Proton Therapy in the Pediatric Population

Jeffrey Buchsbaum, MD, PhD, AM

Associate Professor, IU School of Medicine Departments of Radiation
Oncology, Pediatrics, and Neurological Surgery
Radiation 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
4
Title: "Connectivity of a Cognitive Computer Based
on the Macaque Brain"
Credit: Emmett McQuinn, Theodore M. Wong, Pallab
Datta, Myron D. Flickner, Raghavendra
Singh, 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: <6
Proton sites doing over 100/year: 4
90% of proton pediatric care is done in
4 sites. We currently have the highest
percentage.
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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/jou
rnal/v93/n8/abs/6602754a.ht
ml
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 Back
17yof 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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