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Clinical Application of
Carbon Therapy
Mi-Sook Kim, MD, PhD
Department of Radiation Oncology
Korea Institute of Radiological and Medical Sciences
Contents
 Cancer statistics in Korea
 Short history of technology development of radiotherapy
 Introduction of world wide facility for C-ion treatment
 Benefit of Carbon ion(C-ion) compared to X-ray or proton therapy in cancer tx
 Clinical experiences in Japan
Cancer statistics in Korea
# of Ca. Patients
Death Rate
250,000
200,000
150,000
100,000
50,000
0
(per 100,000 of population)
year
No. of patients received RT
: approximately 30% of cancer patient at 2011
Korea Ministry of Health & Welfare
3 modality for treatment of Cancer
Surgery
Radiotherapy
Chemotherapy
Case
- Early cancer to moderately advanced
cancer
- Early cancer to local advanced cancer - Leukemia or cancers diffused in the
- Local cancer (not diverged nor
- Local cancer
whole body
scattered)
Advantage
- Non invasive treatment
- High technology of RT can replace
operation in some selected case
- In some cases, life prolonging effects is
remarkable
- Limited side effects left
-In general, side effects are strong.
-not curative treatment
- High curability
- It may cause serious loss of form of
function
Disadvantage
- Unsuitable for elderly patient or
patients with physical weakness
Now multimodality treatment with surgery, RT, and chemotherapy
is the recent concept in cancer treatment. The goal of multimodality treatment is to
increase cure rate, prolong life and improve quality of life through taking advantage of each treatment.
Roughly, 50-60% of cancer diagnosed patients would be cured.
Development of Conventional RT
Linac (1961)
Cobalt teletherapy (1950)
2D
3D-CRT
Evolving Radiation Therapy machines
 X-ray beam
CyberKnife
IMRT
VMAT
Tomotherapy
TrueBeam
Particle therapy
( proton, alpha particle, neutron)

Neutron Therapy (KCCH)
Proton Therapy (1954)
BNCT (alpha particle) at
Hanaro
Heavy Ion beam therapy
 beam of such ions as carbon (C), neon (Ne),
silicon (Si) or argon (Ar), etc.
G Kraft et al, 2009
Charged Particle Therapy Facilities
c
Japan – NIRS
the world’s first heavy-ion accelerator dedicated to medical use
Size: 60 x 120 m
Construction cost: $326 million
(Building $146 million)
(machine $180 million)
Germany - Heidelberg
world-wide first scanning beam, robotic couch for the two fixed beam room, 600 ton weighted moving gantry
for one room
Japan - Gunma Univ.
C-ion & proton
: Physical Advantage
 Bragg peak
 Entrance dose
 X-ray>>Proton>C-ion
Tumor
C-ion & proton vs X-ray
: Physical Advantage
C-ion vs proton or X-ray
- Biological Advantage
 High LET : dense breakage of
DNA , no repair during tretment
 RBE (Relative biological effect)
 C-ion (3)>>Proton (1.1)>X-ray(1.0)
 Produce strong cancer killing effect
 Especially in radioresistant cells
 Clincally C-ion treatment is suitable
for refractory cancer
+
X-ray or proton : gravel
C
+
Rock
Carbon ion therapy
Clinical experiences in Japan
Indications of C-ion RT
 Large tumor in any site
 Radioresistant tumor
 Recurrent tumor after
conventional RT
Prostate cancer
Results of Prostate cancer
RT methods
Dose
No. of patients
5yr DFS (%)
(PSA>20ng/ml)
Conventional RT
67-77
189
51
3D CRT
>76
232
26-63
IMRT
81-86
772
81 (3yr)
Proton
75
643
57
Carbon (NIRS)
66
182
80
Complications in Prostate cancer
RT methods
Dose
No. of patients
Complications (> Grade 2)
Rectum (%)
Urology (%)
Conventional RT
67-77
189
15
9
3D CRT
>76
232
11
7
IMRT
81-86
772
2
10
Proton
75
643
4
5
Carbon (NIRS)
66
182
1
4
Osteosarcoma
 C5 vertebra
 Sacrum
Re-ossification
Maxillary sinus tumor
Sacral Chordoma
Conclusion
Radiation technology is rapidly developed.
In technology aspect, recent X-ray radiation therapy machine: precise,
free beam allocation, dedicated image validation tool.
So this technology already achieved more easy, more precise, more safe,
less break-down time.
In clinical aspect, RT goal achieve high local control with less toxicity
In small sized tumor(< 5cm diameter) and well capsulated tumor, recent
technology of X-ray RT already achieved similar local control as surgery.
Vision of C-ion therapy achieve high local control with acceptable toxicity
in large tumor and radioresistant tumor. And finally it would give the cure
chance for refractory cancer patients in the future.
C-ion machine still has technological obstacle. Limited beam allocation,
limited validation tool for dosimetry, complicated gantry and etc. If C-ion
technology adopt , it can develop more rapidly. And then, we can make
final goal, the victory over tumor through C-ion.
25
Thank
you
Lung cancer (stage I)
Results of Lung cancer (stage I)
Peripheral type
No.
Local control (%)
5yr survival (%)
Conventional RT
149
56
22
SBRT
245
86
47
Proton
(Tsukuba Univ.)
28
57
30
Carbon (NIRS)
51
95
76
Surgery (Japan)
4264
-
60
Liver cancer
Results of Osteosarcoma of Pelvis
Studies
Radiations
No. of
patients
5yr survivals (%)
Total (%)
Surgery+RT
Inoperable
RT only
USA
photon
40
34
41
10
UK
photon
36
18
41
0
German
photon
89
27-30
34
0
Japan
(NIRS)
carbon
29
46
-
46
Carbon Ion - Biological Advantage
 Benefit for large fraction dose
Ando et al, 2005
 Carbon ion Tx can finish by 1-10 fractions
 1~2 days to 2 weeks by carbon ion RT
 6~8 weeks by X-ray or proton RT
Carbon Ion - Biological Advantage
 Overcome of radiation tolerance against hypoxic
tumor cells
X-ray
Carbon ion
oxygen
Blood vessel
Carbon ion therapy
Facilities in the world
Cancer statistics in Korea
Death Rate
# of Ca. Patients
(per 100,000 of population)
Korea Ministry of Health & Welfare
Carbon ion therapy
Backgrounds of radiotherapy
Single-wedged kitchen knife
Double-wedged sword
36
Beginning of Radiation therapy
 X-ray beam
 Conventional RT
Cobalt teletherapy (1950)
Linac (1961)
 Neutron beam
Boron Neutron Capture Therapy (1950s)
Gamma-knife
radiosurgery (1968)
Particle therapy
 Proton beam
 beam of protons (nuclei of hydrogen)
 Heavy ion beam
 beam of such ions as carbon (C),
neon (Ne), silicon (Si) or argon (Ar),
etc.
Proton therapy (1954)
Japan-Chiba NIRS
Japan-Gunma Univ.
Indications of C-ion RT
tumor in any site
resistant tumor
rent tumor after conventional RT