G. Cuttone Laboratori Nazionali del Sud - Catania
Transcription
G. Cuttone Laboratori Nazionali del Sud - Catania
INFN-LNS e Centro di AdroTerapia e Applicazioni Nucleari Avanzate G. Cuttone Laboratori Nazionali del Sud - Catania OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Why clinical clinical proton proton beam beam? Why ? Why clinical clinical proton proton beam beam? Why ? • penetration depth is well-defined and adjustable • most energy at end-of -range • protons travel in straight lines • dose to normal tissue minimised • no dose beyond target PROTONS PERMIT TO DELIVER AN HIGH DOSE TO THE TUMOUR SPARING THE SOURRONDING TISSUES IMRT vs vs PROTONS PROTONS IMRT Between the eyes Abdomen Brain OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF INFN && Hadrotherapy Hadrotherapy INFN • In 90’ years INFN supported TERA in R&D project. • INFN, in collaboration with University of Catania, realized in its laboratory (Lab. Naz. Del Sud) the first Italian protontherapy facility. • INFN has UNIQUE capability in Italy in accelerators development. • Considering its particular features, INFN was involved in CNAO to guarantee the necessary expertise. • In 2005 INFN was encharged by Health Minister to produce a document about protontherapy in our country. In Catania we developed a facility (named CATANA) for the treatment of ocular tumours with 62 AMeV proton beams CATANA collaboration Centro di AdroTerapia e Applicazioni Nucleari Avanzate INFN-Laboratori Nazionali del Sud Physics Department, University of Catania CSFNSM G. Cuttone G.A.P. Cirrone L. Calabretta D. Rifuggiato A. Amato M.G. Sabini S. Lo Nigro F. Di Rosa P.A. Lojacono V. Mongelli I.V. Patti L.M. Valastro Ophthalmologic Institute University of Catania A. Reibaldi J. Ott G.Profeta M.L. Rallo Radiologic Institute University of Catania G. Privitera V. Salamone L. Raffaele C. Spatola LNS Superconducting Cyclotron is the unique machine in in Italy and South Europe used for protontherapy Treatment of the choroidal and iris melanoma In Italy about 300 new cases for year Laboratori Nazionali del Sud –INFN Catania, Italy Cyclotron Location Treatment Room Location Proton Beam LNS Accelerator Layout Ocular Protontherapy Unique Italian Facility CATANA CATANA proton proton therapy therapy beam beam line line ((until untilJune June2004 2004)) CATANA CATANA proton proton therapy therapy beam beam line line ((new newlocation location)) CATANA OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF CATANA proton proton therapy therapy beam beam line line CATANA Ligth field Laser Modulator & Range shifter Monitor chambers Scattering system Lateral dose dose distribution distribution Lateral DOUBLE SCATTERER FOIL WITH CENTRAL STOPPER 15 µm + 25 µm + 7 mm thick copper beam stopper Lateral dose dose distribution distribution in in aa clinical clinical proton proton beam beam Lateral 120 100 Relative dose 95 % 80 60 50 % 40 20 % 20 0 -20 -15 -10 -5 0 5 10 15 20 Distance from central axis (mm) Lateral penumbra : d 80 % → 20 % Field ratio : H = 90 % field size 50 % field size Flatness : ϕ = 25 mm ⇒ ≥ 0 . 90 ϕ = 25 mm ⇒ > 20 mm w 95 % : Simmetry Tolleranze ≤ 1 . 50 mm ( Area ratio ) : ABS ( a − b ) × 200 % a+b P − Pmin RT % = max × 100 % Pmax + Pmin Sr = ≤ 3% ≤ 3% Depth dose dose distribution distribution –– Energy Energy modulation modulation Depth Generation of the Spread Out Bragg Peak (SOBP) Modulated clinical clinical proton proton beam beam Modulated 110 100 90 SOBP Dose (%) 80 70 60 Rres 50 40 30 20 Rp(10%) 10 Z REF 0 0 5 10 15 20 25 30 35 Depth in water (mm) MODULATION REGION (SOBP) = W95% ENTRANCE DOSE = D(z=0) DISTAL PENUMBRA = d80%→ →20% LONGITUDINAL UNIFORMITY Rl = [( Dmax / Dmin ) × 100]% Experimental SOBP SOBP curves curves Experimental 120 90 95% 100 Relative Dose (%) R e la tiv e Io n iz z a tio n (% ) 100 80 Markus Ionization Chamber 70 60 50 40 