THE NEEDS OF HADRONTHERAPY IN SPAIN Ignacio Petschen Verdaguer IFIMED 2009.

THE NEEDS OF HADRONTHERAPY IN SPAIN

Ignacio Petschen Verdaguer

IFIMED 2009

Therapeutic Window: Favorabletumor controltumor control toxicitytoxicity

PR

OB

AB

ILIT

YP

RO

BA

BIL

ITY

DOSE OF RADIATIONDOSE OF RADIATION

90%90%

5%5%

H Cárdenas courtesy

HADRONTHERAPY

tumor controltumor control toxicitytoxicity

PR

OB

AB

ILIT

YP

RO

BA

BIL

ITY


90%90%

50% 50%

Therapeutic Window: UnfavorableTherapeutic Window: Unfavorable


HADRONTHERAPY

tumor controltumor control toxicitytoxicity

PR

OB

AB

ILIT

YP

RO

BA

BIL

ITY


90%90%

50% 50%

Therapeutic Window: EffectTherapeutic Window: Effectof reducing Volume of Normal Tissueof reducing Volume of Normal Tissue

VV22VV11

VV2 2 < V< V11 5% 5%


HADRONTHERAPY

Mendenhall courtesy

AK Lee courtesyMD 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

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)

HADRONTHERAPYTHE TERA PROJECT

POTENTIAL INDICATIONS FOR PROTONTHERAPY

Category A:

-Closeness to highly critical structures

- Only way to administer a radical dose without producingserious side effects



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

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

CENTER 5 y. local control 5 y. ocular retention

HADRONTHERAPY: PROTONS BASE SKULL CHORDOMAS AND CHONDROSA.

RESULTS

MGH 73 % 99 %

CPULL 59 % 75 %

CP Orsay 71 % 85 %

CENTER 5 y. local control 5 y. local control

CHORDOMAS CHONDROSA.



Category B :

-Prevalently local evolution

- Low Radiosensitivity



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



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



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)



Category D :

-Tu. with locally advanced conditions and unfavourable prognosis

-Expecting survival with heavy symptomatology - Paliation with photons often unsatisfactory



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 . 232 100% 232-Chordomas 35 100% 35-Chondrosarcomas (head,trunk) 68 100% 68-Meningiomas base of the skull 188 50% 94-Naso-etmoidal/paranasal tumors 105 100% 105-CNS Schwanoma 225 15% 34-Hypophysis adenoma 562 10% 56-Pediatric solid tumors 727 15% 109-TOTAL 2.142 34% 733Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)-modif-

RT-PROTONS: PATIENTSCALCULATIONAccording 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% >190TOTAL >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 therapyTUMOR TYPES: RT pat/y %prot Pat prot/y

-Salivary glands tumours 465 50% 232-ENT mucosal melanoma 23 100% 23-Bone sarcoma 390 10% 39-Soft tissue sarcoma 1.020 10% 102-NSC Lung cancer 23.250 5% 1.162-Hepatocelular carcinoma 3.750 10% 37-Prostata carcinoma 16.748 5% 837

-TOTAL 45.646 5,5% 2.432Krengly 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 Nr pat./day Nr pot. H-indications/day Annual recruit.

Besançon 115 13 130Lyon Bérard 152 13 130 Pierre Benite 100 26 260Dijon 83 11 110Grenoble 82 14 140Total 532 77 (14,5%) 770

RT treatments/year: 160.000 Potential indications for hadron therapy: 23.000 Baron et al. Radiother Oncol, 73, S 15-17 (2004)-modif-

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: 8.000.000New cancerpatients/year: 36.500RT-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 FROMITALY, 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 385

Annual cancer incidence in Spain 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


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


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) 1.300

Nr PTU needed in Spain 11-12

Nr C-ionsTU needed in Spain 2

·Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)

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.

Delaney courtesy

THANK YOU FOR YOUR ATENTION

THE NEEDS OF HADRONTHERAPY IN SPAIN Ignacio Petschen Verdaguer IFIMED 2009.

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