Transcript Needs of Protontherapy in Spain The Catalan Project of Protontherapy

THE NEEDS OF HADRONTHERAPY IN
SPAIN
Ignacio Petschen Verdaguer
IFIMED 2009
HADRONTHERAPY
Therapeutic Window: Favorable
tumor control
toxicity
PROBABILITY
90%
5%
H Cárdenas courtesy
DOSE OF RADIATION
HADRONTHERAPY
Therapeutic Window: Unfavorable
tumor control
toxicity
PROBABILITY
90%
50%
H Cárdenas courtesy
DOSE OF RADIATION
HADRONTHERAPY
Therapeutic Window: Effect
of reducing Volume of Normal Tissue
tumor control
toxicity
PROBABILITY
90%
50%
V1
V2
V2 < V1
5%
H Cárdenas courtesy
DOSE OF RADIATION
Mendenhall courtesy
AK Lee courtesy
MD Anderson CC
AK Lee courtesy
MD Anderson CC
1862-1942
Combs courtesy
HADROTHERAPY: RBE
PROTONS:
Between 0,9 y 1,3 (average: 1,1)
“plateau”: 0,9-1
“Bragg peak”: 1,2-1,3
CARBON IONS:
Between 2 and 3
An increase of apoptosis induction, mainly at Bragg peak level, has been
shown, for protons and ions.
Combs courtesy
HADRONTHERAPY: CARBON IONS
- Reduction in the OER.
- Lesser influence of repair phenomena.
- Reduction of the differences in RS related to
cell cycle position.
HADRONTHERAPY: CARBON IONS
Malignant tumors:
-Well differenciated
-Slowly growing
-Hypoxic (RR)
-Slowly cell cycle redistribution
-repair-proficient tumors
HADRONTHERAPY: IMAGE
Only possible if modern image techniques are available
PET - CT fusion
Vikram courtesy (NCI)
HADRONTHERAPY: IMAGE
Ling et al. IJROBP, 47: 551 (2000)
HADRONTHERAPY: CONFORMALITY
Ling et al. IJROBP, 47: 551 (2000)
HADRONTHERAPY
POTENTIALS:
-High conformal dose distribution
-Higher target dose
-Steepest dose gradients between PTVs and PRVs
-Reduction of patient integral dose
-Increase RBE (ions)
AIMS:
-Tumor dose intensification (Increase of tumor control)
-Low doses to the ORs and non involved tissue (less toxicity)
-Higher survival rates
-Better outcome in patients with RR-tumors (ions)
-Reduction of RT-fractions (less treatment days)
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Category A:
-Closeness to highly critical structures
- Only way to administer a radical dose without producing
serious side effects
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Tumours belonging category A:
- Uveal melanoma
- Base of skull chordoma and chondrosarcoma
- Spinal and paraspinal tumours
- Parasellar meningioma
- Optical nerve glioma
- Acoustic nerve schwanoma
HADRONTHERAPY: PROTONS
UVEAL MELANOMA: RESULTS
CENTER
5 y. local control
5 y. ocular retention
MGH
96%
84%
PSI
94,8%·
86%·
CP Niza
89%
88%
CP Orsay
97%
92%
Berlin
95,5%··
87,5··
PC Clatterbridge
96,5%
90,6%
Useful vision in > 50%
· 10 years
··3 years
HADRONTHERAPY: PROTONS
BASE SKULL CHORDOMAS AND CHONDROSA.
RESULTS
CENTER
CHORDOMAS
CHONDROSA.
5 y. local control
5 y. local control
MGH
73 %
99 %
CPULL
59 %
75 %
CP Orsay
71 %
85 %
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Category B :
-Prevalently local evolution
- Low Radiosensitivity
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Tumours belonging to category B :
- Prostatic adenocarcinoma
- Retroperitoneal sarcoma
- Salivary gland tumours
- Uterine cervix cancer (IIB bulky or IIIB)
- Undiff. tumours of the thyroid gland
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Category C :
-Protons as “boost” in a restricted volume
-Irradiation volume with a large safety margin
- Selection based on the initial response to photon irradiation
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Tumours belonging to category C :
- Head and neck cancer
- Low grade glioma
- Malignant thymoma
- Biliary tract tumours
- Some lung tumours (NSCLC)
- Oesophagus tumours
- Some pediatric tumours (CNS, sarcoma)
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Category D :
-Tu. with locally advanced conditions and unfavourable prognosis
-Expecting survival with heavy symptomatology
- Paliation with photons often unsatisfactory
HADRONTHERAPY
THE TERA PROJECT
POTENTIAL INDICATIONS FOR PROTONTHERAPY
Tumors belonging to category D :
- Pancreas cancer
- High grade glioma
- Paraaortic metastatic adenopathies
- Pelvic recurrences in previously treated areas
- Rhinopharingeal recurrences in previously irradiated areas
- isolated brain metastasis
HADRONTHERAPY: PROTONS
PATIENTS CALCULATION
According to an Italian epidemiological study (reduction to ¾ = 45/60).
Patients with elective indications for protontherapy (cat.A)
TUMOR TYPES:
RT pat/y
%prot
Pat prot/y
-Uveal melanoma .
