Proton Therapy in the Pediatric Population

Jeffrey Buchsbaum, MD, PhD, AMAssociate Professor, IU School of Medicine Departments of Radiation

Oncology, Pediatrics, and Neurological SurgeryRadiation Oncologist, IU Health Proton Therapy Center

AAMD Meeting in Indianapolis

April 13, 2013

Disclosure Slide

The speaker is salaried and is not being paid to speak and has no conflicts of interest.

The speaker is a DABR and is licensed in Indiana, Ohio, Pennsylvania, Florida, and Tennessee.

Standard CME disclosure forms have been filed with IU Health.

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The Conclusions

Protons are better than traditional radiation for children for almost all types of cancer (likely also often better for adults) the dosimetry is different

Protons are not available everywhere because of cost (to build the facilities ~ $150+ M)

IU has perhaps the worlds finest proton beam, not all protons are the same

Dosimetric issues are critical in the optimal treatment of children using proton therapy

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Thoughts on Pediatric Cancer

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Title: "Connectivity of a Cognitive Computer Based on the Macaque Brain"Credit: Emmett McQuinn, Theodore M. Wong, Pallab Datta, Myron D. Flickner, RaghavendraSingh, Steven K. Esser, Rathinakumar Appuswamy, William P. Risk, and Dharmendra S.Modha; IBM Research - Almaden

Pediatric Radiation Oncologists

Total COG Radoncs: 342

Full Members: 68

Those treating over 50 a year:

Numbers

About 12,000 under 21 will be diagnosed this year with cancer in the United States

3,000 will not win their fight

About 5% of pediatric radiation cases will get proton therapy

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Trends: 2010 to 2011 Change

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PPF

Proton Patterns of Care in the USA

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PPF

The Three Largest Centers in 2011

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Pediatric Radiation History

The Classic Parts of Cancer Care

Surgery

Radiation

Chemotherapy

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Where did radiation therapy come from?

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1895 1920s 1950s to today

First MV Linear Accelerator: RB

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This is Gordon Isaacs, the first patient treated with the linear accelerator (radiation therapy) for retinoblastoma in 1957.

Gordon's right eye was removed January 11, 1957, because the cancer had spread. His left eye, however, had only a localized tumor that prompted Henry Kaplan to try to treat it with the electron beam.

Gordon is now living in the East Bay, and his vision in the left eye is normal.

(photo/text: NCI)

The Problem: Pediatric Cancer

Rare

Access (disparity/education)

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The Childrens Oncology Group: The National View on Proton Therapy

All CNS protocols allow protons.

National Q/C is required.

Hypotheses are being tested

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Trends From 1973 to 2008

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International Journal of Radiation Oncology * Biology * Physics 2013; 85:e151-e155

Trends From 1973 to 2008

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International Journal of Radiation Oncology * Biology * Physics 2013; 85:e151-e155

Protons: Why? How?

Why? The Science in the Open

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Figure by Mark Filipak. This was adapted from Figure 1 of "Proton beam therapy" by W P Levin, H Kooy, J S Loeffler, and T F DeLaney, British Journal of Cancer (2005) 93, 849854 downloaded by me from http://www.nature.com/bjc/journal/v93/n8/abs/6602754a.html

How: IU Health Proton Therapy Center

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What does this mean to a patient?

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Old Ideas in a New Format

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What is needed

Standard goals of pediatric radiation therapy Immobilization Anatomic considerations Experience Protocols

Team Good anesthesia (50% need it in this

population)

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Anesthesia

Our local team is exceptional.

Our published data show our safety rate is the highest in the literature with our event rate being 0.07%.

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Medical and Surgical Support

Riley is a COG site.

IU Health Bloomington has a top level ED and can handle any acute issue either in-house or via life-flight.

We see proton appropriate pediatric patients from all over the world.

Local pediatricians help our families get past normal illnesses of childhood and assist us on any number of issues.

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IU CSI Board: Patent Pending

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Plugging

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Other Issues (in preparation for papers)

Beam arrangement

RBE concerns

Toxicity differences from photons

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Some Nice Cases to View

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Case #1 Medulloblastoma (CSI) Disease can be in multiple locations in the

spine and brain so we use craniospinal target

Patients can be very young

Overlap of dose can be lethal, so anesthesia is used

Considered the most complex thing we do in radiation oncology

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Supine CSI with Protons at IUHPTC

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Secondary Cancer Risk

Protons: 5-7% lifetime

X-rays: 93% lifetime

(MDACC model, published 2013)

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Case #2 Pelvic Osteosarcoma

8yof with pelvic osteosarcoma after having had prior neuroblastoma in the same region when an infant about 5 years earlier.

Spacer use via some Bloomington Hospital work that is unique (and recently published).

Currently (3 years later) NED in the pelvis but with MDS from (presumably) all the chemotherapy. Doing well now after transplant for the MDS.

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Pelvic proton therapy with a spacer

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Case #3 - Retinoblastoma

Bilateral, but limited to the eyes only

Not chemoresponsive in this case

Good vision in both eyes however

History suggests that RB patients have extremely high late cancer ratesperhaps 30-40% rate for radiated tissue (normal is 10-15%)

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Bilateral Retinoblastoma

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Case #4 Desmoid of the Back17yof with a desmoid tumor s/p recurrence

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Case #5 Craniopharyngioma

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Case #6 Hodgkins

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Case #6 Hodgkins

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Case #6 Hodgkins

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Case #6 Hodgkins

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Case #6 Ewings Sarcoma (Askins)

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Case #7 Germinoma

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Case #7 Germinoma

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The End

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