Carbon and protontherapy plans at CNAO

Transcription

1 Carbon and protontherapy plans at CNAO Roberto Orecchia HBTC 2009, Erice, 25th April

2 From one D to. 100 years after

3 Future Directions: 5th, 6th, 7th and more D D?

4 Robotics

5 Hadrons electrons e- hadrons are made by quarks atom... Carbon ions = 6 protons + 6 neutrons... protons or neutrons quark u or d

6 The CNAO Facility

7 Created by the Italian Ministry of Health art 92 Law 23 December 2000, n 388 Activated on 21 November 2001 Private foundation (flexible and manageable) Public money (control and transparency) The budget is audited yearly by Corte dei Conti

8 Steering committee Founding members Fondazione Policlinico Ospedale Maggiore - Milan Fondazione Istituto Neurologico C Besta - Milan Fondazione Istituto Nazionale dei Tumori - Milan Istituto Europeo di Oncologia - Milan Fondazione Policlinico San Matteo - Pave Fondazione TERA - Novara Institutional members Istituto Nazionale di Fisica Nucleare (INFN) Università di Milano Politecnico di Milano Università di Pavia Comune di Pavia Partecipants Fondazione Cariplo 8

9 Network of cooperations Italian INFN Comune di Pavia Politecnico di Milano Provincia di Pavia Università di Milano Università di Pavia Università di Torino High technology, education Land and authorization procedures Patient positioning, radioprotection and authorizations Authorization and road network Clinical coordination and education Logistic, power sources betatron, safety, education Patient beam coupling, simulation and treatment planning International CERN (Geneva, CH) GSI (Darmstadt, D) LPSC (Grenoble, F) NIRS (Chiba, Japan) Special magnets, magnetic measures, diagnostic LINAC and diagnostic Betatron, optics, radiofrequency electronics Medical activity education

10 CNAO construction through images

11 June 2005 November 2005

12 January

13 March 2006 April 2006 Basement completed, wall construction starts

14 May 2006 Sandwich walls June 2006 Trusses for roof covering 35m/150 ton July 2006 Syncrotron room The interior 14

15 August 2006 Not only concrete Power transformers 132 kv-15kv/ 20 MVA each October 2006 Construction of the hospital area begins 15

16 November 2006 Synchrotron vault April 2007 Sources are installed October 2007 Cabling the power sources 7 January 2008 Some delay due to the unexpected snowfall March Plants close to be completed

17 Technical area Hospital building To pay attention to QoL 17

18 February 2009 Synchrotron vault Electric Cabin Hospital building

19 Let us follow the beam 19

20 A home made prototype GSI Linac Sources SYNCHROTRON High energy beam lines Treatment rooms 20

21 Sources where protons and carbon ions are produced Each sources produces a cloud of 1 billion carbon ions or 10 billions protons 21

22 The first part of the lines select the right particle and avoids that other ion species enter the line 22

23 The LINAC In 6 meters a speed of 30'000 km/sec is achieved 23

24 From the LINAC to the Synchrotron 24

25 MAGNETIC SYSTEM The higher the speed the bigger the force (SYNCHRO-TRON) 24 Quadrupoles to focus 20 Correctors to steer 16 Dipoles to bend 25

26 14 cm 6 cm Vacuum system Particles travel through steel pipes in which an extremely low pressure is created (one thousand billions time less 26 than atmospheric pressure)

27 RF CAVITY Each time the beam passes through the RF cavity it receives a push To reach the request energy one million turns are necessary 27

28 The vertical line allows more flexibility in the choice of beam angles The final magnet wheights 100 tons

29 Scanning magnets They are used to paint the tumor 29

30 Patient positioning and beam verification 30

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33 CONTROL SYSTEMS SAFE EFFECTIVE RELIABLE 33

34 Who shall we treat at CNAO?

35 Overall hadrontherapy patients Particles Newsletter Protons > Ions > Neutrons (20 000) Pions (1 000)

36 Published data in the years YEARS STUDIES CLINICAL PHYSIC BIOLOGICAL TOTAL IJ ROBP, Lancet, Radiother Oncol, JCO, Semin Oncol, Rad Prot Dosimetry, Phys Med Biol, Head and Neck, Int J Clin Oncol, J Radiat Res, J Thorac Oncol, Lung Cancer

37 From old to new indications

38 Advantage of Protons compared to conventional X-ray or IMRT X-ray IMRT Proton CTV 90% 90% 90% Cochlea Pituitary Hypotalamus Right TMJ Right parotid Pharynx ST Clair WH, IJROBP, 2004

39 9 children primary CNS malignancies Choclea: average mean of 25 ± 4% of the prescribed dose from PRT; 75 ± 6% from photons 40% of temporal lobe volume was completely excluded using protons; with photons 90% of the temporal lobe received 31% of the dose Linn R, 2000

40 Advantage of Protons compared to conventional X-ray or IMRT X-ray IMRT Proton CTV 90% 90% 90% Heart Right lung Esophagous Stomach Right kidney Transvers colon ST Clair WH, 2004

