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Protontherapy at INFN-LNS C.Agodi Laboratori Nazionali del Sud - Catania LEA-COLLIGA – IPN Orsay November 14-16 2011 OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF LNS Why clinical hadron beam? Higher precision and greater biological effectiveness of the applied dose Depth dependence of the deposited dose for different radiation Because of the Bragg peak, protons dose distribution is “inverted” with respect to the almost exponential behaviour produced by a beam of high energy photons. The surface dose is low when compared to the dose absorbed in the region of the peak, at variance with what happens with photons and electrons. Why clinical proton beam? • penetration depth is well-defined and adjustable • most energy at end-of -range • protons travel in straight lines • dose to normal tissue minimised • no dose beyond target PROTONS PERMIT TO DELIVER AN HIGH DOSE TO THE TUMOUR SPARING THE SOURRONDING TISSUES Intensity Modulateted Radiation Therapy vs PROTONS Between the eyes Abdomen Brain PT faces a fast growing demand! 45,000 40,000 patients 45 40,000 40 35,000 35 30,000 30 25,000 22 PT centers 25 20,000 20 15,000 15 PT center under operation 10,000 10 5,000 0 1950 1990 - The Loma Linda University Medical Centre in California heralded the age of “dedicated” medical accelerators with commissioned its proton therapy facility with a 250 MeV Synchroton 5 1960 1970 1980 1990 2000 0 2010 • 1954 - C.Tobias and J.Lowrence: first therapeutic exposure of human patients to hadron beams at the Radiation Laboratory of California, Berkeley • 1957 – Protons treatments : University of Uppsala, Sweden • 1961 – Massachusetts General Hospital-Harvard Cyclotron Laboratory ,USA • 1967 – Dubna, 1969 Moscow, 1975 St Petersbourg in Russia •1979 – Chiba, 1983 Tsukuba in Japa •1984 – PSI-Villigen in Switzerland LNS OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF INFN & Hadrotherapy • In 90’ years INFN supported TERA in R&D project. • INFN, in collaboration with University of Catania, realized in its laboratory (Lab. Naz. Del Sud) the first Italian protontherapy facility. • INFN has UNIQUE capability in Italy in accelerators development. • Considering its particular features, INFN was involved in CNAO to guarantee the necessary expertise. • In 2005 INFN was encharged by Health Minister to produce a document about protontherapy in our country. In Catania we developed a facility (named CATANA) for the treatment of ocular tumours with 62 AMeV proton beams LNS Superconducting Cyclotron is the unique machine in in Italy and South Europe used for protontherapy Treatment of the choroidal and iris melanoma In Italy about 300 new cases for year LNS Accelerator Layout Ocular Protontherapy Unique Italian Facility CATANA CATANA proton therapy beam line (until June 2004) CATANA proton therapy beam line (new location) OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF CATANA proton therapy beam line Ligth field Laser Modulator & Range shifter Monitor chambers Scattering system Lateral dose distribution in a clinical proton beam 120 100 Relative dose 95 % 80 60 50 % 40 20 % 20 0 -20 -15 -10 -5 0 5 10 15 20 Distance from central axis (mm) Lateral penumbra : d 80%20% Field ratio : H 90% field size 50% field size Flatness : 25mm 0.90 25mm 20mm w95% : Simmetry ( Area ratio ) : Tolleranze 1.50mm ABS (a b) 200% ab P Pmin RT % max 100% Pmax Pmin Sr 3% 3% Depth dose distribution – Energy modulation Generation of the Spread Out Bragg Peak (SOBP) OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Dosimetric commissioning: absolute & relative dosimetry Absolute Dosimetry: Energy Released in Water (Gray) Relative Dosimetry: Three dimensional dose distribution measurements Considering the high gradient dose, conformation and small fields often used the detectors have to be kindly characterized in terms of spatial resolution, energy or fluence dependence to be used in protontherapy. Relative and Absolute Dosimetry are fundamental for: Customizing of TPS Monitor Unit Calculation Quality Control Dosimetric commissioning: absolute & relative dosimetry ICRU 59 AND TRS 398 IAEA RECOMMENDATION “ FOR MEASUREMENTS OF DEPTH-DOSE DISTRIBUTION IN PROTON BEAMS THE USE OF PLANE-PARALLEL CHAMBERS IS RECOMMENDED” Parallel plate MARKUS PTW is the golden standard for depth dose measurements GEANT4 Simulation Monte Carlo Simulation of the entire beam line using GEANT4: Improvement of our beam line and dosimetry Give a general purpose tool for the design of new hadrontherapy beam line Validation of the treatment system software GEANT4 simulation OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF A typical treatment The Surgical Phase The Treatment Planning Phase The Verification Phase The Treatment Phase Two orthogonal X-Rays tubes for the visualization of the clips NEW X-RAY SYSTEM FOR PATIENTS POSITIONING Lay-out of the axial X-Ray flat panel with its moving system Hamamatsu XRay axial flat panel [email protected] 26 Treatment Planning System Phase EYEPLAN Originally developed by Michael Goitein and Tom Miller (Massachussetts General Hospital), is now maintained by Martin Sheen (Clatterbridge Center for Oncology) and Charle Perrett (PSI) Fixation Point Choice This point is chosen in order to spare the organs at risk, and to maintain the best polar angle. Fixation Point Isocenter Fixation Light q f q Polar Angle f Azimuthal Angle Treatment Planning System Output Isodoses curves for different planes Treatment Phase At the end of patient positioning phase the radiotherapist draws the eye’s contour on a dedicated monitor in order to monitoring in any moment the eye’s position during the treatment. TREATMENT MODALITIES Dose: 15.0 CGE per day Treatment Time: 45-60 sec. Total Dose: 60 CGE Fractions: 4 OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Clinical results 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Patient Distribution by Pathologies Uveal Melanoma 164 patients Conjunctival Melanoma 4 patients Conjunctival rhabdomyosarcoma 1 patient Eyelid Carcinoma and metastases 2 patient Conjunctival MALT-NHL 1 patient Conjunctival Papilloma 2 patient TOTAL PATIENTS 174 Patient Distribution by Origin Region 10 1 2 Total number of patients : 230 3 2 18 3 29 7 1 10 18 Since feb 2002 70 Patient Distribution by Sex Women Men 51% 49% The patients’age ranges between 14yrs and 81yrs (the mean age is 48 yrs) PATIENTS FOLLOW-UP (March 2002 – November 2008) PatientsTotal Number (April 2009) 174 Patients with Follow up 138 TUMORAL THICKNESS ECOGRAPHIC REFLECTIVITY Reduced Stable 70 % Increased 24 % Stable 77 % 18 % Increased 2 % Not evaluable 5% Not evaluable 2% SURVAIVAL RESULTS PatientsTotal Number (April 2009) 174 Dead patients 4 Metastatis 3 Other 1 Eye retention rate 95 % TOTAL SURVIVAL 98 % LOCAL CONTROL 95 % OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF CATANA Spin-off: Some Important Milestones In 2002, the First Italian Protontherapy Facility Funded by INFN and Catania University started in Catania at INFN-Laboratori Nazionali del Sud Sicilian Region has approved to realize an HadronTherapy Center in Catania, for protons and heavy charge particles. It has to be realized as “Scientific collaboration between Region, INFN and University of Catania also open to private contributions” What is in progress? • • • • Proton computed tomography (PCT) Carbon beams for therapy… Lithium beams for therapy? ……. Remarks • Knowledge gained from basic research influenced the choices of ion, energy, beam delivery system and treatment schedule. • Moreover radiotherapy shall be developed only on the basis of research conducted according to the highest standard of scientific inquiry and using the most advanced method available.