products and solutions on which you’ve
come to rely – including but not limited to MOSAIQ®
,
Monaco®
, HexaPOD™
evo and Clarity®
– with Elekta,
a cohesive company with a solid, instantly recogniz-
able identity.
Under the single Elekta brand, we will continue to focus
on providing you with the best seamless, integrated,
and open-system solutions. Furthermore, you can rely
on Elekta to be your single point of contact to support
all your clinical solutions acquired under our banner.
The Elekta brand, and all it represents, is your gateway
to exceptional, integrated cancer management solutions
and customer service.
We look forward to continuing to serve you and
providing the award-winning products and services
that have become synonymous with the Elekta name.
The "all-Elekta” route to exceptional cancer care
Elekta events in your region
Introducing MOSAIQ® Data Director
Right at home in a proton clinic
Dutch partner expands Elekta linac collection
Elekta – Around the world
Zheng Cao, performance of her life
Advanced cancer care streams into India
Elekta – Case in point
8
10
12
14
16
20
24
4
Tomas Puusepp
President & CEO
ELEKTA
Published by Elekta AB, www.elekta.com
All letters, comments or suggestions for future articles, requests for reprints and permissions are welcome.
Contact: Michelle Lee, Director, Global Public Relations and Brand Management, Elekta Tel: +1 770-670-2447
email: michelle.lee@elekta.com Time zone: EST: Eastern Standard © 2011 Elekta AB. All Rights Reserved
Vol. 14 | No. 1
FEBRUARY 2011Human Care Makes the Future Possible
The Elekta vision is simple: we want to
provide the best technology and service in
the industry, with an ongoing commitment
to open systems that you need and expect.
Experience the Elekta Difference.
Statistics on cover from World Health Organization, 2009, www.who.int
9
The Elekta vision is simple: we want to
provide the best technology and service in
the industry, with an ongoing commitment
to open systems that you need and expect.
Experience the Elekta Difference.

3. 5
Instituto do Cancer do Estado de Sao Paulo
Wladimir Nadalin, M.D.
4
Instituto do Cancer do Estado de Sao Paulo’s radiation oncology team
A comprehensive solution
Although two other major providers
competed to be ICESP’s principal
radiation therapy provider, only Elekta
offered a comprehensive solution that
included advanced treatment systems
and techniques, an OIS that could
integrate all systems, a field engineer
based in the hospital and the
opportunity to be Elekta’s South
American referral and product training
and development center, according to
Dr. Nadalin.
“With MOSAIQ, I knew I would be
able to integrate the treatment systems
in the Hospital das Clinicas, so I could
develop a treatment plan there or in
ICESP and have it available system-
wide,” he says. “After the acquisition,
we were able to send two physicians to
Elekta customers, University Medical
Center Utrecht and University of
Mannheim, where they learned not
only about IMRT, IGRT and Elekta
VMAT, but they also obtained a better
understanding of how to use MOSAIQ.”
The Utrecht and Mannheim training
was only the first component of a
multi-center collaboration that Elekta
facilitated on behalf of ICESP. Elekta
created a formal Scientific Proposal
that will enable ICESP to exchange
knowledge with these and other centers
on clinical protocols, training and the
publication of scientific papers.
“In Brazil, we have some types
of cancer that are not commonly
encountered in Europe, which
our European counterparts find
fascinating,” Dr. Nadalin says. “Our
contribution to multi-center clinical
trials will be mutually beneficial.”
As ICESP ramps up to its full radiation
oncology capabilities, Dr. Nadalin is
confident that Elekta will provide
timely service support for its new
equipment.
“Francisco Mendes is our Elekta
field service engineer in Sao Paulo,
and he has assisted us from the start
in getting the systems ready and
addressing any issues we’ve had
along the way,” he says. “This was
very important to us during the
equipment evaluation. We can’t
wait two weeks for an engineer
to come to ICESP – we have too
many patients waiting.”
The top indications at ICESP and
Sao Paulo in general are breast and
prostate cancer. To address the
volume of patients needing treatment
for prostate cancer, in particular,
Dr. Nadalin is eagerly anticipating
the start of Elekta VMAT on
ICESP’s Elekta Synergy systems
in early 2011.
“I need to be able to treat fast, so
Elekta VMAT will be useful,” he
says. “If I treat 100 patients with
prostate cancer, I will still have 200
waiting for treatment. The reason is
that in Brazil, there is still a lack of
cancer management resources.
Patients are coming not only from
the state of Sao Paulo, but also from
the entire country of 200 million
people.”
Gearing up for 2011
Currently, ICESP is using its Elekta
systems conservatively, performing
3D conformal IMRT for all cases,
however clinicians have begun
preparing to implement IGRT in
early 2011. Also planned for 2011
are services for total body, total skin
irradiation and HDR brachytherapy.
Dr. Nadalin predicts that ICESP’s
ramp up in 2011 will transform the
hospital into a magnet for other
Brazilian centers acquiring Elekta
equipment to take advantage of
training opportunities. “This is very
good, because it will give us another
site with which to exchange
information,” he adds.
Dr. Nadalin’s
vision for ICESP is
for the center to
become a major
referral center in
the continent.
“In Brazil, we have some types of cancer that
are not commonly encountered in Europe, which
our European counterparts find fascinating,”
Dr. Nadalin says. “Our contribution to multi-
center clinical trials will be mutually beneficial.”
The "all-Elekta" route to
exceptional cancer care
Two new centers in South and North America are the most recent examples of clinical customers
that weighed their equipment options and concluded that Elekta could satisfy virtually all their
cancer management needs – from treatment planning and oncology information management to
treatment delivery systems. Dr. Wladimir Nadalin of Instituto do Cancer do Estado de Sao Paulo
(ICESP, Sao Paulo, Brazil) and Dr. Rex Hoffman of The Roy and Patricia Disney Family Cancer Center
(Burbank, CA, USA) shared their perspectives on their comprehensive Elekta solutions.
ICESP emerging as cancer treatment powerhouse in southwestern hemisphere.
With the 2009 acquisition of six new Elekta treatment machines, 30 stations networked to the MOSAIQ®
Oncology
Information System (OIS) and 19 treatment planning systems, the Instituto do Cancer do Estado de Sao Paulo (ICESP)
is reinforcing its role as the largest cancer center for adult patients in Latin America. ICESP opened in May 2008,
and began radiation therapy treatments in June 2010. By December 2010, it had commissioned four of the five
Elekta Synergy®
systems it purchased and is scheduled to bring an Elekta Axesse™
system for stereotactic
treatments – Latin America’s first – on line by February 2011.
“These four linear accelerators treat about 50 patients each day, and when Elekta Axesse is commissioned, we will
treat up to 300 patients per day between these five systems,” says Wladimir Nadalin, M.D., head of ICESP’s radiation
therapy department.
“We want to be the first referral in South America,” he says. “We will most likely have equipment and techniques that won’t
be found in neighboring countries, so patients there will come here for treatment. In that sense, we will be like M. D. Anderson
Cancer Center in the United States or The Royal Marsden, University of Mannheim and University Medical Centre Utrecht
in Europe.”

4. The Roy and Patricia Disney Cancer Center at Providence Saint Joseph
6 7
Providence Saint Joseph Medical Center’s utilization of MOSAIQ OIS also has migrated successfully to the Disney
Family Cancer Center. All of the staff in Radiation Oncology and Integrative Medicine currently use MOSAIQ 2.0.
In the next six to 12 months, Medical Oncology and other sub-specialties within the Disney Cancer Center will be
implementing MOSAIQ into their practices.
“From a radiation oncologist’s viewpoint, MOSAIQ is very user-friendly. It streamlines communication between
different aspects of the department,” he says. “We have become more efficient because of MOSAIQ – and it has
some nice checkpoints in place to avoid any potential issues related to process.”
A multi-faceted approach to improve the patient experience
In addition to having the best treatment equipment and software available for its patients, the center also prioritized
investments to distinguish the patient experience. One important aspect of this effort was the unique adaptation of
Philips Ambient Experience – typically implemented in diagnostic imaging settings – for the radiation oncology
environment.
Ambient Experience technology gives patients the ability to create a personalized, calming environment as they
undergo the rigors of cancer treatment.
“There are two components of Ambient Experience, a radio-frequency identification card [RFID] that patients are
given when they start a treatment course and the ability to modify treatment room ambience,” Dr. Hoffman says.
“As the patient walks through different parts of the department, the RFID card activates different functions based
on patient pre-selects, such as music preference, types of lighting and temperature. It also benefits us by showing
us where the patient is in the facility and queuing it up on MOSAIQ. The other part of Ambient Experience is
empowering patients to choose from 10 different treatment room scenes depicting landscapes from around the world.”
treatment – all overseen by the
same company has helped greatly
to coordinate treatment delivery
for our patients,” explains Rex
Hoffman, M.D., Medical Director
of Radiation Oncology. During the
planning process, we thoroughly
evaluated technology from all of
the major radiation therapy
vendors and concluded that
“Elekta was the company to
go with,” he says.
