Carbon and protontherapy

plans at CNAO

Roberto Orecchia

HBTC 2009, Erice, 25th April

100 years after

From “one” D to….

Future Directions:Future Directions:““ 5th, 6th, 7th and more D5th, 6th, 7th and more D””

??

Robotics

Hadrons

“hadrons are made by quarks

... Carbon ions =

6 protons + 6 neutrons

atom

... protons or

neutrons

quark “u” or “d”

electrons “e-”

The CNAO Facility

• 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 deiConti

8

Steering committee

Founding membersFounding members

Fondazione Policlinico Ospedale Maggiore Fondazione Policlinico Ospedale Maggiore -- MilanMilan

Fondazione Istituto Neurologico C BestaFondazione Istituto Neurologico C Besta-- MilanMilan

Fondazione Istituto Nazionale dei Tumori Fondazione Istituto Nazionale dei Tumori -- MilanMilan

Istituto Europeo di Oncologia Istituto Europeo di Oncologia -- MilanMilan

Fondazione Policlinico San Matteo Fondazione Policlinico San Matteo -- PavePave

Fondazione TERA Fondazione TERA -- NovaraNovara

Institutional membersInstitutional members

Istituto Nazionale di Fisica Nucleare (INFN)Istituto Nazionale di Fisica Nucleare (INFN)

UniversitUniversitàà di Milanodi Milano

Politecnico di MilanoPolitecnico di Milano

UniversitUniversitàà di Paviadi Pavia

Comune di PaviaComune di Pavia

PartecipantsPartecipants

Fondazione CariploFondazione Cariplo

Network of cooperations

ItalianINFN High technology , educationComune di Pavia Land and authorization proceduresPolitecnico di Milano Patient positioning, radioprotection and authorizationsProvincia di Pavia Authorization and road networkUniversità di Milano Clinical coordination and educationUniversità di Pavia Logistic, power sources betatron, safety, educationUniversità di Torino Patient beam coupling, simulation and treatment planning

InternationalCERN (Geneva, CH) Special magnets, magnetic measures, diagnosticGSI (Darmstadt, D) LINAC and diagnosticLPSC (Grenoble, F) Betatron, optics, radiofrequency electronicsNIRS (Chiba, Japan) Medical activity education

CNAO

construction

through

images

June 2005

November 2005

12

January 2006

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

15

August 2006

Not only concrete…

Power transformers 132 kV-15kV/ 20 MVA each

October 2006

Construction of the hospital area begins

16

November 2006

Synchrotron vaultApril 2007

Sources are installed

October 2007

Cabling the power sources

March 2008

Plants close to be completed

7 January 2008

Some delay due to the unexpected snowfall

17

Technical area Hospital building

To pay attention

to QoL

Electric Cabin

February 2009Synchrotron

vault

Hospital building

19

Let us follow the beam…

A “home made” prototype

High energy beam lines

GSI Linac

Treatment rooms

SYNCHROTRON

Sources

20

Sources where protons and carbon ions are produced

21

Each sources produces a cloud

of 1 billion carbon ions or

10 billions protons

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

22

The LINAC

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

23

24

From the LINAC to the Synchrotron…

2516 Dipoles

to bend

24 Quadrupolesto focus

20 Correctorsto steer

MAGNETIC SYSTEM

The higher the speed the bigger the force

(SYNCHRO-TRON)

26

Vacuum system

Particles travel through steel pipes in which an extremely low pressure is created (one thousand billions time less than atmospheric pressure)

14 cm

6 cm

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

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

Patient positioning and beam verificationPatient positioning and beam verification

30

33

SAFE

EFFECTIVE

RELIABLE

CONTROL SYSTEMS

Who shall we treat

at CNAO?

