All posts by Susanna Conchin

COVID-Free Clinic

In connection with the spread of the new coronavirus (COVID-19) and in the light of the current situation and information, the Proton Therapy Center has adopted several measures and recommendations in order to protect the safety of our patients and staff.

Thanks to these measures we have promptly introduced, we have been able to continue to operate ensuring optimal continuum of cancer care to adult and paediatric patients worldwide during the COVID-19 pandemic.

🤝 It is prohibited to shake hands due to the risk of transmission of the virus.
🤭 Do not touch your face. Use the disinfectant to clean your hands.
🗣️ Cough or sneeze into your elbow, covering your mouth.
🥵 If you have a fever, call us and let us know before coming to the clinic.
😷 Everyone entering the building is required to wear a mask.
🌡️ Upon arrival to the clinic, patients’ temperature is taken.

It is prohibited to shake hands due to the
 risk of transmission of the virus.
Do not touch your eyes and face. 
Use the disinfectant to clean your hands.
Cough or sneeze into your elbow, 
covering your mouth.
If you have a fever, call us and let us know before coming to the clinic.
Everyone entering the building is required to wear a mask.
Upon arrival to the clinic, patients’ temperature is taken.

Starting March 16, 2020, we have introduced a new system which allows employees to keep a safe distance from each other, a strict hygienic entry regime, and higher level of disinfection of the premises. As an extra precaution, doctors work on rotation in two separate shifts minimising the risk to both medical staff and our patients.

Patients need to follow their appointments schedule strictly, so that the centre is never crowded.

Additionally, in order to meet our commitment and at the same time protect everyone at the Proton Therapy Center (patients and staff), it is necessary that all patients coming from abroad undergo COVID-19 testing. Our treatment coordinators will be happy to help you find the closest clinic to your home.

Patients Coming From Abroad

The first step is to assess suitability for proton irradiation, which you can do remotely from the comfort of your home. This assessment is free and it only takes a few business days.

Should you be suitable for treatment at our facility, we can offer you a remote consultation with one of our oncologists to discuss treatment in greater detail.

Should you decide to go ahead with treatment at our facility, we will provide you with an official document which will allow you to travel.

Although airway transportation is limited, there are some flights coming to Prague. Alternatively, it is possible to reach us by car.

Should none of the options above be suitable for you, we cooperate with Meditrans ambulance service which can transport patients to Prague from anywhere in Europe and UK. Should this be your preferred option, our treatment coordinators will be happy to arrange it for you.

We hope you will appreciate and support our efforts. Only with mutual cooperation the therapy will be safe for you, other patients, and the Proton Therapy Center employees.

We are delighted to say, thanks to the favourable epidemiological conditions in the Czech Republic, the situation will soon return to normal.

We will be happy to provide you with more detailed information. Please do not hesitate to contact us.

Study Shows Proton Therapy Improves Overall Survival in Patients with Chordoma and Chondrosarcoma

Chordomas and chondrosarcomas are difficult to manage using conventional cancer treatment methods. Areas of the body frequently affected by this type of cancer include the spine, skull, pelvis, hip, and shoulder.

Effective treatment of these tumours using surgical resection is not usually achievable due to neurovascular involvement. As a result, recurrence of the tumour when surgery is used in isolation poses a significant risk for both chordomas and chondrosarcomas. Due to the low risk of metastasis and relative chemoresistance, the use of definitive radiotherapy or perioperative radiotherapy is very important in maintaining local control.

Previous research has shown proton therapy to be beneficial in treating these types of tumours. Using protons, health professionals are able to treat chordoma and chondrosarcoma with higher doses of radiation due to the increased accuracy of proton therapy.

A 2019 study published in the journal ‘Cancer’ entitled: The role of dose escalation and proton therapy in perioperative or definitive treatment of chondrosarcoma and chordoma has shown that proton therapy improves overall survival for those with these forms of cancer.

This study analysed a total of 863 patients with chondrosarcoma and 715 patients with chordoma treated with proton or conventional radiation therapy. The primary endpoint of overall survival (OS) was evaluated, and clinical features, including age, sex, grade, clinical stage, and Charlson‐Deyo comorbidity index, were compared.

This study found that for chondrosarcoma, a high radiation dose of proton therapy was associated with improved OS at 5 years.