Providing clinical value with
the Elekta solution
Disney clinicians currently use
Elekta Infinity to treat eight head
and neck cancer patients per day
with Elekta VMAT, using Monaco
to plan VMAT cases.
“We try to use Elekta VMAT for
most head-and-neck patients if we
can,” he says. “Frequently, we
Coordinated treatment
delivery with all-Elekta
solution
The Roy and Patricia Disney Cancer
Center at Providence Saint Joseph
Medical Center provides state-of-
the-art oncology treatment in a
4-floor, 55,000 sq. ft. integrated
facility in Burbank, California.
Equipped with the full portfolio
of Elekta equipment and software,
including two Elekta Infinity™
systems with VMAT, one Elekta
Axesse system, Monaco®
and
XiO®
treatment planning systems
and MOSAIQ, the Disney Cancer
Center is experiencing a high level
of efficiency and treating patients
effectively, quickly and safely.
“Having the three most essential
components of the treatment
process – planning, EMR and
generate both IMRT and VMAT
plans to see if we can get an
advantage from VMAT. The whole
benefit is increasing throughput and
getting patients on and off the table
more quickly without sacrificing
accuracy. It’s working quite nicely.”
Prior to opening last February,
Disney also elected to substitute
Axesse for a TomoTherapy®
unit in
order to have a machine dedicated to
stereotaxis for body cases, according
to Dr. Hoffman.
The volume of Elekta Axesse
stereotactic cases is, on average, two
to five patients per week, but this is
likely to increase in coming months,
Dr. Hoffman predicts. The case mix
is divided between brain, lung and
liver tumors, with spine tumors on
the horizon.
The "all-Elekta" route to
exceptional cancer care
from left to right: Rex Hoffman MD , Medical Director, Radiation Oncology; Marc Botnick MD,
Radiation Oncologist; Lauren VanderSpek MD, Radiation Oncologist; Mona Sanghani MD, Radiation Oncologist

5. 98
MOSAIQ UK & IRE
Users Meeting
Birmingham, UK
March 29-20, 2011
International Symposium on
Stereotactic Radiosurgery with Gamma
Knife Shaio Clinic Foundation
Bogotá, Colombia
April 15-16, 2011
Monaco / Monaco VMAT workshop
London, UK
May 6, 2011
ESTRO Elekta Users Meeting
London, UK
May 7, 2011
11th Biennial ESTRO Meeting - ESTRO
Anniversary, EIOP, GEC-ESTRO-ISIORT
London, UK
May 8-12, 2011
2011 Elekta Cancer Registry
Users Meeting
Orlando, Florida, US
May 15, 2011
2011 PowerPath Users Meeting
Clement Intercontinental Hotel
Monterey, California, United States
May 18-20, 2011
2011 Leksell Gamma Knife
Administrators Meeting of
North America
LaPlaya Beach Resort
Naples, Florida, US
June 6-9, 2011
5th European Users' Conference
Warnemünde, Germany
June 16-19, 2011
Elekta Australasian Users Meeting
Shangri La Hotel
Sydney, Australia
September 9-11, 2011
20th North America Users Meeting
Radiation and Medical Oncology
Miami, Florida, US
October 1, 2011
31st Annual Conference of
Association of Medical Physicists
of India (AMPICON 2011)
Vellore, India
November, 2011
24th Annual Meeting of Japan
Japanese Society for Therapeutic
Radiology and Oncology (JASTRO)
Tokyo, Japan
November 18, 2011
* events sponsored by Elekta and for
customers only
Advances in cancer treatment
techniques have improved the lives
of millions of patients worldwide.
The consequence of enhanced
oncology methods has been an
explosion in the volume of images
and data for each patient’s case.
Now more than ever, oncology
professionals need a way to organize
and direct the flow of vital images
and data throughout the patient’s
treatment journey. To address the
requirements of the modern
oncology workflow, Elekta has
introduced MOSAIQ®
Data
Director, the next evolutionary
step in oncology information
management.
“A traditional clinical departmental
PACS can archive and move images
well, but it is under-equipped to
meet the diverse demands of the
oncology environment,” says
David Nikolai, Business Line
Manager, Oncology Information
Systems at Elekta. “MOSAIQ Data
Director was explicitly developed to
handle all DICOM and non-DICOM
images and data, particularly
DICOM RT objects, and enables
the user to orchestrate all data
and image traffic through tight
integration with the patient chart.”
Fully integrated with Elekta’s
mainstream MOSAIQ®
Oncology
Information System, MOSAIQ Data
Director transforms the patient chart
into the centralized control point to
manage, view, move and archive
patient images and data. Tight
integration with the patient chart
also eliminates the need to access
stand-alone applications and
separate log-ins or patient searches.
Web-based viewer ideal
for oncology
Users can also harness the new
Web-based viewer to explore data
and archived images or objects
online using powerful 3D function-
ality. The new Web-based DICOM
RT 3D viewer enables centers to
avoid installing a viewer application
in discrete stations. Any workstation
with Internet access can interface
with the MOSAIQ Data Director
viewer, increasing convenience
and efficiency.
The viewer’s powerful 3D
functionality allows physicians to
manipulate all applicable data sets
required for the patient’s treatment.
“Clinicians want to see dose
distributions, beam trajectories and
structure sets in a three-dimensional
view – and to be able to rotate
around that view to see how the
dose is delivered,” says Michele
Verst, Chief Physicist at Hux
Cancer Center at Union Hospital
(Terre Haute, Ind.), which tested
much of the functionality of
MOSAIQ Data Director.
“The functionality is specific to the RT domain,” says
Terry Michaelson, Director of Technical Systems at Princess
Margaret Hospital (Toronto, Canada), one of Elekta’s technology
development partners. “And, all of this information – the
discrete DICOM RT elements, in addition to DICOM and
non-DICOM images and other files – can be viewed and
analyzed in the context of the patient’s treatment from a
single point of access. This is very compelling functionality
from both a clinical and a research perspective.”
Elekta introduces MOSAIQ®
Data Director,
image and data management for oncology
Designation as an Elekta
technology show site
Less than a year old, Disney is
already thriving with its all-Elekta
solution, Dr. Hoffman says.
The opportunity to witness multiple
Elekta solutions operating in a single
clinical environment is attracting
prospective and existing customers
to Disney, which, as an Elekta show
site, hosts routine visits from the
United States and international
clinics.
Most often clinicians are interested
in visiting the facility to better
understand what VMAT can do, Dr.
Hoffman explains. “They also are
interested in the integration of XiO
and Monaco with the treatment
systems and seeing how the center
has experienced workflow benefits.
In February 2011, we were excited
about an XVI update with
Symmetryand Intuity we received
this month, which will allow us
to perform four-dimensional CT
imaging. This technology will
enables us to reduce – to a greater
degree than we have been able to –
the area in one’s body exposed to
radiation. Accordingly, this should
translate into less treatment-related
side effects.
“Since we opened, I have been
very pleased with Elekta regarding
what their equipment can offer –
in treatment quality and in terms
of response time if there is an issue
and we need their help,” he
continues. “It certainly has been
a very positive experience. I feel
comfortable recommending
Elekta solutions.”
Rex Hoffman, M. D., Medical Director
of Radiation Oncology
“Elekta was the company to go with.”
Directing image, data traffic
MOSAIQ Data Director can serve
as the central repository and director
of the department’s data and enables
users to locate and move images and
data from other PACS, with its
Query Spanning and Move
Forwarding features.
“Move Forwarding will allow us to
move images from one entity to
another,” Verst says. “For instance,
we can move a CT image from the
radiology PACS and push it directly
to the treatment planning system,
bypassing Data Director altogether.
Once the TPS is done with the CT
image, it can come to Data Director
with the plan and all of the RT
structure objects attached to it. It’s
smart data management and we’re
excited to get it.”
MOSAIQ Data Director viewer showing
3D surface rendering with beams
Slice View can display beams, structures,
dose and other plan data
Don’t miss out on Elekta events* in your region!

6. UFPTI at a glance
• Established: 2006
• Square footage: 98,000 sq. ft.
• Staff: 8 physicians, 7 physicists,
8 dosimetrists, 25 therapists
• Services: proton therapy, photon
therapy, infusion and anesthesia,
psychosocial, dietary
• Daily proton treatments: 122
• Daily photon treatments: 45
• Imaging equipment: PET-CT,
large bore CT, 0.23 T open MRI
• Proton therapy: IBA Proteus
235 Proton Therapy System
(3 gantries), 230 MeV cyclotron
• Photon therapy: two Elekta
Synergy systems, one equipped
for couch-mounted Leksell
Stereotactic System®
10 11
Elekta OIS, respiratory management and immobilization solutions for radiation
Oncology a great fit at University of Florida Proton Therapy Institute (UFPTI).
account for workflow changes,”
Dr. Li observes. “We can specify
privileges based on staff functions
to a very detailed level, which has
proven to be extremely useful to
us and prevents errors.”
Options for respiratory,
patient motion management
Because organ motion is more
critical in proton therapy versus
conventional radiotherapy from
a dosimetry standpoint, UFPTI
employs three different options:
Active Breathing Coordinator™
,
BodyFIX®
or free-breathing.
Determining which alternative
to use is patient-specific, he says.
“For every proton therapy patient,
lung cancer patient or Hodgkin’s
patient treated with protons, we
always evaluate organ motion,
quantify the motion magnitude
and determine which strategy
gives us the smallest organ motion
magnitude or reproducibility of
respiration accuracy,” Dr. Li
explains. “Typically, we will use
Active Breathing Coordinator when
we can predict at least a 30 percent
improvement in the magnitude of
motion. So, while it is used
infrequently for proton cases, when
we need to use it Active Breathing
Coordinator is very effective.”
BodyFIX, used in concert with
BlueBAG™
, is Elekta’s dual vacuum
immobilization system and is also
used in select proton therapy cases
(e.g., pancreatic cancer) to provide
non-invasive, accurate and
reproducible patient positioning
and breathing motion reduction,
he adds. It finds it greatest use for
UFPTI’s lung stereotactic body
radiation therapy cases.
For proton therapy cases that require
firm yet gentle head fixation, UFPTI
clinicians use HeadFIX™
, Elekta’s
vacuum-activated head frame
system. HeadFIX uses a mouthpiece
with the patient’s upper palate
impression and solid vacuum
bonding with the hard palate.
“We use HeadFIX on all patients
with an optical sheath meningioma
and for some patients with brain
tumors,” Dr. Li notes.
Right at home in a proton clinic
While they are both radiation
therapy techniques, proton
therapy and traditional (photon)
radiotherapy differ significantly in
hardware requirements, physics and
especially workflow. Fortunately,
for centers such as University of
Florida Proton Therapy Institute,
proton clinics needn’t seek out
dedicated proton therapy solutions
for their treatment services. Since its
inception in 2006, UFPTI has relied
on Elekta’s MOSAIQ®
Oncology
Information System and respiratory
management and immobilization
solutions in a practice that also
includes photon-based radiation
therapy using Elekta linear
accelerators.
UFPTI’s parent organization, the
University of Florida (UF, Shands
Jacksonville) trusted on the success
it had achieved dating back to 1997
and currently has two Elekta
Synergy®
systems currently in
use at UFPTI.
“It was a natural solution for us to
continue to use MOSAIQ for proton
therapy as well as for combined
photon/proton therapy,” says
Zuofeng Li, D.Sc., UFPTI Director
of Physics. “In 2006, we worked
with Elekta to interface to the IBA
proton system and that work
continues in terms of product
improvement.”
MOSAIQ directs information
Among the most critical MOSAIQ
features for a proton-photon center
is the capability to enable access to
patient records from a single
database, particularly when patients
receive both therapy forms.
“We have head and neck protocols
that specify IMRT followed by
proton boost, prostate pelvic lymph
node treatments followed by proton
boost to the prostate, and several
other joint-therapy protocols,
including those for Hodgkin’s
disease, pancreatic cancer, sarcomas,
chordomas and chondrosarcomas,”
Dr. Li says. “That is the number one
case in which a single database is
indispensable. We need to have a
complete record of all the patient’s
treatments regardless of the
treatment modality, where MOSAIQ
allows us to be certain of all the
doses and provides us with set up
notes for review on the same
database. I can’t imagine treatment
using different modalities and not
having the patient record
consolidated.”
The proton therapy workflow often
is unpredictable due to uncertainty
when custom-fabricated patient
accessories, such as apertures and
compensators, will become available
for a given patient, in addition to
the need to barcode scan these
components and immobilization
devices. MOSAIQ has provided
considerable flexibility in its
record-and-verify functionality
to accommodate UFPTI’s proton
workflow, he adds.
“MOSAIQ allows us to schedule all
treatments in the treatment calendar
in an unambiguous way, and in a
way that is easily adjustable to
‘In proton therapy, we don’t have
a way to put everything together in
one shot, so the distributed approval
process that MOSAIQ provides is
very helpful.”
Zuofeng Li, D.Sc., UFPTI Director of PhysicsUniversity of Florida Proton Therapy Institute (UFPTI)

7. Elekta Axesse serves
as the centerpiece
of the hospital’s new
stereotactic cancer
treatment unit, and is
the 10th Elekta linear
accelerator currently
operating at the site.
1312
“Precision in radiation therapy comes not only from
image guidance, but also from patient comfort,”
Dr. van Herk observes.
NKI-AVL’s Elekta-only collection
of linear accelerators speaks both to
the center’s trust in Elekta radiation
therapy technology and to the
strength of their longtime research
and development relationship.
“I am extremely pleased about
continuing our collaboration with
Elekta – we make a very good team,”
he says. “Every time there is a new
release there is a bit of stress and
we think things should go faster, but
in the end we get there. The features
we are jointly adding to the market
are quite unique, and that is a good
thing for both of us and for radio-
therapy in the world.”
Flying Dutchman suite
honors Elekta innovator
The death in 2008 of Gerry van
Oortmarssen, the Dutch founder
and nurturer of the NKI-AVL/
Elekta relationship, was a blow to
the hospital’s research team, which
regarded him not only as a business
associate and visionary, but also as
a friend. To honor Gerry’s role in
advancing concepts to improve the
patient experience, Elekta and
Philips Healthcare partnered to
integrate Philips’ Ambient
Experience for the Elekta Axesse
vault, a project enabled by a
memorial fund created by his wife,
Joni van Oortmarssen.
Acknowledging Gerry’s love of flying
and his experience as a private pilot,
the NKI-AVL team named the room
the Flying Dutchman suite.
Dutch RD partner expands
Elekta linac collection,
improves stereotactic capabilities
The Netherlands not only uses more
Elekta linear accelerators than any
other brand – Elekta has a 75
percent market share – but it also is
the home of Amsterdam's NKI-AVL,
the country’s only comprehensive
cancer center, and principle
developer of critical imaging and
operational software used in Elekta
IGRT systems. Now, with NKI-
AVL’s acquisition of Holland’s fifth
Elekta Axesse™
system, Dutch
patients with cancer will benefit
from their country’s tradition of
innovation.
Axesse is equipped with
sophisticated tools to enable highly
precise stereotactic radiosurgery
(SRS) and stereotactic radiation
therapy (SRT) and stereotactic
body radiation therapy and body
radiosurgery (SBRT, SBRS).
NKI-AVL clinicians are combining
the precision that the 4 mm leaves
of the Axesse system’s Beam
Modulator™
provides with the
speed of Elekta VMAT to improve
performance in non-stereotactic
prostate cases and stereotactic
lung and brain cases.
“Within the first two months, Elekta
Axesse was running a full schedule,”
says Floris Pos, M.D., Ph.D.,
radiation oncologist at NKI-AVL.
“For small tumors in the lung and
brain, the smaller leaf width has
given us more degrees of freedom.
It makes us more comfortable
treating these small tumors. For
the stereotactic cases in particular,
VMAT has substantially reduced
treatment time.”
The image of a perfect
partnership
While Elekta systems’ imaging
hardware, beam shaping, patient
positioning and immobilization
form the functional skeleton of
these IGRT systems, XVI software
enables clinicians to create 3D
reconstructions of acquired patient
images, which can then be registered
to a reference image. The integration
of sophisticated hardware and
software makes Elekta radiation
therapy targeted, safe and effective.
In 2003, just three years after Elekta’s
Gerry van Oortmarssen (see Flying
Dutchman sidebar) facilitated the
collaboration between Elekta and
the hospital, NKI-AVL received
an Elekta Synergy®
prototype
and clinicians and scientists began
developing the XVI image analysis
software to guide its 3D and 4D
imaging systems.
We impressed Elekta with our work,
so they decided to integrate the tools
we built into their product,” says
Marcel van Herk, Ph.D., head of the
physics research team at NKI-AVL.
The Elekta/NKI-AVL collaboration
intensified over the years and has
yielded some of the industry’s most
important IGRT innovations, among
which are the XVI version 4.5 tools,
Symmetry™
and Intuity™
.
Symmetry provides tools to manage
shifts in the relative positions of the
tumor and organs-at-risk during the
respiratory cycle, and Intuity ensures
that not only is the tumor’s position
accounted for, but also the position
of nearby healthy critical structures.
Both innovations contribute to a
more patient-friendly and safe
treatment.
“Contrary to the earlier release, this
time we played a role in formal
testing,” Professor van Herk notes.
“It was interesting, because we had
never done that before. We gained
an understanding of why it can take
awhile to introduce new function-
ality. There are numerous studies
you need to perform, particularly
related to the GUI functions and
how they behave. You have to
create the full clinical use scenario
and try to uncover things that could
go wrong and what you should
catch to optimize the system.”
From left to right: Dr. Peter Remeijer, Dr. Jan-Jakob Sonke, Dr. Marcel van Herk, Dr. José Belderbos. Elekta and Philips Healthcare partnered to integrate Philip’s Ambient Experience to the Elekta Axesse treatment room
System software developer, Netherlands Cancer Institute
Antoni van Leeuwenhoek (NKI-AVL) Hospital, acquires
Netherlands’ fifth Elekta Axesse

8. 15
AROUNDTHEWOR
LDAR
OUND THE WOR
LD
Beijing, China
Prototype Software Takes First Place in
Two Autosegmentation Contests
Elekta continues its autosegmentation
domination with first place rankings in two
recent challenges for new prototype software.
The top finishes were for lung, as well as head
neck at MICCAI 2010 in Beijing. We are
delighted to once again gain recognition for
refinements to our highly regarded prototype
software,” says David Murphy, Director of
Marketing, Business Area Software Systems.
“It has been Elekta’s tradition to integrate
new award-winning functionality into future
Atlas-Based Autosegmentation (ABAS)
releases, so we expect to add these methods
to ABAS as soon as possible.”
Dubai, United Arab Emirates
New Dubai Office Demonstrates Strong
Commitment to Middle East Customers
In October 2010, Elekta opened an office in the upper levels of the
newly-built Concord Towers in Dubai Media City. “We’ve always
had good distributors and a great deal of success throughout the
Middle East, but we needed to establish a direct presence there
in order to support – not replace – our distributors,” says Nabil
Elias Romanos, Vice President Eastern Europe and Middle East.
“With a local office and staff, we can serve our customers better
and show them greater responsiveness. We are able to develop
and leverage face-to-face relationships in a culture in which
trust is often derived from good personal contact.”
Patna, India
U.S. Clinicians Share Experience with Advanced
Elekta Treatment Techniques in India
During the 32nd National Annual Conference of the Association
of Radiation Oncologists of India (AROICON), Elekta hosted an
special symposium on image guided SBRT and VMAT where Dr. Vivek
Mehta (Swedish Cancer Institute) and Dr. Jatinder Palta (University
of Florida) shared their clinical experience utilizing Elekta solutions.
“The leadership physicians from India who attended the symposium
were highly engaging with tremendous interaction with Dr. Mehta
and in these discussions there was an inspiring sense to find solutions
that offer the best possible care for their cancer patients,” says Rajinder
Singh Dhada, Vice President Strategic Partnerships.
Otawara-shi, Tochigi-ken, Japan
Elekta Signs Sales and Marketing
Agreement with Toshiba in Japan
Years of teamwork between Elekta and
Toshiba came to fruition when Toshiba
agreed to sell and market Elekta’s clinical
solutions to the Japanese radiotherapy
market. “I am pleased we have entered
into this important agreement with Toshiba
Medical Systems Corporation,” says
Tim Rooney, President and Managing
Director of Elekta K.K. “As a world leader
in diagnostic imaging systems, Toshiba
is the perfect long-term partner for Elekta
K.K. This collaboration will enable both
companies to extend and enhance their
commitment to providing world class,
cutting-edge solutions.”
Stockholm, Sweden
Karolinska and Elekta Collaborate on Stereotactic
Radiation Therapy Research
Each members of the Swedish medical technology industry,
Karolinska University Hospital and Elekta recently signed a letter
of intent to launch a joint research project that will evaluate and
improve the efficacy of stereotactic radiation therapy for cancer
patients and to enhance the management of metastatic lesions.
“Stereotactic treatments are well-established for targets inside the
skull, so with our clinical colleagues at Karolinska, our aim is to
improve the sophistication of stereotactic radiation therapy to tumor
targets in the body,” says Tomas Puusepp, President and CEO.
Zagreb / Split, Croatia
Elekta Receives Multiple Order from Croatian
Ministry of Health
Following nearly two years of strong efforts from our Business Unit in
Innsbruck, Elekta, in cooperation with the local Croatian Distributor
Medicem, won a tender to deliver the company’s treatment planning,
oncology information management and treatment delivery systems to
hospitals in Croatia. “This acquisition is a milestone for Croatia, where
the majority of linacs have no MLC or portal imaging and the wait time
for patients is more than three months,” says Dejan Cvetkovic, Area
Sales Manager of South East Europe. “Four Elekta Synergy®
linacs
equipped with CMS and MOSAIQ software will bring huge benefits
and improvement to radiotherapy in Croatia.”
Novosibirsk, Russia
Leading Research Center in Russia Offers
New Hope with Elekta Axesse
The Meshalkin Research Institute of Circulation Pathology is now
treating patients with Elekta Axesse™, which will, for the first time
in Russia, allow clinicians to treat tumors throughout the body with
ultra-high precision. “We are proud to be a part of the expansion
of cancer care in Russia, and in making the latest clinical treatment
solutions available to more patients throughout the country,” says
Olof Sandén, Executive Vice President, Elekta Europe, Africa,
Latin America and Middle East. ”Elekta has created
a new structure and strategies to support our focus
on emerging markets where a large number of patients
can benefit from life-saving technologies at an affordable
cost per patient.”
Bundang, South Korea
South Korea Office Opens to Support Growing
Cancer Management Needs
With an installed base of 16 Leksell Gamma
Knife®
units, Elekta has had a presence in South
Korea since 1990. And now, with the opening
of a new office in Bundang, an hour drive from
Seoul, Elekta excepts to build on its leading
position in radiosurgery and strengthen its share
of the radiotherapy market. “South Korean
clinics and medical centers are addressing an
increasing demand for healthcare in general,
and cancer management in particular,” says
Ian Alexander, Executive Vice President of
Elekta’s Asia Pacific Region.
Campinas, Brazil
Elekta Hosts Opera Singer at Brazilian
Radiotherapy Congress
Elekta Latin America was in the spotlight at
the 12th Brazilian Radiotherapy Congress
where San Francisco mezzo-soprano, Zheng
Cao, who recently was treated with Gamma
Knife® radiosurgery for brain metastases,
performed at the opening ceremony as a
guest of the company. “The more than 700
attendees were touched by Zheng’s powerful
speech, some even moved to tears,” says
Rebeca Polito, Marketing Communications
Manager, Elekta Latin America. “Following
this year’s congress, we hope to continue
exceeding customer expectations, as well as
continue to build Elekta’s image as a partner,
innovator and first choice company.”
Ottawa, Ontario, Canada
The Canadian Association of Radiation
Oncology and Elekta Award Research
Fellowship
In its fourth year, the 2010 CARO-Elekta
Research Fellowship was awarded to
Dr. Philip Wong. The fellowship will allow
Dr. Wong to conduct research with the
University of Toronto, Department of
Radiation Oncology for a period of two
years. “Dr. Wong’s fellowship will be of
great benefit to the Canadian Radiation
Oncology population who will benefit
from the knowledge he will gain from this
unique opportunity,” says Gerry Hogue,
Vice President, Elekta Canada.
Crawley, United Kingdom
Spare Parts Management Benefits Patients,
Customers and Elekta
In 2010, Elekta’s supply chain management
team received the European Supply Chain
Excellence Award for Innovation for its ability
to reduce cost, increase performance and
enhance customer satisfaction. “When an
Elekta machine needs repairing, a great
number of people rely on spare parts arriving
as quickly as possible,” says Nigel Weston,
Vice President, Supply Chain Management.
“This is a backbone service for the entire
company.” Currently, Elekta is involved
in trials that will be very positive for the
industry. These involve real-time tracking,
text messaging and greater accuracy in
delivery times.
Marseilles, France
University Hospital La Timone Celebrates
10,000th Radiosurgery Patient
On October 27, a group of clinicians from
France, Switzerland and the U.S. gathered at
University Hospital La Timone in Marseilles,
France, the site of the first Leksell Gamma
Knife Perfexion installed in the world, to
celebrate the ten thousandth radiosurgery
patient treated. Elekta’s President and CEO,
Tomas Puusepp also attended. “A site of many
firsts, it took only 18 years for La Timone to
join the group of centers worldwide that have
treated 10,000 patients,” says Per Nylund,
Vice President, Leksell Gamma Knife
Business Line.
New York, New York, USA
Elekta Among Major Sponsor of Rocks
Against Cancer Fundraiser
Benefiting the Entertainment Industry
Foundation’s cancer programs, including
Stand Up to Cancer, an initiative created to
speed the development and deployment of
promising new therapies to improve and
save patient lives, Elekta served as a leading
supporter of the Rocks Against Cancer
benefit in New York City. “As a human care
company, Elekta was honored to support
Rocks Against Cancer,” says Jay Hoey,
Executive Vice President of Elekta North
America. “It is only though the medical
community and philanthropic out reach that
we can complete our mission, which is putting
into the hands of healthcare professionals the
tools they need to treat cancer and brain
disorders, and to improve and prolong and
save patient lives.”
Santiago, Chile
Hospital Militar de Santiago Receives
Chile’s First Gamma Knife
With a new neuroscience team in place, the
Hospital Militar de Santiago has received
the first Leksell Gamma Knife radiosurgery
system in Chile, with plans to treat the first
patient in early 2011. “Offering a gentler
option to treat brain tumors and other
disorders, the Gamma Knife installation at
Hospital Militar de Santiago represents a
major advance in brain radiosurgery for the
people of Chile,” says Antonio Ponce,
Vice President, Elekta Latin America.
“To date, there are seven Gamma Knife
centers in Latin America, including sites in
Argentina, Brazil, Colombia, Puerto Rico
and Venezuela. In 2011, Elekta will welcome
the Gamma Knife Center Ecuador (Guayaquil,
Ecuador), Instituto Neurológico de Curitiba
(Curitiba, Brazil) and the Centro Gamma
Knife Dominicano (Santo Domingo,
Republica Dominicana) to the Elekta
Gamma Knife family.”

9. 1716
Opera star Zheng Cao battles lung cancer with Gamma
Knife®
surgery, chemotherapy and radiation therapy.
Non-small cell lung cancer (NSCLC) is notorious for its ability to metastasize prolifically and
stealthily, often without causing any serious or notable symptoms until the disease is far
advanced. San Francisco Opera mezzo-soprano Zheng Cao attributed her occasional aches and
pains to the rigors of frequent stage performances. When neck pain lingered for months after
an accidental fall during the September 13, 2008 world premiere of “The Bonesetter’s Daughter,”
Zheng went to a physician. The doctor’s suspicions on that day, April 16, 2009, prompted a visit
the next day for diagnostic scans – and the Shanghai-born performer met the only enemy she
has ever made in her life. Nearly two years and many treatments later, Zheng and her loved
ones continue to fight her up-and-down battle with lung cancer. In November 2010.
Elekta writer Jerry Duncan spoke with Zheng Cao and the University of California San Francisco’s (UCSF) Dr. David Larson.
Zheng Cao
The performance of her life
Jerry: Zheng, would you walk
through how you were diagnosed?
Zheng: On April 16th, 2009, a
cervical spine MRI showed a
shadow on my right lung, which
really alarmed my doctor. On the
17th she ordered a chest CT. It
turned out I had lung cancer which
had spread everywhere. The
following Monday, I went to UCSF,
where I had a brain MRI and a
whole body CT scan. The scans
confirmed showed tumors
throughout my body, and on top
of that the doctor told me I had 24
tumors in my brain.
Jerry: Up to this point, though,
you had been fairly asymptomatic?
Zheng: Yes, just aches and pains
in my bones – some mild upper
back pain and slight numbness of
my left heel. I just thought I injured
something from the fall during
“The Bonesetter’s Daughter.”
Jerry: How many tumors in total
did the doctors find?
Zheng: In addition to the 24 brain
mets and the right lung tumor,
they found a very large liver met,
many bone mets in my spine, collar
bone, ribs and pelvis, and a very
large destructive mass at the level
of my 6th and 7th cervical vertebrae,
just behind my vocal cords. I’d say
50-something tumors.
Jerry: Based on those findings,
what was the prognosis?
Zheng: The doctors said I had
possibly six months to live. At the
time I was just thinking ‘What’s the
point’? You have never met me, but
I am not that big – so I was like:
Oh my God, the tumors have just
completely taken over my body!
Jerry: Zheng, tell me how the
treatment process began.
Zheng: My medical oncologist,
Dr. Thierry Jahan, said my first
treatment would be radiation
therapy and he would refer me to
Dr. David Larson. He said Dr.
Larson is really the best doctor to
treat your disease and right now
you really need him. So, the day
after I came out of the hospital I
had a meeting with him.
Jerry: What did Dr. Larson tell
you about your options?
Zheng: The first thing he said
was I should have Gamma Knife®
surgery. He did tell me about whole
brain radiation therapy, and I had
heard about it as well from the
medical residents when I was in the
hospital. It was a pretty frightening
reality concerning whole brain
radiotherapy – you would lose your
hair, be fatigued, and I might have
difficulty memorizing opera in the
future. It seemed like a brutal
option. I thought: Oh jeez, just to
survive and stay alive, but then be
totally numb. At the time, my
outcome seemed pretty grim.
Jerry: Dr. Larson, would you
recount how Zheng’s case unfolded
from your perspective?
Dr. Larson: I’m the former
director of the Gamma Knife
program at UCSF, but currently I
perform Gamma Knife surgery only
at Washington Hospital, Fremont.
After reviewing Zheng’s case, I
recommended that she have
Gamma Knife surgery with
Perfexion*
, instead of whole
brain radiation therapy [WBRT].
Jerry: Is WBRT still considered
a frontline therapy for a case such
as Zheng’s, in which there are
multiple mets?
Dr. Larson: It depends on who
you ask. Many clinicians who have
Leksell Gamma Knife®
Perfexion™
will say WBRT should be avoided.
Most doctors at centers without
Perfexion will prescribe WBRT.
There seems to be a widespread
notion that WBRT should be used
in cases of more than three or four
metastatic sites in the brain. In fact,
many recommend WBRT even for
one or two mets, although data
supporting WBRT as the best choice
are limited. So, which is the best
option is somewhat controversial.
I have often asked physicians who
deliver WBRT what they you do if
the patient was your mother or
father or daughter or son or
spouse who needed treatment.
Many have said that in that case
they would probably not use WBRT.
It’s somewhat disingenuous,
unfortunately.
Jerry: In Zheng’s case, we’re not
talking about three or four tumors,
there are 24. While that’s a number
Gamma Knife Perfexion is
specifically designed to handle,
what if you hadn’t had Perfexion?
Dr. Larson: I’m not sure what we
would have done in that situation,
because we have treated large
numbers of tumors with a previous
generation Gamma Knife – the
maximum was 31 mets. But
certainly, one is much more inclined
to use Gamma Knife surgery if one
can do it easily in a reasonable
amount of time. It’s a lot easier to
do that with Perfexion, since this
latest generation Gamma Knife is
specifically designed to treat large
numbers of mets efficiently.
Jerry: Tell me about Zheng’s
Gamma Knife surgery and
other treatments.
Dr. Larson: We treated her on
May 6, 2009, using 48 isocenters
and 9,216 beams with a total
Gamma Knife treatment time of
five hours. She then received IMRT
to the C6-7 lesion, with a dose plan
designed to avoid her vocal cords.
She also received conventional
radiation therapy to the lumbar-
sacral spine and part of her pelvis.
Thereafter she received daily
Tarceva®
– a targeted drug – and
monthly infusions of Zometa®
.
Jerry: Zheng, you had a follow-up
MRI brain scan just four weeks
later. What did the scan show?
Zheng: I was really anxious waiting
to know what the results were,
because Dr. Larson said if you have
three or more metastases, the
chance of developing more within
12 months is very high. The news
was wonderful – 19 of the 24 lesions
had disappeared or were significantly
smaller, none had progressed– and
there were no new ones. I was just
ecstatic, all of my friends – everyone
was overjoyed.
Jerry: Dr. Larson, to have this
dramatic of a response only a month
after Gamma Knife surgery isn’t
typical, is it?
Dr. Larson: It is unusual. There is
a spectrum of responses – some
patients don’t respond so quickly
and some respond very quickly.
Fortunately for her, Zheng is in the
patient category that is very
responsive to radiation. For patients
with non-small cell lung cancer, in
particular, the response typically
takes more time than in Zheng’s
case. She is in the top one percentile
based on her results – so it’s very
dramatic and unexpected to have
such a quick response and such a
durable response now at 19 months
post-Gamma Knife surgery.
Jerry: So, with respect to her
brain metastases, what is Zheng’s
present status?
Dr. Larson: Her brain is considered
totally controlled.
Jerry: What about the body
metastases?
Dr. Larson: Based on the July 9,
2009 whole-body PET scan, she had
an impressive response for all the
tumors from the therapy. Most of
them had either decreased in size or
were no longer considered active.
Recently, she was thought to have
progression of her primary lung
tumor and a few other areas of
progression, including painful bone
mets. Zheng received additional
radiotherapy to several body sites,
by Dr. Igor Barani at UCSF, with
excellent pain relief. She also recently
enrolled in a Stanford clinical trial of
a targeted drug called XL184, which
she takes in combination with
Tarceva, under the direction of
Dr. Heather Wakelee.
Jerry: Zheng, during the last
nearly two years of treatment
you’ve maintained a great deal of
optimism and you’ve kept an active
performance schedule. Where do
you get your inspiration?
Zheng: I feel lucky I have music in
my life and now, more than ever,
I need it. Music gives me so much
expression and hope. Whenever I
am on stage singing – in that
moment the cancer no longer
exists. It is just me and the music
on stage. That feeling just gives me
tremendous peace. I am totally
addicted to it because now I sing
all the time. It is very hard for me
to cancel a concert or singing
engagement, because the singing
and the music alone eliminated my
fear – it took over the place where
the fear should be.
Jerry: Physically, how do you feel?
Zheng: By early December 2010,
I will find out for sure if the tumors
are shrinking, but the doctors tell
me to go with your general feeling.
If you wake up every morning and
you feel good, that means the tumors
are not bothering you. They are either
not active or they are shrinking.
Around the time I was diagnosed,
I know the tumors were very active
because I wasn’t feeling well when
I would wake up every day. So,
these days if I wake up and I have no
pain it is an incredible day. I was
thinking no matter what new scans
tell me, I feel good.*
fifth generation of Leksell Gamma Knife designed to treat multiple brain metastases with speed and accuracy.

10. Zheng's sister, Dan Cao, Zheng's niece, Keli
Sheng, and Dr. David Larson at a Bonnie J.
Addario charity event
18
April 27, 2009
Dearest friends:
This is the first time I feel strong enough to write to all of you, and to tell you how deeply, deeply touchedI am by this most incredible outpouring of love you’re all sending to me. It’s like thousands of hands areliterally carrying me through the most devastating hours of my life and all those sleepless nights. I read it,and enjoying your encouraging words, every day.It has been a very tough week, but so productive. I can’t believe how this whole thing – doctors, healers,tests, and more – came together in just one week. I was lucky enough to have the Angels around me at theright place and right time.
I was a girl from China and came to this country with only $45 in my pocket, and no English – only thewords “Merry Christmas!” And I remember how each one of you has come into my life and brought me somuch joy and love, and taught me most of the English (even the dirty words), and now I thank God for allyour love, which sure will carry me through this fight of my life, one minute at the time.
I thank you from the bottom of my heart.
Love,
Zheng
Monday, May 4, 2009 9:53 PM, PDT
Dear Friends of Zhengie,
Zheng asked me to write to request your extra prayers and support on Wednesday, May 6.
That is the day she will undergo the most important and intense procedure of her radiation
treatment. It will last all day: from 7am into the evening. Her beloved oncologist, Dr. Larson,
will be “in charge of the zapping” (Zheng’s words). Those prayers, stories and loving words in
the guest book make a HUGE difference. Keep ‘em coming!
Thank you so much. - Jake
June 4, 2009
(Zheng) admitted something yesterday to Dr. Larson, her sister, and I that was very
encouraging about her belief in her ability to survive and thrive after this illness: When
Dr. Larson told her that he would do special calculations to avoid her vocal cords, and
that he had to get the insurance company’s approval to do so, she asked him, “You mean
you think I can sing again? And go on with my career?”She says now that that was the moment she realized that her doctor believed she would
survive and go on with her life, and that even if she was encouraged by her friends and
loved ones that this is true, to hear it from him turned on a light for her. She wanted to
celebrate last night, and went out to a quiet dinner. I know she’ll want to celebrate with
you on Caring Bridge. Ya-HOOOOOOOOOOOO!!!
June 4, 2009
Hello everybody,
Zheng wanted me to write you all to let you know the wonderful news
she got Tuesday. As you know, Zheng underwent Gamma Knife radiation
four weeks ago. Yesterday, she had a follow up MRI and her oncologist,
Dr. Larson, discovered that a majority of the lesions were dramatically
smaller, and the remaining teeny, tiny ones hadn’t changed at all. AND
there were no new ones. She said that was the first time she left a doc-
tor’s appointment not depressed.
Study1
: Combined SRS/WBRT therapy shows patients at
greater risk of neurocognitive decline versus patients
receiving SRS alone.
A recent 58-patient, randomized trial evaluating the outcomes of patients
who received either stereotactic radiosurgery (SRS) alone or SRS followed
by whole brain radiation therapy (WBRT), to treat their brain metastases,
revealed that patients in the combined therapy group were more likely to
show significant deterioration in learning and memory functions than those
having SRS alone. The results provide additional support for using SRS alone
in the initial management of patients with one to three brain metastases,
investigators reported.
Researchers led by Eric Chang, M.D., at M. D. Anderson Cancer Center
(Houston, Texas, USA), randomly assigned 58 patients with one to three
newly diagnosed brain metastases to SRS plus WBRT or SRS alone during
2001-2007. The investigators conducted sophisticated neurocognitive and
imaging tests at baseline and during follow-up visits. Dr. Chang indicated
that the study probably “represents the first completed, randomized
controlled trial using formal neurocognitive testing to adequately address
the issue of SRS plus WBRT versus SRS alone” to manage these case types.
The results showed that the patients who were randomly assigned to SRS
plus WBRT were more likely to show significant neurocognitive decline
(i.e. as measured by total recall) at four months than were patients randomly
assigned to SRS alone (52% vs. 24%, respectively), despite the fact that
patients in the SRS alone group showed a higher overall brain tumor
recurrence than did those in the combined therapy group. The preliminary
outcomes were sufficiently important that the trial was stopped on the basis
that there was 96% confidence that total recall at four months for SRS plus
WBRT was inferior to total recall for SRS alone.
The researchers reported that their major findings regarding memory
decline “should be applicable and relevant to other centers using the same
entry criteria, given the widespread availability of SRS at many hospitals.
However, applicability of the findings is dependent on the willingness of
patients and their physicians to adhere to a schedule of close monitoring,
having consistent access to high-quality MRI (and) a neurological team willing
and able to perform salvage resections when indicated, and applying strict
physics quality assurance procedures for SRS.”
1. Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, Arbuckle RB, Swint JM, Shui AS,
Maor MH, Meyers CA. Neurocognition in patients with brain metastases treated with
radiosurgery or radiosurgery plus whole-brain irradiation: a randomized controlled trial.
The Lancet Oncology 2009; 10: 1037-1044.
Jerry: Is there anything else you
wanted to add about your Gamma
Knife experience in particular?
Zheng: Through my volunteer
work with the Bonnie J. Addario
Lung Cancer Foundation and from
the publicity around my story,
I have met many people who have
told me they had whole brain
radiation therapy. And I asked them
if Gamma Knife was ever presented
to them as an option and they say
no, never. They didn’t even know
about it.”
My message for all oncologists
would be that I am so grateful
that my radiation oncologist
presented this alternative and
explained it to me. I was able to
choose an option that allowed
me to live and still sing in public.
It is so important for patients to
have a choice. I am not against
whole brain radiation therapy
if patients decide to have it, but
they should have a right to have
all the options presented to them.
I feel like I’m a patient advocate
now.
I have often asked physicians
who deliver WBRT what they
you do if the patient was your
mother or father or daughter
or son or spouse who needed
treatment. Many have said that
in that case they would probably
not use WBRT. It’s somewhat
disingenuous, unfortunately.
Zheng Cao
The performance of her life
19

11. 2120
Tejinder Kataria, M.D. Medanta - The Medicity (Gurgaon, Haryana, India)
And Varian didn’t offer an open
networking system,” she says. “In
addition, I wanted to rapidly start
an SRS program because we have
very strong neurosurgery and brain
institutes here, so Elekta Synergy®
S
with Beam Modulator™ and VMAT
seemed a more versatile option
than Novalis Tx™
.”
In 2009, with the facility still under
construction, Medanta acquired
the country’s first Elekta Infinity™
system, in addition to an Elekta
Synergy S with Beam Modulator,
and advanced patient positioning,
immobilization and respiratory
management products. Both linear
accelerators are equipped with
VMAT. Medanta also acquired
three sophisticated Elekta treatment
planning systems, as well as
workstations for simulation and
contouring. MOSAIQ for Radiation
Oncology unites planning, treatment
and the patient record in the local
area network.
Elekta Synergy S became clinical
when Medanta – The Medicity
opened in February 2010, followed
by Elekta Infinity in April.
Dr. Kataria began using Elekta
VMAT on Elekta Infinity in
September, and – using Elekta
Synergy S – treated two patients
with brain metastases in December,
officially launching the SRS
program. From the beginning,
she has used XiO as the
department’s planning workhorse,
and began using Monaco to plan
VMAT in July and ERGO++ in
December.
Medanta adds cancer care
capacity
Across India, head-and-neck cancer
and tobacco-related cancers (mainly
lung cancer) constitute 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 most common. In metro
areas, such as Gurgaon, (population
640,000) prostate and breast cancer
incidences are increasing.
Among the 50 patients per day
treated on average at Medanta,
40 percent are for prostate cancer
and nearly 30 percent each are for
brain and breast cancer, followed
by smaller numbers of patients with
lung, GI and head-and-neck cancers.
In September, Medanta began using
Elekta VMAT on its Infinity system
in select brain and re-irradiation
cases. Its first two cases were a male
patient with a recurrent sinus tumor
and a 58-year-old man with a brain
stem glioma involving the pons.
Clinicians have started therapy for
an additional five patients with
brain and neck lesions.
Ability to plan
“VMAT is particularly useful for
patients with tumors located near
critical structures and for those
who can’t lie still for an extended
time, where any movement can
impair radiation delivery,” Dr.
Kataria says. “It’s also beneficial
for patients undergoing reirradiation,
because we can achieve a sharp
dose fall-off close to previously
treated fields. In fact, in our
evaluation of VMAT IMRS for
metastatic disease, we compared
the dosimetry between VMAT and
IMRT and found that the dose to
surrounding tissues is almost 15
percent less with VMAT. We’re
obtaining a very sharp dose gradient.
“Among the most distinct
differentiators of Elekta VMAT,”
she continues, “is the ability to plan
with Monaco, which uses the most
advanced and accurate dose
calculation engine, the Monte Carlo
algorithm. The software accounts
for many biological considerations,
such as whether the organ treated
is a serial [i.e., spine] or parallel
[i.e. lung] organ.”
Medanta – The Medicity opens with full array of Elekta
solutions, including India’s first Elekta Infinity with VMAT
India’s population of 1.15 billion
significantly dwarfs the number of
radiotherapy systems available to
serve its residents. Among 289
radiation therapy centers country-
wide are approximately 250 linear
accelerators, 270 telecobalt
machines and 170 HDR
brachytherapy systems. To match
a developed nation’s ratio of
inhabitants to linear accelerators
alone, India would need about 10
times as many treatment systems,
says Tejinder Kataria, M.D.,
Chairperson of the Radiation
Oncology department at Medanta
Cancer Institute, part of Medanta–
The Medicity (Gurgaon, Haryana,
India).
“Although there is a huge shortfall
in radiation therapy capacity, the
situation is rapidly changing for
the better,” she says. “Fifteen years
ago, there were three public
hospitals in Delhi that offered
radiation therapy. Today, Delhi has
13 public and private hospitals now
providing radiotherapy. Moreover,
the availability of health insurance is
making it possible for patients to
afford radiotherapy.”
Improved treatment quality
Cancer treatment quality is
improving in pace with access to
radiation therapy, as advanced linear
accelerators gradually replace
outmoded telecobalt technology.
“Especially in metro areas, the
public has tasted the better side of
radiation oncology,” Dr. Kataria
observes. “Modern technological
options are becoming increasingly
available so that patients don’t
have to suffer the side effects and
limitations of cobalt therapy. It has
whetted their appetite that they
can have good treatment provided
by experienced healthcare
professionals.”
Medanta – The Medicity, which
opened in February 2010, is among
India’s largest multi-specialty
medical centers. Medanta’s founder,
renowned cardiac surgeon Dr.
Naresh Trehan, created the center
with the vision to match the highest
standards of healthcare delivery
across the world. As one of
Medanta’s eight super-specialty
institutes, the Medanta Cancer
Institute needed to offer patients the
most advanced oncology treatments
and techniques.
Preparing for launch
“To address the current scarcity of
cancer care service providers in our
country, Medanta Cancer Institute
is based on a futuristic model to
accommodate the rising demand for
multi-modality oncology treatments
provided under one roof,” Dr.
Trehan says. “The Institute also
will cater to the medical needs of
cancer-afflicted patients through
the specialized services available in
the other Medanta Institutes.”
For a year, Drs. Trehan and Kataria
worked within the framework of
this vision to evaluate cancer
treatment technology. Ultimately,
several factors tipped the balance
in Elekta’s favor.
“We chose Elekta as a provider
because of their high precision
radiation therapy equipment, their
commitment to customer care, their
innovation and forward-thinking
attitude about technology, and
because of their passion for patient
care,” Dr. Trehan observes. “We
are a start-up center with a scope
for future expansion, so choosing
Elekta gives us a flexible platform
on which to build our program in
the coming years.”
As a radiation oncologist,
Dr. Kataria focused on specific
technical advantages Elekta offered
over major competitors.
“Siemens does not have kV cone
beam; they use a modified MVbeam
for imaging.
Advanced cancer care
technology streams into India

12. 22 23
Dr. Kataria (right, front row) and her team
“This institution is community-
oriented, looking to the needs of
average people,” says M.K.
Mahajan, M.D., Professor and
Head, Department of Radiotherapy
at CMC, also a preeminent
educational and research center in
the state.
In 2009, CMC officials saw an
opportunity to replace its aging
cobalt unit and better serve patients
with more advanced linear
accelerator technology. Among the
offerings of three providers, CMC
selected the Elekta Compact™
(6MV) system for its affordability,
sophisticated capabilities,
upgradeability and rapid access to
field service, Dr. Mahajan notes.
The center’s Elekta Compact
became clinically operational in
November 2010, and will be
upgraded with real-time portal
imaging and MLCi in January 2011,
making it the first MLC-equipped
Elekta Compact in India.
“The price of Elekta Compact
helped us replace our cobalt unit,”
Dr. Mahajan notes. “And, it
enabled us to afford a complete
package that included a treatment
planning system, radiation field
analyzers, surveys and phantoms,
so that our physicists and clinicians
can confidently perform quality
assurance in addition to
sophisticated radiotherapy.”
Optimal combination
Elekta Compact was designed for
modular upgrades, to facilitate
technological improvements as
they become available or when
CMC is ready for them, he adds
“We know that at some time in
the future we can upgrade the table
to permit us to provide non-coplanar
beams, and that we can convert
from the autowedge to dynamic
wedging,” Dr. Mahajan observes.
“Since Elekta Compact was designed
for modular upgrades, this will help
us incorporate technological
improvements as they become
available or when CMC is ready for
them,“ he adds.
“I’ve heard that some Elekta
Compact sites are treating 70 or
more patients each day,” he says.
“The number of treatment centers
in India is quite low in comparison
to the population, so all departments
have to be busy. Therefore a
combination of Elekta Synergy and
Elekta Compact would be a good
combination for the average
hospital.”
Dr. Mahajan predicts that CMC’s
daily patient volume on Elekta
Compact should quickly increase
to 50 per day within a year.
Consequently, he was encouraged
to learn that Elekta was committed
to providing not only a
comprehensive multi-year service
contract, but also rapid service
response to address equipment
issues.
“They were glad to tell us that they
will be able to provide service to us
in less than 24 hours.”
Christian Medical College
(CMC) Hospital to
acquire India’s first MLC-
equipped Elekta Compact
Established in 1894, Christian
Medical College Hospital’s
(Ludhiana, Punjab) first foray
into radiation therapy was in
1938, when it began providing
brachytherapy treatments
– using Irridium-192 needles,
then Cesium-137 needles and
tubes – for several types of
interstitial and intra-cavity
treatments. In 1958, CMC
became the first center in
Punjab to acquire a cobalt-
60 teletherapy unit.
Serving Ludhiana’s current
population of about 1.4 million
inhabitants, CMC operates on
charitable donations alone and
as recently as 2008, charged
$45 (USD) for a full treatment
course, regardless of the
number of treatment days.
In December, commissioning tests
had begun to prepare Medanta’s
Elekta Synergy S to use Elekta
VMAT. Presently, the newly
established SBRT program is
treating lung and vertebral
metastases using IMRT and 3D
conformal techniques planned
with XiO. For lung treatments,
Dr. Kataria has been using Active
Breathing Coordinator to manage
respiratory motion.
MOSAIQ integration
MOSAIQ brings order to Medanta’s
multi-faceted department,
Dr. Kataria maintains.
“MOSAIQ gives me the complete
picture of the patient’s treatment
experience, from the time patients
enter the clinic to when they return
for follow-up,” she says. “We can
visualize all of our clinics, schedule
patients, perform record-and-verify,
transmit the plan and treat the
patient through MOSAIQ. I don’t
have to go through the print system
to determine what has been done.
We also can capture reactions and
toxicity data, stage patients and
create code captures.
The flexibility and scope of
MOSAIQ are wonderful.”
A promising new beginning
in India
Approaching its first year of clinical
operation, Medanta’s radiation
oncology department of 37
healthcare professionals has
achieved an admirable level of
efficiency. On an average day,
Dr. Kataria can turn around five to
six new cases on the contouring
stations and an equal number on
the planning systems. Medanta’s
turnaround time from simulation
to treatment time is approximately
four days for a complex plan.
“That’s remarkably good – it used
to take six or seven days at my
previous organization,” she says.
“In an emergency palliative case,
we can turn around a case in as
few as six hours. Lastly, we’ve been
able to reduce our turnaround time
for an SBRT case to about two days.
Daily throughput for the Elekta
Infinity system averages 27 patients,
while Elekta Synergy S averages
20 patients per day.
“We have had a positive experience
working with team Elekta from
within and outside India and are
thankful to the international office
for supporting our endeavor,” says
Medanta’s founder, Dr. Trehan.
“We deeply appreciate the diligence
and support Elekta provided to us
during installation and
commissioning and hope to have a
long, fruitful role in their research
consortium.”
Note: Approval of indications may vary
between different countries and
additional regulatory clearances may be
required in some markets

13. 2524
Background
The Department of Radiotherapy and Radiation Oncology at the University Medical Center Mannheim has been
active in the application and improvement of advanced treatment techniques based on multileaf collimators (MLC).
Through the use of the most advanced radiation therapy technology available, the Mannheim center has become one
of the most important treatment facilities for cancer patients in the Rhein-Neckar area, treating 2,300-2,400 patients
per year.
The clinical team at University Medical Center Mannheim has worked closely with Elekta on the development of
Elekta Integrity*
, the 6th generation Elekta digital control system.
The department has four linacs on site, including two Elekta Synergy®
linacs with the Integrity digital control system
and the latest Elekta MLC (MLCi2), with one additional Elekta Synergy linac at a collaborating unit off site.
All are connected to MOSAIQ®
(version 2.0), the image-enabled Elekta oncology information system (OIS) and
electronic patient record (EMR). The department has also recently implemented the Monaco® treatment planning
system (TPS) for IMRT with static gantry and VMAT, incorporating the Monte Carlo dose calculation algorithm,
with 4 workstations connected to one database.
Challenge
A synoptical review of available clinical data suggests that at least 50% of patients would benefit from intensity
modulated radiation therapy (IMRT)1-3.
However, it is important that any new technique must fit into the current departmental infrastructure.
Therefore, in order to provide modulated treatment for this many patients in our clinic, it is necessary to reduce
treatment times of modulated therapy.
Our experience has shown that volumetric intensity modulated arc therapy (VMAT) can be used to deliver high
quality modulated treatment plans in very short treatment times.
Clinical evidence suggests that most indications can be treated using VMAT, including head and neck, rectal,
anal prostate and many other cancers. The impetus for increasing the use of VMAT in our department is theclinical
benefit for patients using modulated treatments.
Solution Implementation
The combination of Integrity digital control system, Monaco with VMAT and MLCi2 has the potential to reduce
treatment times in the delivery of VMAT by allowing complex plans that incorporate continuous variable dose rate
(CVDR) and interdigitation. We were, therefore, very keen to evaluate this combination in order to meet our
patient demands for modulated treatments - so that more patients could benefit from modulated treatments in a
resource neutral way.
Figure 3. Advantages of Continuously
Variable Dose Rate (CVDR).
Delivery Time (seconds)
DoseRate(MU)
20 40 60 80 100 1200
0
50
100
150
250
200
300
350
400
450
In order to speed up the VMAT treatment process, we created new pre-sets in MOSAIQ and XVI (X-ray volume
imaging) for image guided radiation therapy (IGRT). This allowed cone beam image acquisition in a counter
clockwise rotation of the gantry, prior to initiation of VMAT treatment in a clockwise rotation of the gantry,
thus further minimizing total imaging and treatment time.
Results
The result of the new pre-sets in MOSAIQ, in combination with the benefits of Integrity, Monaco with VMAT
and the Elekta MLCi2, meant that, in a typical one hour period during the treatment day on one linac, the total
VMAT treatment time (including cone beam CT) was reduced to 27 minutes, with beam-on times of between only
2-7 minutes (Figure 5), with the remaining 33 minutes incurred by patient logistics.
Figure 5. One hour routine treatment. Patient logistics vs. treatment time (IGRT + VMAT): 50% / 50%.
Beam-on times between 2 and 7 minutes.
5 min 4 min
10 min 8 min
Interdigitation allows accurate planning and beam shaping of multiple target islands during all treatment
techniques, including static, arc, IMRT, Omniwedge, dynamic, dynamic arc and VMAT. This precise, beam-
shaping capability ensures maximum conformance to target volumes, improved efficiency of dose delivery,
and reduced radiation to both normal tissue and critical structures
•
• CVDR allows the dose rate to be adjusted to its ideal value during delivery of VMAT prescriptions.
This option makes the delivery of the prescribed dose smoother and faster, when compared to previous discrete
dose rates, and can reduce delivery time by 30% (Figure 3).
Professor Frank Lohr, Oncologist
Professor Frederik Wenz, Oncologist
Brigitte Hermann, Oncologist
Yasser Abo-Madyan, Oncologist
Volker Steil, Physicist
Florian Stieler, Physicist
Lennart Janke, Physicist
Jens Fleckenstein, Physicist
Frank Schneider, Physicist
Kerstin Siebenlist, Dosimetrist
Authors:
Elekta - Case in point
Monaco®
with VMAT, Elekta Integrity™
and Elekta MLCi2

14. Elekta AB (publ)
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www.elekta.com Human Care Makes the Future Possible
26
Art. No. 018939.00 ©2011 Elekta AB (publ). All mentioned trademarks and registered trademarks are the property of the Elekta Group.
All rights reserved. No part of this document may be reproduced in any form without written permission from the copyright holder. Specifications subject to change without notice.
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Discussion
The combination of Elekta Integrity, Monaco with VMAT and Elekta MLCi2 resulted in 20-30% faster treatment
times consistently. This was achieved, primarily, through CVDR (allowing 50% higher dose rates than before) and
interdigitation. This meant that, in a one hour time slot, a high degree of modulation could be achieved with
significantly faster treatment times (Figure 6).
Figure 6. DVH-parameters and treatment efficiency for different treatment modalities (mean + SD). The two values
for the treatment time of VMAT display the old (a) and the most recent (b) linac control system.
MIMIC
(Corvus)
IMRT 7F
(Hyperion)
IMRT 9F
(Hyperion
VMAT
(Monaco)
DmeanPTV1
[Gy] 59.9 + 0.1 60 + 0.4 60.1 + 0.5 60.6 + 0.3
DmeanPTV2
[Gy] 55.7 + 0.7 56.4 + 0.4 56.5 + 0.4 56.7 + 0.7
D99%PTV1
[Gy] 56.0 + 0.4 51.7 + 1.5 52.0 + 1.6 53.3 + 0.6
D99%PTV2
[Gy] 53.0 + 0.7 50.3 + 0.8 50.6 + 0.8 51.6 + 1.7
DmeanParotis
[Gy] 19.5 + 0.9 14.1 + 1.1 13.9 + 1.5 14.9 + 0.6
CI 2.5 + 0.6 1.8 + 0.2 1.9 + 0.2 1.6 + 0.4
HIPTV1
1.9 + 0.5 1.7 + 0.2 1.7 + 0.2 1.6 + 0.1
HIPTV2
1.5 + 0.3 1.4 + 0.1 1.4 + 0.0 1.3 + 0.1
MU 2551 + 349 945.2 + 201 925 + 234 521.5 + 53
Treatment Time [min] 12.8 + 1.7 7.6 + 0.3 8.5 + 0.4 6.2 + 1.0a
4.3 + 0.6b
Since imaging (for IGRT) and VMAT treatment times were reduced significantly, more patients could receive
modulated treatments per day.
Currently, the two Elekta Synergy Linacs in the department are used exclusively for modulated treatments, allowing the
clinic to treat around 70 patients with modulated radiation therapy every day.
Not only do these efficiencies enable more patients to receive the clinical benefits of modulated therapy, but the shorter
treatment time is easier and more comfortable for patients, particularly if they have painful lesions or severe discomfort.
In addition, position insecurities are reduced to ensure more accurate treatment delivery.
The center will soon be able to treat around 1000 patients per year with modulated radiation therapy, approaching
50% of the total treatments performed. Already, 60% of the modulated treatments are VMAT but it is anticipated
that this will increase to 80% VMAT in mid-2011, with the remainder receiving static gantry IMRT with dynamic
MLC sequencing.
Significantly, the use of Monaco with VMAT for treatment planning has been beneficial in a number of ways:
• The Monte Carlo dose calculation algorithm gives extremely precise dose calculation.
• It is very easy to commission additional machines, especially if they have the same set up, which saves time.
• Both static and VMAT treatment plans can be planned on the same interface.
• The system is very robust, intuitive and easy to use, delivering good quality plans consistently, thus, the high
number of modulated plans can be handled efficiently.
Leaf speed is currently the rate limiting factor. The next generation Elekta MLC* will have double the leaf speed
compared to the current MLC, which will allow the beam-on time to be reduced by a further 50%.
This will take the delivery of normofractionated modulated treatments consistently to 3 minutes and therefore to an
extremely low percentage of total slot time.
* The next generation Elekta MLC is a works in progress and is not available for sale or distribution in all markets. Note: Specifications are provisional.
References
[1] Veldeman L, Madani I, Hulstaert F, et al (2008) Evidence behind use of intensity-modulated radiotherapy:
a systematic review of comparative clinical studies..Lancet Oncol. 9(4):367-75.
[2] Mayles WP: Radiotherapy Development Board (2010) Survey of the availability and use of advanced radiotherapy
technology in the UK. Clin Oncol (R Coll Radiol) 22(8):636-42. Epub 2010 Jul 27.
[3] Staffurth J; Radiotherapy Development Board (2010) A review of the clinical evidence for intensity-modulated
radiotherapy. Clin Oncol (R Coll Radiol) 22(8):643-57. Epub 2010 Jul 31.
Elekta - Case in point

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