Proton Therapy for Head & Neck Cancers
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1 Proton Therapy for Head & Neck Cancers Robert S Malyapa, MD, PhD and William M Mendenhall, MD University of Florida Proton Therapy Institute, Jacksonville, USA Carmen Ares, MD and Ralf Schneider, MD Paul Scherrer Institute, Villigen, Switzerland PTCOG Educational Workshop, Essen, 2013
2 Why protons for H&N Cancer? Protons are attractive to radiotherapy because of their physical dose distribution The RBE of protons are indistinguishable from 250 kv X-rays, which means that they are 10-15% more effective than 60 Co (RBE=1.1) The OER of proton beams is not distinguishable from X-rays (2.5 3) Protons are sparsely ionizing, except for a region at the end of particles range This high LET component is restricted to a tiny portion of the terminal track (this should be kept in mind when planning treatment close to critical structures)
3 Why protons for H&N Cancer? Biggest advantage is physical dose distribution Target
4 Why protons for H&N Cancer? Preservation of visual function by reduction in dose to optic apparatus Potential to further improve quality of life o Improved salivary gland function by sparing of parotid and submandibular glands o Improved swallowing function Potential to escalate dose for hypoxic tumors while maintaining improvement in quality of life
5 Is there a benefit? The Potential Benefit of Radiotherapy with Protons in Head and Neck Cancer with Respect to Normal Tissue Sparing: A Systematic Review of Literature Tara A. van de Water, Hendrik P. Bijl, Cornelis Schilstra, Madelon Pijls-Johannesma, and Johannes A. Langendijk 877 papers were retrieved and 14 relevant and eligible studies were identified and included in this review. Four studies included paranasal sinus cancer cases, three included nasopharyngeal cancer cases, and seven included oropharyngeal, hypopharyngeal, and/or laryngeal cancer cases. Seven studies compared the most sophisticated photon and proton techniques: intensity-modulated photon therapy versus intensity-modulated proton therapy (IMPT). Four studies compared different proton techniques. All studies showed that protons had a lower normal tissue dose, while keeping similar or better target coverage. Two studies found that these lower doses theoretically translated into a significantly lower incidence of salivary dysfunction. Oncologist, March 2011, 16(3):366
6 Is there a benefit? 42% Oncologist, March 2011, 16(3):366
7 Is there a benefit? Oropharyngeal Carcinoma 72 Gy IMRT PROTONS
8 Is there a benefit? IMRT Proton Therapy % PRV Dose PTV coverage: 95% of PTV receives Rx dose PTV coverage: 99% of PTV receives 93% of Rx dose Hot spot in PTV72 ( 20% of PTV 72 receives 110% of prescribed dose ) Contralateral Parotid (mean dose <2600 cgy Brainstem (5500 cgy to 0.1 c.c.) Spinal cord (5000 cgy to 0.1 c.c.) 101.6% 99.7% 100.3% 96.7% 107.3% 106% % % %
9 Is there a benefit? IMRT Proton Therapy Composite CCB only Composite CCB only 72 Gy 1.5x12=18 Gy 72 CGE 1.5x12=18 CGE Contralateral parotid (mean dose 2600 cgy Brainstem (5500 cgy to 0.1 c.c.) Spinal cord (5000 cgy to 0.1 c.c.) Contralateral submandibular gland
10 Is there a benefit? IMRT Protons
11 Is there a benefit? LON SC OC BS RON
12 Patient selection criteria for H&N proton therapy Lymph node involvement Tumor extent that may require overly complex beam arrangements Tumor location relative to high-z dental implants
13 CT simulation for H&N cancer 1 mm slice thickness non-contrast scan for dose calculation CT with contrast injection used for segmentation but not for dose calculation
14 Metal Artifacts H&N patients often have tooth fillings and metal implants Tooth fillings can completely stop the proton beam Titanium objects can perturb proton beams. Their presence in the beam path should be minimized by selection of beam angles Streaking and high intensity artifacts should be contoured and appropriate HU values assigned to them
