Radiotherapy for Childhood Cancers: Photons & Protons · Malignant Disease and Its Treatment By...
Transcript of Radiotherapy for Childhood Cancers: Photons & Protons · Malignant Disease and Its Treatment By...
The Royal Marsden
Radiotherapy for Childhood Cancers 1
Radiotherapy for Childhood
Cancers: Photons & Protons
Dr Henry C. Mandeville
Consultant Clinical Oncologist
Children’s and Young People’s Unit
The Royal Marsden Radiotherapy for Childhood Cancers 2
The Royal Marsden
Outline of talk
• Introduction to Childhood Cancers
• The role and challenges of radiotherapy
• Different types of radiotherapy
• Future developments
Radiotherapy for Childhood Cancers 3
How common are childhood cancers? - proportion of all cancer diagnoses in UK
A. 10%
B. 5%
C. 2%
D. 1%
E. <1%
Radiotherapy for Childhood Cancers 4
10% 5% 2% 1%<1%
13%
28%
15%
21%23%
The Royal Marsden
Childhood Cancers: Key Facts
• Very Rare:
• <1% of all Cancer diagnoses
• Increasing incidence
• 11% increase since early 1990s
• Approximately 40–50% of children with cancer receive
radiotherapy as part of their initial treatment
• Improving Outcomes
Radiotherapy for Childhood Cancers 5
NRCT report 2012; http://www.ncin.org.uk/publications/
Radiotherapy for Childhood Cancers 6
What is the commonest type of childhood solid tumour?
A. Soft tissue tumours (sarcomas)
B. Upper abdominal tumours e.g. Renal/ Suprarenal
C. Leukaemia
D. Brain tumours
E. Bone tumours
Radiotherapy for Childhood Cancers 7
Soft tis
sue tu
mours
(sar..
.
Upper abdom
inal t
umour..
.
Leukaem
ia
Brain
tum
ours
Bone tum
ours
13% 13%
3%10%
63%
Incidence of Childhood Cancers
Radiotherapy for Childhood Cancers 8
Children’s Cancer Incidence
http://www.cancerresearchuk.org
Incidence of Childhood Cancers
Radiotherapy for Childhood Cancers 9
Children’s Cancer Incidence
http://www.cancerresearchuk.org
The Royal Marsden Radiotherapy for Childhood Cancers 10
Paediatric Radiotherapy What makes it different?
Immobilisation
– Play specialists
– Anaesthesia
Normal Tissues
– Growth and development
– Late effects
Tumour types
- Pathology
- Radiobiology
Service organisation
- Multiprofessional working
- Shared care
The Royal Marsden
Some things have changed!
Radiotherapy for Childhood Cancers 11
http://news.stanford.edu/news/2007/april18/med-accelerator-041807.html
The Royal Marsden Radiotherapy for Childhood Cancers 12
Preparing children for radiotherapy
The Royal Marsden Radiotherapy for Childhood Cancers 13
Challenges for Immobilisation
General Anaesthesia
Play specialists
Tattoos
The Royal Marsden Radiotherapy for Childhood Cancers 14
Mould Room
The Royal Marsden Radiotherapy for Childhood Cancers 15
CT Planning & Radiotherapy Treatment
The Royal Marsden Radiotherapy for Childhood Cancers 16
End of treatment gift and certificate
The Royal Marsden
Patient environment
• Age appropriate environment + ability for family to be
present
• Schooling/health education
• Psychological support
• Financial support
• Peer support/mentoring
17 Radiotherapy for Childhood Cancers
The Royal Marsden Radiotherapy for Childhood Cancers 18
Survivorship
– 80% of children with cancer will survive ≥5 years
– Approx 73% develop treatment- related complications
– Children grow and develop
– Radiotherapy can interfere with that
– Management of chronic consequences of treatment
Newhauser WD and Durante M, Nature Reviews Cancer 11, 438-448 (June 2011)
The Royal Marsden
Radiotherapy for Childhood Cancers 19
Current & future photon RT techniques
The Royal Marsden
Modern Paediatric Radiotherapy!
