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Radiotherapy for Childhood Cancers 1

Radiotherapy for Childhood

Cancers: Photons & Protons

Dr Henry C. Mandeville

Consultant Clinical Oncologist

Children’s and Young People’s Unit

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Outline of talk

• Introduction to Childhood Cancers

• The role and challenges of radiotherapy

• Different types of radiotherapy

• Future developments

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How common are childhood cancers? - proportion of all cancer diagnoses in UK

A. 10%

B. 5%

C. 2%

D. 1%

E. <1%

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10% 5% 2% 1%<1%

13%

28%

15%

21%23%

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Childhood Cancers: Key Facts

• Very Rare:

• <1% of all Cancer diagnoses

• Increasing incidence

• 11% increase since early 1990s

• Approximately 40–50% of children with cancer receive

radiotherapy as part of their initial treatment

• Improving Outcomes

Radiotherapy for Childhood Cancers 5

NRCT report 2012; http://www.ncin.org.uk/publications/

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What is the commonest type of childhood solid tumour?

A. Soft tissue tumours (sarcomas)

B. Upper abdominal tumours e.g. Renal/ Suprarenal

C. Leukaemia

D. Brain tumours

E. Bone tumours

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Soft tis

sue tu

mours

(sar..

.

Upper abdom

inal t

umour..

.

Leukaem

ia

Brain

tum

ours

Bone tum

ours

13% 13%

3%10%

63%

Incidence of Childhood Cancers

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Children’s Cancer Incidence

http://www.cancerresearchuk.org

Incidence of Childhood Cancers

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Children’s Cancer Incidence

http://www.cancerresearchuk.org

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Paediatric Radiotherapy What makes it different?

Immobilisation

– Play specialists

– Anaesthesia

Normal Tissues

– Growth and development

– Late effects

Tumour types

- Pathology

- Radiobiology

Service organisation

- Multiprofessional working

- Shared care

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Some things have changed!

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http://news.stanford.edu/news/2007/april18/med-accelerator-041807.html

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Preparing children for radiotherapy

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Challenges for Immobilisation

General Anaesthesia

Play specialists

Tattoos

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Mould Room

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CT Planning & Radiotherapy Treatment

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End of treatment gift and certificate

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Patient environment

• Age appropriate environment + ability for family to be

present

• Schooling/health education

• Psychological support

• Financial support

• Peer support/mentoring

17 Radiotherapy for Childhood Cancers

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Survivorship

– 80% of children with cancer will survive ≥5 years

– Approx 73% develop treatment- related complications

– Children grow and develop

– Radiotherapy can interfere with that

– Management of chronic consequences of treatment

Newhauser WD and Durante M, Nature Reviews Cancer 11, 438-448 (June 2011)

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Radiotherapy for Childhood Cancers 19

Current & future photon RT techniques

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Modern Paediatric Radiotherapy!

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Malignant Disease and Its Treatment By Radium:

Volume 4. Sir Stanford Cade.

London. 1952

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Target definition - Where is the tumour?

- Extent of disease?

- Microscopic extension

- Regional lymph nodes

- Metastatic disease

21

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Target definition - Where was the tumour?

― Post surgical resection

― Neuroblastoma

― Wilm’s Tumour

― Difficulties with Fusion

― Pre + post op imaging

― Change in contour

― Respiratory motion

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Posterior fossa radiotherapy

3D CRT IMRT VMAT

Lee YK et al. ISPNO 2012

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Stereotactic Radiotherapy

– Delivery of high radiation dose to small volume

– Small number of fractions (1 to 5)

– Different techniques can be used

– VMAT, Cyberknife, Gammaknife

– Possible paediatric indications:

– Re-irradiation for local relapse

– Oligometastatic disease

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Magnetic Resonance-Guided RT

Prototype developed in Utrecht- partnership with Elekta & Phillips

International Consortium- RM/ ICR first machine in UK

Exploitable Advantages:

Enhanced soft tissue contrast of MRI

Real-time imaging/ treatment adaptation

No radiation dose and non-invasive

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Current In-Room

Cone Beam CT

Future In-Room

MRI

Elekta Unity- MR Linac

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Radiotherapy for Childhood Cancers 26

Protons

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Why protons?

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Yock T et al. IJROBP 2005

Which children & young people are currently funded for Protons in the UK?

A. None

B. Base of skull and spinal tumours only

C. All brain tumours & sarcomas

D. Specified brain tumours, sarcomas & rare tumours <age 16y

E. Specified brain tumours, sarcomas & rare tumours < age 25y

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None

Base o

f sku

ll and sp

inal .

..

All bra

in tu

mours

& sa

r...

Specifie

d bra

in tu

mours

,...

Specifie

d bra

in tu

mours

,...

27%

3%

16%

49%

5%

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Indications for Children(<16y) & TYA (16-24y)

General Criteria

• A clear indication for radiotherapy and defined as curable

• Expectation of 40% 5 year survival

• No comorbidities likely to limit life expectancy to <5 years

• No evidence of distant metastasis, with the exception of:

• Rhabdomyosarcoma

• Ewing’s Sarcoma

• where limited and only lung disease

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Radiotherapy for Childhood Cancers 31

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Producing the Proton Beam

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Protons in the UK… 2018- 2020

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NHS sites:

University College Hospital, London

The Christie Hospital, Manchester

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Conclusions

– Radiotherapy remains an important component in the treatment of tumours in TYA and children

– Needs to be done in specialised centres with experienced multiprofessional team

– Balance cure with potential late effects

– Dosimetric benefits with Image guided IMRT and Stereotactic RT treatments

– Potential long term benefits with Proton beam radiotherapy

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Acknowledgements

The ICR/ RMH Joint Department of Physics

Greg Smyth

Prof Uwe Oeflke

The Royal Marsden Radiotherapy Department

Dr Frank Saran

Sarah Helyer

Claire Riddell

Advanced Photons 36