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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