Proton therapy at Kraków, Poland: Fighting cancer with accelerator technologies

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1 Proton therapy at Kraków, Poland: Fighting cancer with accelerator technologies Pawel Olko Institute of Nuclear Physics Krakow Poland Democritus BC

2 Outline 1. Rationale for hadron therapy 2. We started in Kraków from proton therapy of eye. 3. Full option the project of the National Centre of Hadron Radiotherapy in Poland 4. Do it yourself: how to build a proton therapy facility?

3 Radiation cancer therapy is more than 100 years old Radium applicators Maria Skłodowska Curie born in Warsaw

4 Radiation interacts with DNA in cell nucleus and stops cancer proliferation

5 Arguments for proton therapy - Dose distribution - Verification - Radiobiology Increased biological effectivness in Bragg peak

6 What proton energy is needed? 100 arbitrary organ Range/ cm 10 1 eye Energy/MeV

7

8 CMS detector at Large Hadron Collider

9 Spin-off from high-energy and nuclear physics Computation and data analysis - www protocol developed at CERN (1989) - Monte Carlo transport codes: FLUKA and GEANT - GRID calculation network developed for LHC for handling large amount of data CERN first www protocol Accelerators ACCEL Instruments superconducting dipols (technology transfer from CEA Sacley and CERN for LHC) Detectors Wire detectors (Charpak), gas detectors, new scintillators Coordination of big projects CMS involved 4300 particle physicists, engineers, technicians 250 MeV Comet first superconducting cyclotron for proton therapy (ACCEL)

10 Cyclotrons the powerful tool for research and medicine Nuclear physics Ernest Lawrance, 1932 Nobel Prize for cyclotron Cancer treatment Radiobiology Space research Radioisotopes for medicine

11 Types of accelerators applied in proton therapy cyclotrons synchrotrons synchrocylotrons B= const f = const d ~ 4-5 m P = 500 kw B= var f = var d ~ 20 m P = kw B= const f = var d ~ m P = 50 kw

12 Development of proton therapy technology 1) More vendors with new technologies coming on the market - IBA - Varian Medical Systems - Hitachi - MEVION - Still River Systems - ProTom International - Compact Particle Acceleration Corporation 2) Small, single room solutions with gantry and superconducting synchrocyclotrons IBA, Proteus-One installed in Nice, Dec Proteus-One with small gantry IBA, Belgium - MEVION Medical, USA. 3) The price of proton therapy systems is decreasing. MEVION at the S. Lee Kling Center for Proton Therapy at Barnes-Jewish Hospital, Dec. 2013

13 Proton radiotherapy offers the lowest dose to healthy tissue and protection of Organ At Risk Cancer of rectum Wolff H.A. et al. Radiother Oncol 2012; 102: 30-37

14 Medical indications for proton therapy Golden standard - head and neck - Central Nervous System - ophtalmic tumors - children - prostate (USA) Promising - breast (left breast) - liver - rectum Pancreas? Lungs?

15 Active Pencil Beam Scanning replaces Scattering 2nd - In 2008 only two proton centers in the world treated with PBS - No Treatment Planning Systems, TPS, available - No specialized QA and dosimetry available - Intensity Modulated Proton Radiotherapy (IMPT) known only in theory

16 Operational: 9 centres 1. DKFZ Heidelberg 2. Dresden (2014) 3. Essen (2014) 4. Munchen 5. Orsay 6. Pavia (2013) 7. PSI Villigen 8. PTC Prague (2013) 9. Trento (2014) In tests: 4 centers Proton therapy is booming in Europe 1. Krakow (2015) 2. Nice (2016) 3. Uppsala (2015) 4. Wiener Neustadt (2017) Contracts signed: - Aarhus (DK), Archade, Caen (F), Delft (2017) - Groningen (NL) In operation Tenders & Planned: - UK ( London, Manchester, Oxford) - Maastricht (NL) Amsterdam (2019) - Belgium 2 centers - Poznań, Warsaw In construction

17 3. We started in Kraków from proton therapy of eye.