Overall hadrontherapy

patients

Particles Newsletter

Protons > 50 000

Ions > 5 000Neutrons (20 000)

Pions (1 000)

STUDIES

YEARSCLINICAL PHYSIC BIOLOGICAL TOTAL

2004-2007

100 41 21 162

2000-2003

46 29 18 93

1995-1999

27 33 8 68

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

Published data in the years

2008

From ”old“ to “new” indications

X-ray IMRT ProtonCTV 90% 90% 90%

Cochlea 101.2 33.4 2.4Pituitary 62.7 19.3 0.1

Hypotalamus 8.5 5.9 0.1

Right TMJ 29 16 0.1

Right parotid 6.6 8.5 0.1

Pharynx 3.9 3.7 0.1

ST Clair WH, IJROBP, 2004

Advantage of Protons compared to

conventional X-ray or IMRT

Linn R, 2000

• 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

ST Clair WH, 2004

X-ray IMRT ProtonCTV 90% 90% 90%

Heart 18.2 17.4 0.1Right lung 3.5 21.9 0.1

Esophagous 11.9 32.1 10.2

Stomach 3.7 20.6 0.1

Right kidney 3.3 29.8 0.1

Transvers colon

2.6 18.0 0.1

Advantage of Protons compared to

conventional X-ray or IMRT

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

Number of potential patients in Italy

• Conventional X-ray therapy20'000 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 B10-15 % of X-ray patients = 2'000 pts/y every 10 M

Category A. Protons New patientsper year

Patients treatable with protons

Uveal Melanoma 310 310 100%

Chordomas of the skull base and of the spinal column 45 45 100%

Chondrosarchomas of the cephalic extremity and of the trunk

90 90 100%

Meningiomas of the skull base 250 125 50%

Paraspinal tumours 140 140 100%

Schwannomas of the cranial nerves 300 45 15%

Hypophyseal adenomas 750 75 10%

Paediatric solid tumours 960 144 15%

TOTAL1.885 974

Category A. Carbon ions New patientsper year

Patients treatable with Carbons

Salivary gland tumours 620 310 50%

Maxillary sinuses adenocarcinomas 450 45 10%

Mucosal melanoma of the head and neck areaand other districts

30 30 100%

Bone sarcomas 520 104 20%

Soft tissue sarcomas 1360 272 20%

Liver/Biliary tract/Pancreatic tumours 4500 450 10%

Recurrent tumours 750 225 30%

TOTAL

7672 1436

Hadrontherapy facilities in Italy

PaviaCNAO

CataniaINFN-Catana

TrentoATREP

Mestre

Clinical Area

Technical Coordinator

Medical

PhysicsClinical

Molecular

Imaging

Radio

biology

Bio

engineeringTransl

Research

Technologists

Scientific Direction

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

The working groups will produce clinical protocolsdefining:

– 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

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

Marie Slodowska Curie Pierre Curie

(1867 – 1934) (1859 – 1906)

�Cure

�Research

�Learning

CNAO, Pavia, Italy Courtesy of Schaer Engineering AG, Switzerland

Positioning systemPositioning system

- Standard MRI imaging

- Spectroscopy on VOI

- Standard MRI imaging

- Spectroscopy on VOI

Morphofunctional imagingMorphofunctional imaging

Brain

- Search of metaboilte peaks:

MyoinositolCholine

CreatineN-acetilaspartate

LipidsLactateCitrate

In room autoactivation PET

W. Enghardt et al., Nucl. Phys. A 654, 1999

Molecular Hadron Therapy

ITALIAN NETWORKITALIAN NETWORK

INTERNATIONAL INTERNATIONAL NETWORKNETWORK

EU initiative

Partner

CNAO FORMATION STRATEGY

� Accelerator experts and machine operators

� Medical doctors

� Medical physicists and technicians

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

EU: Infrastructure FP7

ULICE

Union of Light Ions

Centres in Europe

Three types of activities are in the project

� Trans-national Access (TA )

� Joint Research Activities (JRA)

� Networking Activities (NA)

European project: ULICE

• Coordination: CNAO (R. Orecchia)

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

Hadrontherapy:

EBM?

Correct methodologyClear guidelinesControlled clinical trials

Reproducibily of results

Small series Technical heterogeneityClinical heterogeneity

Hadrontherapy needs

One does not always need research to find

the correctanswer

ConclusionConclusion

Search for

individualized

therapy

Thank you !!!!!