30 20 10 0 80% 80 60 Modulated Region 40 20% 20 0 0 5 10 15 20 25 30 35 R90% 0 Depth in water (mm) 10 20 Depth in water (mm) 30 DETECTOR Peak Depth Peak-Plateu Ratio F.W.H.M. Distal dose falloff d80%-20% Practical Range (d10%, ICRU 59) MARKUS 30.14 4.68 3.19 0.50 31.15 DETECTOR Modulation (SOBP) Maximum Dose (%) Distal dose falloff d90%-10% Distal dose falloff d80%-20% Beam Range (90% Distal) MARKUS 21.31 103.9 0.84 0.57 28.39 40 Experimental lateral lateral dose dose distribution distribution Experimental FULL ENERGY BEAM S ig n al [ % ] 100 Radiochromic Film 80 60 40 20 0 -20 -15 -10 -5 0 5 10 15 20 Distance from axis [ mm ] DETECTOR Field Ratio P80% - 20% (mm) Simmetry (%) Width of 95% level (mm) 0.85 2.40 22 90% / 50% GAF HS (ISP) 0.92 OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Dosimetric commissioning commissioning:: absolute absolute&&relative relativedosimetry dosimetry Dosimetric Absolute Dosimetry: Energy Released in Water (Gray) Relative Dosimetry: Three dimensional dose distribution measurements ⇓ Considering the high gradient dose, conformation and small fields often used the detectors have to be kindly characterized in terms of spatial resolution, energy or fluence dependence to be used in protontherapy. Relative and Absolute Dosimetry are fundamental for: Customizing of TPS Monitor Unit Calculation Quality Control Dosimetric commissioning commissioning:: absolute absolute&&relative relativedosimetry dosimetry Dosimetric ICRU 59 AND TRS 398 IAEA RECOMMENDATION ⇓ “ FOR MEASUREMENTS OF DEPTH-DOSE DISTRIBUTION IN PROTON BEAMS THE USE OF PLANE-PARALLEL CHAMBERS IS RECOMMENDED” ⇓ Parallel plate MARKUS PTW is the golden standard for depth dose measurements Dosimetric commissioning commissioning:: absolute absolute&&relative relativedosimetry dosimetry Dosimetric ADVANCED MARKUS CHAMBER VP = 400 V V× ×cm-1 = 4000 Pressure equilibrium ≤ 10 sec Temperature equilibrium = 2-3 min./K kS = 1.00 (1÷ ÷100 Gy/min.). Response: 670 pC/Gy Directional dependence: smaller than 0.1% for tilting of the chamber by up to 10º Electrode Acrylic (PMMA), graphite coated 5 mm Ø Leakage current ± 4 fA Dosimetric commissioning commissioning:: absolute absolute&&relative relativedosimetry dosimetry Dosimetric 1 2 5 4 1) Film Kodak: XV and EDR2 4) Scanditronix Diode • 3 2) TLD 5) PTW Natural Diamond 6 3) Radiochromic Film 6) Mosfet In collaboration with ISS (S. Onori..) and DFC Florence (M. Bucciolini…) THE MOPI MOPI ONLINE ONLINE MONITOR MONITOR THE 2 ionization chambers with anode segmented in strips (x,y) anode cathode electronics card horizontal strips spacer beam cathode anode aluminized mylar 15µm Al strips Sensitive area Total thickness Number of strips/chamber Strip width Pitch Readout rate 35µm kapton 12.8X12.8 cm2 ~ 200 µm H2O equiv. 256 400 µm 500 µm up to 4 kHz (1 Hz) THE MOPI MOPI ONLINE ONLINE MONITOR:TEST MONITOR:TEST SET SET-UP THE -UP x-y ion. strip chambers MOPI p beam ionization chambers GEANT4Complete Completesimulation simulationof ofthe theCATANA CATANAbeam beam line: line: GEANT4 Design possibility of a general hadron therapy beam line Optimization of its elements GEANT4 simulation TPS check respect the very precise Monte Carlo method GEANT4Simulation Simulation GEANT4 Monte Carlo Simulation of the entire beam line using GEANT4: Improvement of our beam line and dosimetry Give a general purpose tool for the design of new hadrontherapy beam line Validation of the treatment system software GEANT4 simulation Physicsmodels models Physics Standard + hadronic Standard Processes Kolmogorov test process P-value Test Standard. 0.069 OK Standard + Had. 0.40 Low Energy 0.51 OK Low Energy OK + hadronic Low En. + Had 0.699 OK Low Energy OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Surgical Phase Phase (Tantalum (Tantalum clips clips insertions) insertions) Surgical CLIPS: characterize position and size of tumour volume typical treatment treatment AA typical The Surgical Phase The Treatment Planning Phase The Verification Phase The Treatment Phase Two orthogonal X-Rays tubes for the visualization of the clips Treatment Planning Planning System System Phase Phase Treatment EYEPLAN Originally developed by Michael Goitein and Tom Miller (Massachussetts General Hospital), is now maintained by Martin Sheen (Clatterbridge Center for Oncology) and Charle Perrett (PSI) OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Patient’s follow up 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Fixation Point Point Choice Choice Fixation This point is chosen in order to spare the organs at risk, and to maintain the best polar angle. Fixation Point Point Fixation Isocenter Fixation Light θ φ θ Polar Angle φ Azimuthal Angle Introduction of of data data in in the the simulation simulation phase phase Introduction Treatment Planning Planning System System Output Output Treatment Isodoses curves for different planes Fixation Point Point Fixation Patiens look the fixation light during the treatment PROTON BEAM Treatment Phase Phase Treatment At the end of patient positioning phase the radiotherapist draws the eye’s contour on a dedicated monitor in order to monitoring in any moment the eye’s position during the treatment. TREATMENT MODALITIES Dose: 15.0 CGE per day Treatment Time: 45-60 sec. Total Dose: 60 CGE Fractions: 4 OUTLINE OUTLINE 1. Why proton beams in tumour radiation treatment 2. INFN & HADRONTHERAPY: THE CATANA PROTON THERAPY CENTER • Beam line elements • The DOSIMETRIC COMMISIONING: Absolute and relative dosimetry • Treatment procedure • Clinical results 3. ACTUAL STATUS OF HADRONTHERAPY: THE CATANA SPIN-OFF Patient Distribution Distribution by by Pathologies Pathologies Patient Uveal Melanoma 92 patients (89.89 %) Conjunctival Melanoma 4 patients (4.04 %) Conjunctival rhabdomyosarcoma 1 patient (1.01 %) Eyelid Carcinoma and metastases 2 patient (2.02 %) Conjunctival MALT-NHL 1 patient (1.01 %) Conjunctival Papilloma 2 patient (2.02 %) Patient Distribution by Origin Region 9 1 1 Total number of patients : 150 3 1 15 2 16 6 1 8 14 60 Patient Distribution Distribution by by Sex Sex Patient Women Men 51% 49% The patients’age ranges between 14yrs and 81yrs (the mean age is 48 yrs) PATIENTS FOLLOW FOLLOW-UP PATIENTS -UP (March 2002 2002 –– November November 2007) 2007) (March PatientsTotal Number (June 2007) 150 Patients with Follow up 128 TUMORAL THICKNESS ECOGRAPHIC REFLECTIVITY Reduced Stable 70 % Increased 24 % Stable 77 % 18 % Increased 2 % Not evaluable 5% Not evaluable 2% SURVAIVAL RESULTS PatientsTotal Number (November 2007) 128 Dead patients 4 Metastatis 3 Other 1 Eye retention rate 95 % TOTAL SURVIVAL 98 % LOCAL CONTROL 95 % CATANASpin Spin-off: SICILIANPROTONTHERAPY PROTONTHERAPYProject Project CATANA -off: SICILIAN The realization of a ProtonTherapy center in Catania has been stated in the Health Framework Agreement Document signed on 23 dec. 2003 by: Ministero della Salute Regione Siciliana Ministero dell’ dell’Economia e delle Finanze Omissis Articolo 6 Centro di protonterapia nell’area di Catania Le parti si impegnano ad effettuare le verifiche di ordine programmatico e tecnico-sanitario ai fini della realizzazione di un centro di protonterapia nell’area di Catania, in conformità alle indicazioni contenute in un recente studio dell’AIRO (Associazione Italiana di Radioterapia Oncologica) nell’ambito della nascente rete italiana dei centri di adroterapia e ad individuare le fonti finanziarie cui attingere per la relativa copertura. Omissis CATANA Spin Spin-off: Some Important Important Milestones Milestones CATANA -off: Some In 2002, the First Italian Protontherapy Facility Funded by INFN and Catania University started in Catania at INFN-Laboratori Nazionali del Sud In 2003, the 5th