15 Metal Artifacts Appropriate auto-contouring technique selected to match the physical dimension of titanium rod All of artifacts outside titanium rod overridden with tissue HU Beam paths chosen to avoid dental implant alloy
16 Proton beam arrangements in H&N
17 Proton-specific treatment planning concepts Distal Margin calculated from estimated uncertainty in CT HUstopping power conversion table Range uncertainty (~2.5% of total range) Relative Biological Effect (RBE): accounting for higher RBE near distal range Proximal Margin Compensator smearing: 5 mm for H&N Compensator border smoothing: 10 mm for H&N Through-patch fields
18 Proton-specific treatment planning concepts High skin dose: Selection of beam angles to minimize field overlap on skin Higher dose inhomogeneity at air-bone or tissue/implanted metal interfaces Range and penumbra uncertainties due to presence of metal objects: avoid beams passing through and stopping on cord Increased RBE at the end of range: AVOID/Minimize number of beams exiting on critical organs
19 Proton-specific treatment planning concepts Aperture margins account for beam penumbra at target depth Overly tight aperture margins increase dose distribution inhomogeneity and reduce dose distribution calculation accuracy Due to limited variation of range in H&N treatments, an aperture margin of 0.6 cm is generally used
20 Normal tissue constraints
21 Proton-specific treatment planning concepts SOBP and distal blocking
22 Proton-specific treatment planning concepts SOBP and distal blocking
23 Image-guided treatment delivery
24 Verification scans during treatment
25 Clinical examples Ca ethmoid 30 year male with adenoid cystic carcinoma Lt ethmoid and extension to base of skull
26 Ca ethmoid IMRT vs. Protons
27 Ca ethmoid Post treatment
28 Ca ethmoid IMRT vs. Protons LON OC BS Brain
29 Esthesioneuroblastoma
30 Esthesioneuroblastoma CGE BID
31 Esthesioneuroblastoma: Sinus slice view
32 Esthesioneuroblastoma: Orbital slice view Protons IMRT
33 Proton-Photon Match Fields
34 Skin with perineural invasion CGE BID
35 Re-irradiation: Skin with perineural invasion CGE BID
36 Re-irradiation: Skin with perineural invasion 32.7 CGE
37 Dr. Ralf Schneider Spot Scanning Proton treatment delivery PTCOG Essen Spot Scanning Technique: Developed at PSI and in Clinical Practice since 1996 Magnetic scanner Proton pencil beam Target Range shifter plate Patient Spot scanning speed on Gantry 1: Spots / min
38 Spot Scanning Proton treatment delivery PTCOG Essen Adenoid Cystic Carcinoma Submandibular Gland: 59.4 CGE; 68.4 CGE; CGE/fx Dr. Ralf Schneider
39 Ca nasopharynx: IMRT + Protons IMRT: PTV 60 Gy; PTV 69.6 Gy Proton Boost: 4.8 Gy Total PTV Dose = Gy BID
40 IMPT Full Treatment 74.4 Gy(RBE) Center for Proton Therapy C. Ares
41 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
42 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
43 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
44 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
45 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
46 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
47 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
48 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
49 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
50 Full Treatment 74.4 Gy(RBE) UF PTI PSI CPT Center for Proton Therapy C. Ares
51 Full Treatment 74.4 Gy(RBE) Center for Proton Therapy C. Ares
52 Full Treatment 74.4 Gy(RBE) Center for Proton Therapy C. Ares
53 Full Treatment 74.4 Gy(RBE) Center for Proton Therapy C. Ares
54 Full Treatment 74.4 Gy(RBE) Center for Proton Therapy C. Ares
55 Full Treatment 74.4 Gy(RBE) VOIs: L_COCHLEA Center for Proton Therapy C. Ares
56 Acknowledgement UFPTI Zhong Su, PhD Daniel Yeung, PhD Craig McKenzie, CMD Man Yam, CMD Zuofeng Li, DSc Roelf Slopsema, MS PSI Alessandra Bolsi, PhD Lorentzos Mikroutsikos, PhD Francesca Albertini, PhD Tony Lomax, PhD
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