41 Category A All the tumors in which the use of hadrontherapy is clearly demonstrated to be advantageous, being the only way to give a curative dose to the target volume minimizing the incidence of severe side effects Category B A great variety of tumors characterized mainly by a local evolution, with a limited probability of distant spread, and therefore potentially cured if the locoregional control can be obtained

42 Number of potential patients in Italy Conventional X-ray therapy 20'000 patients/year every 10 M Hadrontherapy Category A Protontherapy: 0.5-1% of X-ray patients = 200 pts/y every 10 M Carbon ions: up to 6% of X-ray patients = 600 pts/y every 10 M Category B % of X-ray patients = 2'000 pts/y every 10 M

43 Category A. Protons New patients per year Patients treatable with protons Uveal Melanoma % Chordomas of the skull base and of the spinal column % Chondrosarchomas of the cephalic extremity and of the trunk % Meningiomas of the skull base % Paraspinal tumours % Schwannomas of the cranial nerves % Hypophyseal adenomas % Paediatric solid tumours % TOTAL

44 Category A. Carbon ions New patients per year Patients treatable with Carbons Salivary gland tumours % Maxillary sinuses adenocarcinomas % Mucosal melanoma of the head and neck area and other districts % Bone sarcomas % Soft tissue sarcomas % Liver/Biliary tract/pancreatic tumours % Recurrent tumours % TOTAL

45 Hadrontherapy facilities in Italy Pavia CNAO Trento ATREP Mestre Catania INFN-Catana

46 Scientific Direction Clinical Area Technical Coordinator Medical Physics Clinical Molecular Imaging Radio biology Bio engineering Transl Research Technologists

47 The CNAO Disease Specific Working Groups Soft tissue and bone sarcomas Melanoma (mucosal and eye) Brain and paraspinal tumours Head & Neck tumours Liver/Biliary tract/pancreatic cancer Lung cancer Pediatric neoplasms

48 The working groups will produce clinical protocols defining: Indications for hadrontherapy Total dose and fractionation Additional procedures (organ motion control, immobilization devices, special treatment planning imaging, etc. ) Work up and follow up exams Considering not only tumor s and patient s characteristics, but also alternative treatment s availability

49 In order to support both the activities of the Working Groups and the Training Program, a Medical Advisory Service has been set-up serviziomedico@cnao.it

50 Cure Research Learning Marie Slodowska Curie Pierre Curie ( ) ( )

51 Positioning system CNAO, Pavia, Italy Courtesy of Schaer Engineering AG, Switzerland

52 Morphofunctional imaging Brain - Standard MRI imaging - Spectroscopy on VOI - Search of metaboilte peaks: Myoinositol Choline Creatine N-acetilaspartate Lipids Lactate Citrate

53 In room autoactivation PET W. Enghardt et al., Nucl. Phys. A 654, 1999

54 Molecular Hadron Therapy

55 ITALIAN NETWORK INTERNATIONAL NETWORK

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58 EU initiative Partner CNAO FORMATION STRATEGY Accelerator experts and machine operators Medical doctors Medical physicists and technicians

59 European project: Partners CNAO involvement: One experienced researcher to deal with clinical studies One experienced researcher to deal with epidemiology & patient selection One early stage researcher to deal with Image Guided Hadron Therapy One early stage researcher to deal with novel gantry design

60 EU: Infrastructure FP7 Three types of activities are in the project Trans-national Access (TA) Joint Research Activities (JRA) Networking Activities (NA) ULICE Union of Light Ions Centres in Europe

61 Coordination: CNAO (R. Orecchia) European project: ULICE No. Organisation (full name) Short Name Country 1 Centro Nazionale di Adroterapia Oncologica CNAO Italy 2 Medical University of Vienna MUV Austria 3 University Hospital of Heidelberg UKL-HD Germany 4 CERN CERN Switzerland 5 MedAustron MEDA Austria 6 Etoile ETOILE France 7 RKA Marburg UKM Germany 8 Gesellschaft für Schwerionenforschung GSI Germany 9 Karolinska Instititute KAR Sweden 10 Oxford University UOXF UK 11 Technical University of Dresden TUD Germany 12 Siemens AG - MED PT PLM P SAG Germany 13 European Society for Therapeutic Radiology and Oncology ESTRO Belgium 14 Université Catholique de Louvain UCL Belgium 15 Medical University Aarhus AAR Denmark 16 Radboud Medical University Nijmegen UMCN Netherlands 17 Ion Beam Applications SA IBA Belgium 18 Istituto Nazionale di Fisica Nucleare INFN Italy 19 Maria Skłodowska Curie Memorial Institute Krakow COOK Poland 20 Archade ARC France

62 Hadrontherapy: EBM?

63 Hadrontherapy needs Correct methodology Clear guidelines Controlled clinical trials Reproducibily of results Small series Technical heterogeneity Clinical heterogeneity

64 One does not always need research to find the correct answer

65 Conclusion Search for individualized therapy

66 Thank you!!!!!