18 Cyclotrons at the Institute of Nuclear Physics IFJ PAN Krakow - first cyclotron in Poland developed by IFJ, 48 cm (1955) - classical cyclotron U-120 (opened , stopped 1994) -cyclotron isochronic AIC-144 (from 80 s) 60 MeV protons - Proteus C-230 (Ion Beam Applications, IBA) AIC MeV proton cyclotron developed at IFJ PAN in 1995

19 Eye melanoma Eye melanoma: -malignous cancer, -growing inside the eye-ball -mainly in white population, -250 cases/year in Poland Proton radiotherapy of eye - the most successful cancer treatment survival > 90% In Europe 7 centers - Berlin, HMI, D - Catania, INFN, I - Orsay, Inst. Curie, F - Nice, F - Claterbridge, UK - PSI Villigen, CH - IFJ PAN Kraków, PL (from 2011) B. Romanowska-Dixon B. Romanowska-Dixon Eye melanoma cancer USG of eye cancer

20 The long way to proton therapy of eye at IFJ PAN Kraków Arguments for: - Clinic of Ophthalmology and Ophthalmic Oncology in Kraków treats 95% of ocular melanoma cases in Poland, more than 200 new patients per year - Started in 1960 s using Co-60 brachytherapy plaques, now using surgery, laser, Ru-106 and I at IFJ PAN 60 MeV cyclotron Timetable: 1994 first seminar on proton therapy installation of AIC-144 cyclotron first funds from medicine: therapy room 2011 first patient 2013 reimbursement of eye treatment Prof. B. Romanowska-Dixon Chief of the clinic 17 years!!!

21 FACILITY AIC-144 FACILITY Pawel Olko, Kiev, 10 June 2010 Eye treatment room Treatment room 22 (year 2000)

22 IFJ PAN eye treatment room at AIC-144 Therapy room developed at IFJ in collaboration with P. Olko Helmholtz M. Jezabek Centre, NCRH Berlin

23 Regular patient treatment The first patient treated at IFJ PAN in February 2011 From April 2013 the eye proton therapy financed by the National Health System 103 patients till now

24 Lessons learned from the proton therapy of eye The proton therapy of eye in Krakow was an importnat starting point for the big project We have learned cooperation between physicists and external partners (physicians) Medical physicists were trained in proton dosimetry and QA Cyclotron and technical staff learned operation for therapy - responsibility, flexibility Now patients are routinely treated

25 Full option the project of the National Centre of Hadron Radiotherapy in Poland

26 The NCRH-CCB project National Consortium of Hadron Radiotherapy Bronowice Cyclotron Centre Poland joined European Union on May 1, In billion for infrastructure in science and technology from Structural Founds of EU IFJ PAN proposal : - Modern MeV cyclotron - New eye treatment room - Experimental room for physics and radiobiology - Gantries with active Pencil Beam Scanning (PBS)

27 National Consortium of Hadron Radiotherapy NCRH get together major players Established: IFJ PAN Kraków coordinator Akademia Górniczo-Hutnicza Center of Oncology, Gliwice Center of Oncology, Krakow Center of Oncology, Poznań Center of Oncology, Warsaw Collegium Medicum UJ, Kraków Holycross Center of Oncology, Kielce Jagiellonian University, Kraków Medical University, Warszawa, National Center of Nuclear Research, Warsaw Silesia University Warsaw Polytechnic Warsaw University 28

28 Funding was collected from three projects Centrum Cyklotronowe Bronowice rzut parteru 1 st project - cyclotron + experimental room 30 mln Euro Gantry 2 Gantry 1 Eye treatment Exp. area Cyclo vault Medical building Utility rooms Laboratories

29 Funding was collected from three projects Centrum Cyklotronowe Bronowice rzut parteru 2nd project - medical building + gantry 20 mln Euro Gantry 2 Gantry 1 Eye treatment Exp. area Cyclo vault Medical building Utility rooms Laboratories

30 Funding was collected from three projects Centrum Cyklotronowe Bronowice rzut parteru 3rd project - gantry 2 15 mln Euro Gantry 2 Gantry 1 Eye treatment Exp. area Cyclo vault Medical building Utility rooms Laboratories

