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THE NEEDS OF HADRONTHERAPY IN SPAIN

THE NEEDS OF HADRONTHERAPY IN SPAIN. Ignacio Petschen Verdaguer IFIMED 2009. HADRONTHERAPY. Therapeutic Window: Favorable. tumor control. toxicity. 90%. PROBABILITY. 5%. DOSE OF RADIATION. H Cárdenas courtesy. HADRONTHERAPY. Therapeutic Window: Unfavorable. tumor control. toxicity.

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THE NEEDS OF HADRONTHERAPY IN SPAIN

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

  2. HADRONTHERAPY Therapeutic Window: Favorable tumor control toxicity 90% PROBABILITY 5% DOSE OF RADIATION H Cárdenas courtesy

  3. HADRONTHERAPY Therapeutic Window: Unfavorable tumor control toxicity 90% PROBABILITY 50% DOSE OF RADIATION H Cárdenas courtesy

  4. HADRONTHERAPY Therapeutic Window: Effect of reducing Volume of Normal Tissue tumor control toxicity 90% V1 V2 PROBABILITY 50% V2 < V1 5% DOSE OF RADIATION H Cárdenas courtesy

  5. Mendenhall courtesy

  6. AK Lee courtesy MD Anderson CC

  7. AK Lee courtesy MD Anderson CC

  8. 1862-1942

  9. Combs courtesy

  10. 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.

  11. Combs courtesy

  12. HADRONTHERAPY: CARBON IONS - Reduction in the OER. - Lesser influence of repair phenomena. - Reduction of the differences in RS related to cell cycle position.

  13. HADRONTHERAPY: CARBON IONS Malignant tumors: -Well differenciated -Slowly growing -Hypoxic (RR) -Slowly cell cycle redistribution -repair-proficient tumors

  14. HADRONTHERAPY: IMAGE Only possible if modern image techniques are available

  15. Vikram courtesy (NCI)

  16. HADRONTHERAPY: IMAGE Ling et al. IJROBP, 47: 551 (2000)

  17. HADRONTHERAPY: CONFORMALITY Ling et al. IJROBP, 47: 551 (2000)

  18. 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)

  19. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Category A: • Closenesstohighlycriticalstructures • - Onlywaytoadminister a radical dosewithoutproducing • serioussideeffects

  20. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Tumoursbelongingcategory A: • Uveal melanoma • Base of skullchordoma and chondrosarcoma • Spinal and paraspinaltumours • Parasellarmeningioma • Opticalnerve glioma • Acousticnerveschwanoma

  21. HADRONTHERAPY: PROTONSUVEALMELANOMA: 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

  22. HADRONTHERAPY: PROTONS BASE SKULL CHORDOMAS AND CHONDROSA. RESULTS CHORDOMASCHONDROSA. CENTER 5 y. local control 5 y. local control MGH 73 % 99 % CPULL 59 % 75 % CP Orsay 71 % 85 %

  23. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Category B : • Prevalently local evolution • - LowRadiosensitivity

  24. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Tumoursbelongingtocategory B : • Prostaticadenocarcinoma • Retroperitoneal sarcoma • Salivaryglandtumours • Uterinecervixcancer (IIB bulkyor IIIB) • Undiff. tumours of thethyroidgland

  25. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Category C : • Protons as “boost” in a restrictedvolume • -Irradiationvolumewith a large safety margin • - Selectionbasedontheinitial response tophotonirradiation

  26. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Tumoursbelongingtocategory C : • Head and neckcancer • Low grade glioma • Malignantthymoma • Biliarytracttumours • Somelungtumours (NSCLC) • Oesophagustumours • Somepediatrictumours (CNS, sarcoma)

  27. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Category D : • Tu. withlocallyadvancedconditions and unfavourable prognosis • -Expectingsurvivalwith heavy symptomatology • - Paliationwithphotonsoftenunsatisfactory

  28. HADRONTHERAPYTHE TERA PROJECT • POTENTIAL INDICATIONS FOR PROTONTHERAPY • Tumorsbelongingtocategory D : • Pancreascancer • High grade glioma • Paraaorticmetastaticadenopathies • Pelvicrecurrences in previouslytreatedareas • Rhinopharingealrecurrences in previouslyirradiatedareas • isolatedbrainmetastasis

  29. 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% 733 Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)-modif-

  30. RT-PROTONS: PATIENTSCALCULATION • AccordingtoanItalianepidemiologicalstudy (reductionto ¾ = 45/60). • Patientstobeincluded in clinicaltrials (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 • -Biliarytracttumors 3.225 10% 322 • -Bladder carcinoma 12.713 10% 1.271 • -Head and Necktumors 5.085 15% 763 • -Brain gliomas 1.950 20% 390 • -Esophageal carcinoma 2.130 5% 106 • Undiff. thyroidcancer 75 50% 37 • Uterinecervixcancer 2.243 20% 448 • Hepaticcancer 10.005 10% 1.000 • -Pelvicrecurrence >375 50% >190 • TOTAL >86.539 13% >11.624

  31. 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 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% 2.432 Krengly and Orecchia. Radiother Oncol, 73, S21-23 (2004)-modif-

  32. HADRONTHERAPY: PATIENTSCALCULATION POTENTIAL RECRUITMENT FOR HADRONTHERAPY IN FRANCE “ One-daysurvey” in 5 radiationtherapydepartments: InstitutionsNr pat./dayNrpot. H-indications/dayAnnualrecruit. Besançon 115 13 130 Lyon Bérard 152 13 130 Pierre Benite 100 26 260 Dijon 83 11 110 Grenoble 82 14 140 Total 532 77 (14,5%) 770 RT treatments/year: 160.000 Potentialindicationsforhadrontherapy: 23.000 Baron et al. Radiother Oncol, 73, S 15-17 (2004)-modif-

  33. HADRONONTHERAPY: PATIENTS CALCULATION POTENTIAL RECRUITMENT FOR HADRONTHERAPY IN AUSTRIA “Nationwidesurvey” in 12 austrianradiationtherapydepartments. Accordingtothecriteriafrom 5 EuropeanUniversityHospitalsinvolved in hadronprojects (Heidelberg, Milan, Lyon, Vienna and Innsbruck) Inhabitants Austria: 8.000.000 New cancerpatients/year: 36.500 RT-treatments/year: 15.141 Potentialindicationsforhadrontherapy/year: 2.044 (13,5% RT) Mayer et al. Radiother Oncol, 73, S 24-28 (2004)-modif-

  34. 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)

  35. 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

  36. 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

  37. 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) 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)

  38. HADRONTHERAPY: PROTONSSOME 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.

  39. THANK YOU FOR YOUR ATENTION Delaney courtesy

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