Scientific Commission of INFN funded SCENT, an R&D project studying a Superconducting Cyclotron for Medical Applications On March 7th 2003 Sicilian Region has approved to realize an HadronTherapy Center in Catania, based on a Cyclotron for protons and heavy charge particles. It has to be realized as “Scientific collaboration between Region, INFN and University of Catania also open to private contributions” SCENT “A New Cyclotron for Hadron Therapy” Superconducting Cyclotron for Exotic Nuclei and Therapy February 2003: the 5th CSN-INFN approve SCENT experiment March 2003: the Sicily region, inside its developing plane for the health, decided to include the realization of a centre for hadrotherapy in Catania area April 2006: contact between IBA and INFN to find out a collaboration agreement July 2006: agreement of cooperation between IBA and INFN for marketing and construction of a SCENT Cyclotron Whyproposing proposingaacyclotron? cyclotron? Why • A vast majority of the tumors treated in MGH, Chiba or GSI do not require the very highest energy of a synchrotron • The minority of tumours located too deep to be treated in Carbon (Prostate, Uterus) could also be treated with lighter ions such as Helium or Protons • A cyclotron offers the best beam current control for ultra-fast pencil beam scanning • The cyclotron is a much simpler machine, with most of the parameters constants. It does not require a large team of Ph. D. physicists to operate • A cyclotron is significantly smaller (6 m vs. 20 m in diameter) and significantly less costly than the synchrotron. SCENT: AA SC SC for for Medical Medical Applications Applications SCENT: SC able to accelerate H2+ and light ions up to 300 A MeV The magnetic field is produced by twin coils The isochronous fields for H2+ and for light ions fully stripped are very similar (±0.4%) Ions qac→qe Emax A MeV Bρ ρ T× ×m RF* MHz Isource nA Iextr. nA Pex W H2 1 2 250 4.883 91 2500 500 125 12C 6 300 4.890 91 2000 100 + 50 * armonich h=4, +without buncher & extraction efficiency 50% Range in water: Protons 250 MeV 374 mm Carbon 300 A MeV 174 mm Whyis isitituseful useful to to get get 300 300AMev AMevCarbon CarbonIons? Ions? Why AIRO Report on Hadrontherapy states that in Italy more than 3600 patients are elegible for carbon ions treatment. In the framework of SCENT we defined some pathologies taking clinical advantages from the availability of 300 AMeV Carbon Ions: Base of skull and Brain tumors NSCLT Spinal Cord tumors Soft Tissue Sarcoma SC(EN)T Max. Energy for Proton, 6Li, C Sectors a Superconducting Cyclotron for Therapy (250) 300 AMeV 4 Rpole 132 cm Bo 3.07 T <Bmax> 4.22 T Spiral angle (73°) 80° Hill gap (50) 30 mm Valley gap (105) 90 cm RF frequency (93)97 MHz Outer Diameter 5100 mm Weight ≈ 420 tons 6Li @ 300 AMeV 339 mm, 100% of patients 12C @ 300 AMeV,Max. depth 174mm, 74% of targets Distribution of maximum depths in HIMAC treatments patients 1750, N° targets 6323 SC(EN)T E. D. inside RF DEE, width= 34°, Electric Field 92 kV/cm Proton Beam Extracted by stripper @ 250 Mev Carbon beam extracted be E.D. @ 300A MeV sala medici sala medici pr epar. sala occhio s ala 3 w.c. w.c. w.c. segreteria segreteria sala attesa accompagnatori sala attesa accompagnatori sala medici archivio sala attes a pazienti w.c. w.c. sala attes a pazienti w.c. sala medici sala medici prepar. sala occhio sala 3 w.c. w.c. w.c. archivio sala attesa pazienti w.c. w.c. segreteria sala attesa accompagnatori sala attesa accompagnatori segreteria sala medici sala medici sala medici pr epar. sala occhio s ala 3 archivio sala medici w.c. sala attesa pazienti archivio prepar. sala occhio sala 3 sala medici Catania Project at Cannizzaro Hospital Funded in the specific line “COMBATING CANCER” INFN: LNS & Turin sect. WP4 Medical Applications and QA Definition That’s all, folks LNS Thank You for Your Attention !!!