232
-Chordomas
35
-Chondrosarcomas (head,trunk)
68
-Meningiomas base of the skull
188
-Naso-etmoidal/paranasal tumors 105
-CNS Schwanoma
225
-Hypophysis adenoma
562
-Pediatric solid tumors
727
-TOTAL
2.142
Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)-modif-
100%
100%
100%
50%
100%
15%
10%
15%
34%
232
35
68
94
105
34
56
109
733
RT-PROTONS: PATIENTSCALCULATION
According to an Italian epidemiological study (reduction to ¾ = 45/60).
Patients to be included in clinical trials (cat B)
TUMOR TYPES:
RT pat/y
%Prot Pat prot/y
-Brain gliomas
1.950
20%
390
-Prostate carcinoma
16.750
25%
4.188
-Pancreatic carcinoma
6.788
20%
1.357
-NSCLC
23.250
5%
1.162
-Biliary tract tumors
3.225
10%
322
-Bladder carcinoma
12.713
10%
1.271
-Head and Neck tumors
5.085
15%
763
-Brain gliomas
1.950
20%
390
-Esophageal carcinoma
2.130
5%
106
-Undiff. thyroid cancer
75
50%
37
-Uterine cervix cancer
2.243
20%
448
-Hepatic cancer
10.005
10%
1.000
-Pelvic recurrence
>375
50%
>190
TOTAL
>86.539
13%
>11.624
HADRONTHERAPY: C-IONS
PATIENTS CALCULATION
According to an Italian epidemiological study (reduction to ¾ = 45/60).
Patients elegible for C-ions therapy
TUMOR TYPES:
RT pat/y
%prot
Pat prot/y
-Salivary glands tumours
-ENT mucosal melanoma
-Bone sarcoma
-Soft tissue sarcoma
-NSC Lung cancer
-Hepatocelular carcinoma
-Prostata carcinoma
465
23
390
1.020
23.250
3.750
16.748
50%
100%
10%
10%
5%
10%
5%
232
23
39
102
1.162
37
837
-TOTAL
45.646
5,5%
2.432
Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)-modif-
HADRONTHERAPY:
PATIENTSCALCULATION
POTENTIAL RECRUITMENT FOR HADRONTHERAPY
IN FRANCE
“ One-day survey” in 5 radiation therapy departments:
Institutions
Besançon
Lyon Bérard
Pierre Benite
Dijon
Grenoble
Total
Nr pat./day Nr pot. H-indications/day Annual recruit.
115
152
100
83
82
532
13
13
26
11
14
77 (14,5%)
RT treatments/year: 160.000
Potential indications for hadron therapy: 23.000
Baron et al. Radiother Oncol, 73, S 15-17 (2004)-modif-
130
130
260
110
140
770
HADRONONTHERAPY: PATIENTS
CALCULATION
POTENTIAL RECRUITMENT FOR HADRONTHERAPY
IN AUSTRIA
“Nationwide survey” in 12 austrian radiation therapy departments.
According to the criteria from 5 European University Hospitals
involved in hadron projects (Heidelberg, Milan, Lyon, Vienna and
Innsbruck)
Inhabitants Austria:
8.000.000
New cancerpatients/year:
36.500
RT-treatments/year:
15.141
Potential indications for hadron therapy/year: 2.044 (13,5% RT)
Mayer et al. Radiother Oncol, 73, S 24-28 (2004)-modif-
HADRONONTHERAPY:
PATIENTS CALCULATION
CONCLUSIONS ACCORDING EXPERTGROUP FROM
ITALY, GERMANY, FRANCE AND AUSTRIA (% RTpatients
who need HT):
Main indications for protons
1%
Indications for protons which require clinical trials
12%
Indications for C-ions which require clinical trials
3%
Amaldi and Kraft. Rep Prog Phis, 10, 478-85 (2005)
HADRONTHERAPY: PATIENTS
CALCULATION
Cancer incidence rate in Spain
Annual cancer incidence in Spain
385
173.250
Nr of cancer patients elegible for RT in Spain (50%)
86.625
Nr of cancer patients undergoing RT in Spain (43%)
74.500
Nr of RT patients elegible for PT in Spain (13%)
9.750
Nr of RT patients elegible for C-ions in Spain (3%)
2.250
HADRONTHERAPY: PATIENTS
CALCULATION
Averagetime per fraction:
20’ (3 fr/h)
Double shift :
2x7h: 14h/day
Nr of patients/day for PTU:
42 fr/day
5 days/week:
250 treatment days/year
Output for PTU:
10.500 fr/year
HADRONTHERAPY: PATIENTS
CALCULATION
Average Nr fractions/patient (for protons):
12·
Average Nr fractions/patient (for C-ions):
8·
Nr patients/year treated /PTU (for protons)
875
Nr patients/year treated /PTU (for C-ions)
Nr PTU needed in Spain
Nr C-ionsTU needed in Spain
·Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)
1.300
11-12
2
HADRONTHERAPY: PROTONS
SOME CONCLUSIONS
-Advantages due mainly to excellent dose distribution.
-Main indications in recognized tumor types and locations (> 10%).
-Need to have at least one protonterapy center in Spain: Valencia
-Need to perform fase II y III trials comparing protons with photons.
-Further increase of protontherapy facilities to cover the spanish needs.
THANK YOU FOR YOUR ATENTION
Delaney courtesy