For chordoma, proton therapy was associated with improved OS at 5 years and a high dose for chordoma was significant for improved OS.

The authors concluded that in the largest retrospective series to date, dose escalation and proton radiotherapy were associated with improved overall survival in patients with chondrosarcoma and chordoma. Evidence continues to accumulate in support of improved outcomes with high‐dose proton therapy in the treatment of chordoma and chondrosarcoma with acceptable toxicity.

If you or a loved one are suffering with chordoma or chondrosarcoma, the Prague Proton Therapy Center oncologists are available for consultation.

Associated Resources:

DEGRO. Stellungnahme zur Strahlentherapie mit Protonen in Deutschland Juni 2015.

T. F. DeLaney, N. J. Liebsch, F. X. Pedlow et al., “Phase II study of high-dose photon/proton radiotherapy in the management of spine sarcomas,” International Journal of Radiation Oncology∗Biology∗Physics, vol. 74, no. 3, pp. 732–739, 2009.

E. B. Holliday, H. S. Mitra, J. S. Somerson et al., “Postoperative proton therapy for chordomas and chondrosarcomas of the spine: adjuvant versus salvage radiation therapy,” Spine, vol. 40, no. 8, pp. 544–549, 2015.

B. Rombi, T.F. DeLaney, S.M. MacDonald, et al. “Proton radiotherapy for pediatric Ewing’s sarcoma: initial clinical outcomes” Int J Radiat Oncol Biol Phys, 82 (2012), pp. 1142-1148

Prostate Cancer Studies

Extreme hypofractionated proton radiotherapy for prostate cancer using pencil beam scanning: Dosimetry, acute toxicity and preliminary results
https://www.ncbi.nlm.nih.gov/pubmed/31486267

Quality of life and toxicity from passively scattered and spot-scanning proton beam therapy for localized prostate cancer
http://www.ncbi.nlm.nih.gov/pubmed/24139077

Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate
http://www.ncbi.nlm.nih.gov/pubmed/20124169

Comparison of high-dose proton radiotherapy and brachytherapy in localized prostate cancer: a case-matched analysis
http://www.ncbi.nlm.nih.gov/pubmed/21470787

Dose-volume comparison of proton therapy and intensity-modulated radiotherapy for prostate cancer
http://www.ncbi.nlm.nih.gov/pubmed/17904306

Early outcomes from three prospective trials of image-guided proton therapy for prostate cancer
http://www.ncbi.nlm.nih.gov/pubmed/21093164

Erectile function, incontinence, and other quality of life outcomes following proton therapy for prostate cancer in men 60 years old and younger
http://www.ncbi.nlm.nih.gov/pubmed/22253020

Five-Year Outcomes from 3 Prospective Trials of Image-Guided Proton Therapy for Prostate Cancer
http://www.redjournal.org/article/S0360-3016(13)03310-5/abstract

Hypo-fractionated passively scattered proton radiotherapy for low-and intermediate-risk prostate cancer is not associated with post-treatment testosterone suppression
http://www.ncbi.nlm.nih.gov/pubmed/23477360

Long-term quality of life outcome after proton beam monotherapy for localized prostate cancer
http://www.ncbi.nlm.nih.gov/pubmed/21621343

Management of complications of prostate cancer treatment
http://www.ncbi.nlm.nih.gov/pubmed/18502900

Patient-reported long-term outcomes after conventional and high-dose combined proton and photon radiation for early prostate cancer
http://www.ncbi.nlm.nih.gov/pubmed/20233822

Urinary functional outcomes and toxicity five years after proton therapy for low-and intermediate-risk prostate cancer: results of two prospective trials
http://www.ncbi.nlm.nih.gov/pubmed/23477359

Long-term Efficacy and Toxicity of Hypofractionated Salvage Radiation Therapy for Biochemically Recurrent Prostate Cancer
https://www.redjournal.org/article/S0360-3016(15)01755-1/fulltext

Prague Proton Therapy Center Study Shows Proton Therapy Greatly Reduces the Risk of Side Effects Compared with Conventional Radiotherapy

Patients who undergo conventional radiotherapy treatment are exposed to a far greater amount of unnecessary radiation to healthy tissue, in comparison to patients undergoing proton therapy treatment. As a more targeted treatment modality, proton therapy spares a greater quantity of healthy tissue. Treatment plans using proton radiotherapy reduce radiation exposure by 50% compared to conventional radiotherapy treatment.

The Prague Proton Therapy Center Medical Team published their treatment plan comparison findings for patients with advanced prostate carcinoma in the December 2019 edition of Radiation Protection Dosimetry, entitled ‘Low dose bath from IMPT vs IMXT for the pelvic area when treating advanced prostate cancer‘. This study compared treatment plans for patients undergoing Intensity Modulated Proton Therapy (IMPT) with patients undergoing conventional Intensity Modulated X-Ray Therapy (IMXT) for advanced prostate cancer.

Existing studies have already shown that cancer patients receiving proton therapy experience a significantly lower risk of unnecessary side-effects from radiation therapy in comparison to patients receiving traditional photon radiation. Cure rates remain however essentially identical between the two groups.

The results of this study confirm these existing findings, demonstrating the clear superiority of proton therapy over conventional x-ray (photon) radiotherapy. Proton therapy treatment was shown to halve the amount of dangerous radiation exposure to the abdominal cavity and rectum (50% less radiation to healthy tissue). This thereby reduces the risk of side-effects and offers patients a greater chance at maintaining a higher quality of life during and after their cancer treatment.

Proton therapy was also shown to use a significantly lower number of treatment fields for the same target dose coverage, when compared to conventional photon (x-ray) treatment techniques. The authors state that proton therapy treatment ‘irradiates just half of the tissue volume with a low dose compared to conventional x-ray treatments without compromise in target volume coverage’. In this way the risk of secondary cancer development and other possible complications is also greatly reduced.

Optimum proton dose distributions can be achieved with intensity modulated proton therapy. Currently, proton therapy is undergoing transitions that will move it into the mainstream of cancer treatment. For example, proton therapy is now reimbursed, there has been rapid development in proton therapy technology, and many new options are available for equipment, facility configuration, and financing.

Proton therapy might be an appropriate treatment option for you or a loved one that is suffering from cancer. Please contact us if you would like to find out more.

Associated Resources:

B. Glimelius, U. Isacsson, E. Blomquist, E. Grusell, B. Jung, and A. Montelius, “ Potential gains using high‐energy protons for therapy of malignant tumors,” Acta Oncol. 10.1080/028418699431537 38, 137– 145 (1999)

B. Glimelius et al., “ Number of patients potentially eligible for proton therapy,” Acta Oncol. 10.1080/02841860500361049 44, 836– 849 (2005)

R. Flynn, D. Barbee, T. Mackie, and R. Jeraj, “ Comparison of intensity modulated x‐ray therapy and intensity modulated proton therapy for selective subvolume boosting: A phantom study,” Phys. Med. Biol. 10.1088/0031‐9155/52/20/001 52, 6073– 6091 (2007)

L. Haisen, H. Romeijn, H. Fox, J. Palta, and J. Dempsey, “ A computational implementation and comparison of several intensity modulated proton therapy treatment planning algorithms,” Med. Phys. 10.1118/1.2836954 35, 1103– 1112 (2008)

A. J. Lomax et al., “ A treatment planning inter‐comparison of protons and intensity‐modulated photon therapy,” Radiother. Oncol. 10.1016/S0167‐8140(99)00036‐5 51, 257– 271 (1999)

Luca’s Craniopharyngioma Story

Luca is a young boy who was diagnosed with craniopharyngioma. His mother, Mariana, has decided to share their journey.

When I found out about Luca’s craniopharyngioma I started researching all the possible treatment opinions both in my country, Romania, and abroad. At that time, there were three neurosurgeons in America with whom I corresponded and they recommended surgical removal of the tumor followed by proton therapy. It was the first time I heard of such therapy.

Two surgeries were performed in the hospitals in Bucharest and the tumor was completely removed along with the pituitary gland. The doctors hoped that everything would go well and we would not need proton therapy. Shortly after, however, we realised that it was not the case and the doctors gave us two options: we could repeat the surgeries whenever the tumor recurred or we could do proton therapy. We chose proton therapy. We had to decide which of the centres in Europe to go to. A Romanian student who was studying in Prague recommended us the Proton Therapy Center (PTC). He recommended PTC as it is one of the newest centres, therefore with the latest technology, but also with a lot of experience and well trained doctors. