Vero Radiotherapy System: A Short-Lived Linear Accelerator with Lasting Impact

In the highly specialized world of advanced medical equipment, some systems carve out a legendary, if niche, status. The radiotherapy system known initially as the MHI-TM2000 by Mitsubishi Heavy Industries (MHI), and later as the Vero (or Vero4DRT) under BrainLab, is one such fascinating case. Its journey from a beta installation in 2008 to its recent reimagining offers valuable insights into the complexities of medical technology development, deployment, and evolution.

Why the Vero Linear Accelerator Was Developed

The Vero linear accelerator was launched to meet the growing demand for more precise, image-guided radiation therapy, particularly for tumors that move during treatment, such as those in the lung or liver. The system’s most distinctive feature was its gimbaled head design, which allowed the radiation beam to pan and tilt in real time—enabling dynamic tumor tracking during treatment (Hiraoka et al., 2020).

Developed by Mitsubishi Heavy Industries and later commercialized by Brainlab, the system was designed with an innovative O-ring gantry and a gimbal-mounted treatment head, allowing the radiation beam to pivot and track tumor motion in real time. This enabled clinicians to deliver highly conformal doses with sub-millimeter accuracy, reducing the need for large safety margins and helping to spare surrounding healthy tissue.

With integrated imaging systems and the ability to deliver non-coplanar beams without moving the patient couch, Vero offered a powerful platform for advanced techniques like stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS).

Vero Linac’s Limited Global Install Base

Between its first installation in 2008 and Mitsubishi’s termination of the product line in 2016, only 25 of these sophisticated systems were sold and installed worldwide. This rarity itself makes its history noteworthy. In its home market of Japan, MHI sold 13 units under the MHI-TM2000 model name. The remaining 12 systems were branded as Vero or Vero4DRT by BrainLab and found their way to international sites, including the US, Canada, South Korea, France, Germany, Italy, and Belgium.

Domestically in the US, some installations were in Texas (UT Southwestern), Ohio, New York (Upstate Cancer Center), and Florida (University of Florida). The system received several updates, with its last, version 3.5, gaining FDA clearance in 2015 for Dynamic Wave Arc (DWA) therapy. DWA was an advanced therapeutic technique intended to offer advantages over conventional Volumetric Modulated Arc Therapy (VMAT).

Vero System Recalls and Post-Market Challenges

The Vero system’s operational history was not without its difficulties. It faced several recalls across the US, Canada, Germany, and Italy, some classified as urgent. These issues primarily revolved around:

• Console/software errors leading to incorrect beam angle or location.
• Failures with the ExacTrac imaging software in relaying correct patient positioning.
• Malfunctions in couch kick adjustments.

Critically, these issues could result in incorrect irradiation of patients, a serious concern in radiotherapy. The final OEM-initiated recall occurred at the end of 2017, with the FDA issuing it in 2018. In 2025, there is one system still in the U.S. and one in Canada, but both are being decommissioned later in the year.

Why Vero Linacs Are Rare in the Refurbished Equipment Market

Unlike conventional linear accelerators, which are often removed, refurbished, and reinstalled at new clinics, Vero systems have never entered the refurbished equipment market. High-end machines like the Vero, originally priced around $10 million, face several barriers to relocation: a limited installed base, scarce parts availability, minimal engineering support, and costly installation requirements.

As a result, these systems are unlikely to see a second or third life. Their value is largely tied to staying in place and continuing to treat patients at their original installation sites. The same holds true for other high-cost, niche platforms like the ViewRay MRIdian.

Vero Becomes OXRAY: From Discontinuation to Redesign

One of the speculated reasons for the dissolution of the Vero project under Mitsubishi was related to the relationship between MHI and its Treatment Planning System (TPS) vendor. The intricate integration required between the delivery system and the TPS is paramount in radiotherapy, and challenges in this partnership can significantly impact a product’s viability.

However, the story didn’t conclude in 2016. Hitachi acquired the intellectual property rights for the system and embarked on a redesign, incorporating certain modifications. The result was a new version of the platform launched under the name OXRAY. In a significant shift, Hitachi is now collaborating with RaySearch for its Treatment Planning System.

Currently, two clinical sites in Japan are equipped with this next-generation platform. It’s a testament to the underlying potential seen in the original technology. Prospective adopters should note, however, that the OXRAY system retains a significant installation requirement: a 7-foot pit below the floor, which will limit its placement options.

Key Takeaways from the Vero and OXRAY Radiotherapy Systems

The story of the MHI-TM2000/Vero, and its evolution into the OXRAY, underscores the challenges of bringing complex, innovative medical devices to market. From limited adoption and high installation costs to software integration and service hurdles, the Vero system highlights how technical promise alone does not guarantee long-term commercial success. For healthcare providers, it also emphasizes the value of ongoing technical support, realistic installation planning, and strong vendor collaboration when investing in advanced radiotherapy platforms.