Vision and implementation for the first U.S. carbon ion therapy center part II: Design philosophy and clinical implementation.

The anticipated clinical demand for carbon ion radiotherapy (CIRT) in the United States is expected to include a substantial proportion of clinically complex disease sites that require accurate, highly conformal, and adaptive treatment. These clinical needs, together with the unique physical and biological characteristics of carbon ion beams, form the foundation of the design philosophy for the Mayo Clinic Florida (MCF) CIRT program. The program remains under active development, with clinical deployment planned for 2028. Building upon the clinical rationale and anticipated U.S. patient population discussed in Part I of this two-part review, this Vision Article describes how MCF intends to develop an integrated CIRT treatment system. The program is guided by two overarching principles: fast, accurate, and safe beam delivery and accurate treatment planning and treatment delivery, supported by an integrated patient-specific quality assurance framework. Key elements include high-dose-rate dose-driven continuous scanning with advanced beam monitoring and irradiation control, delivery-aware treatment planning, the Monte Carlo-based BioPhys computational platform integrating physical and biological dose modeling, a hierarchical adaptive workflow, and patient-specific quality assurance spanning pretreatment, on-treatment, and post-treatment verification. This framework provides a technical roadmap for the integrated clinical implementation of CIRT at MCF.