Radiotherapy for Childhood Cancers 20
Malignant Disease and Its Treatment By Radium:
Volume 4. Sir Stanford Cade.
London. 1952
The Royal Marsden Radiotherapy for Childhood Cancers
Target definition - Where is the tumour?
- Extent of disease?
- Microscopic extension
- Regional lymph nodes
- Metastatic disease
21
The Royal Marsden Radiotherapy for Childhood Cancers
Target definition - Where was the tumour?
― Post surgical resection
― Neuroblastoma
― Wilm’s Tumour
― Difficulties with Fusion
― Pre + post op imaging
― Change in contour
― Respiratory motion
22
The Royal Marsden Radiotherapy for Childhood Cancers 23
Posterior fossa radiotherapy
3D CRT IMRT VMAT
Lee YK et al. ISPNO 2012
The Royal Marsden Radiotherapy for Childhood Cancers 24
Stereotactic Radiotherapy
– Delivery of high radiation dose to small volume
– Small number of fractions (1 to 5)
– Different techniques can be used
– VMAT, Cyberknife, Gammaknife
– Possible paediatric indications:
– Re-irradiation for local relapse
– Oligometastatic disease
The Royal Marsden
Magnetic Resonance-Guided RT
Prototype developed in Utrecht- partnership with Elekta & Phillips
International Consortium- RM/ ICR first machine in UK
Exploitable Advantages:
Enhanced soft tissue contrast of MRI
Real-time imaging/ treatment adaptation
No radiation dose and non-invasive
Radiotherapy for Childhood Cancers 25
Current In-Room
Cone Beam CT
Future In-Room
MRI
Elekta Unity- MR Linac
The Royal Marsden
Radiotherapy for Childhood Cancers 26
Protons
The Royal Marsden Radiotherapy for Childhood Cancers 27
Why protons?
The Royal Marsden Radiotherapy for Childhood Cancers 28
Yock T et al. IJROBP 2005
Which children & young people are currently funded for Protons in the UK?
A. None
B. Base of skull and spinal tumours only
C. All brain tumours & sarcomas
D. Specified brain tumours, sarcomas & rare tumours <age 16y
E. Specified brain tumours, sarcomas & rare tumours < age 25y
Radiotherapy for Childhood Cancers 29
None
Base o
f sku
ll and sp
inal .
..
All bra
in tu
mours
& sa
r...
Specifie
d bra
in tu
mours
,...
Specifie
d bra
in tu
mours
,...
27%
3%
16%
49%
5%
The Royal Marsden
Indications for Children(<16y) & TYA (16-24y)
General Criteria
• A clear indication for radiotherapy and defined as curable
• Expectation of 40% 5 year survival
• No comorbidities likely to limit life expectancy to <5 years
• No evidence of distant metastasis, with the exception of:
• Rhabdomyosarcoma
• Ewing’s Sarcoma
• where limited and only lung disease
Radiotherapy for Childhood Cancers 30
Radiotherapy for Childhood Cancers 31
Radiotherapy for Childhood Cancers 32
Producing the Proton Beam
Radiotherapy for Childhood Cancers 33
Protons in the UK… 2018- 2020
Radiotherapy for Childhood Cancers 34
NHS sites:
University College Hospital, London
The Christie Hospital, Manchester
The Royal Marsden Radiotherapy for Childhood Cancers 35
Conclusions
– Radiotherapy remains an important component in the treatment of tumours in TYA and children
– Needs to be done in specialised centres with experienced multiprofessional team
– Balance cure with potential late effects
– Dosimetric benefits with Image guided IMRT and Stereotactic RT treatments
– Potential long term benefits with Proton beam radiotherapy
The Royal Marsden
Acknowledgements
The ICR/ RMH Joint Department of Physics
Greg Smyth
Prof Uwe Oeflke
The Royal Marsden Radiotherapy Department
Dr Frank Saran
Sarah Helyer
Claire Riddell
Advanced Photons 36