31 Time schedule of the NCRH-CCB project - signing the contract start of the construction installation of the cyclotron starts of experiments gantry 1 operational gantry 2 operational end of the contract

32 Just before the start.. P. Olko M. Jezabek NCRH

33 11 May 2012 P. Olko M. Jezabek NCRH

34 Installation of the Proteus C-235 cyclotron 11 May 2012

35 Gantry the precise giant for patient irradiation Factory test Weight 120 T Proton beam

36 Beam lines at NCRH-CCB - signing of the contract start of the construction installation of the cyclotron cyclo acceptance tests beam for experiments medical building and gantry installation of gantry end of the contract the first patient

37 Facility and equipment at NCRH-CCB MeV cyclotron - 2 gantries with PBS - TPS/OIS - Computer Tomography - Dosimetry and QA - Eye treatment room - Experimental hall C-235 Proteus produced by Ion Beam Applications S.A. (IBA), Louvain-la-Neuve, Belgium energy selector : 70 MeV 230 MeV time to change energy by 10 MeV: < 1 s

38 Facility and equipment at NCRH-CCB MeV cyclotron - 2 gantries with PBS - TPS/OIS - Computer Tomography - Dosimetry and QA - Eye treatment room - Experimental hall - dedicated IBA gantry (Pencil Beam Scanning) degrees - 2 spot sizes 1 s = 2.7 mm and 4 mm (at 230 MeV) - irradiat. 1 liter volume to 2Gy in less than 90 s - max. field 30 cm x 40 cm - robotic treatment table, 6 degrees of freedom - orthogonal kv X-rays positioning - Vision RT optical positioning - gating - anesthetic arm

39 Facility and equipment at NCRH-CCB MeV cyclotron - 2 gantries with PBS - TPS/OIS - Computer Tomography - Dosimetry and QA - Eye treatment room - Experimental hall - developed by group of J. Swakon (IFJ) - no limitation of energy (range) - isocentric treatment chair (HEPHA BFI, France) - CE marking in collaboration with IBA

40 Our main clinical partners Adults Center of Oncology Prof. B. Sas-Korczyńska 5.5 km from IFJ PAN Eyes University Hospital Prof. B. Romanowska- Dixon 7 km from IFJ PAN Children Children University Hospital Dr. K. Małecki 30 km by highway Proton therapy facility IFJ PAN NCRH CCB

41 Operation of CCB-NCRH MeV cyclotron is used for research since January The medical part of the center will be fully operational in October The first patient on the gantry is planned for November After the initial learning period (1-2 years) it will be possible to treat in CCB up to patients per year ( patients per one gantry plus 100 patients in the eye treatment room) - The procedure is still not reimbursed by the National Health Fund (NFZ).

42 4. Do it yourself: how to build a proton therapy facility?

43 1. Find an influencial oncologist, who will fully support the project and a physicist who will lead the project at the director position 2. Make consortium with all the major players in the country to participate in the project 3. Be sure that local and central politicians and media are informed and involved 4. Consult your project with existing centers 5. Use local specialists (accelerator / detector / medical physics) to participate in the project (verification of the vendor) 6. Make yourself some of the work (tenders, integration of systems) The receipe Plan research and development

44 Find a physician

45 .. and a physicist..

46 or.

47 From acceptance tests to commissioning... Train your personel... Several stages of the training: 1) Before starting the project - leaders 2) Training in the operating centers 3) Academic training 4) Hands-on training 5) Certificates

48 From acceptance tests to commissioning... Do not buy a pig in a poke...

49 Do not buy a pig in a poke... User requirements Public tender Define your crutial tests here!!! Contract Delivery Dry runs Stay involved during installation Acceptance tests Commissioning First patient

50 Summary and Conclusions - Proton therapy is a quickly developing part of modern cancer radiotherapy - In Poland eye melanoma patients are treated since The new proton therapy center at IFJ PAN starts patient treatment at the end of The progress in technology leads to decrease of price and improving the quality of the treatment. Do it yourself - good luck!

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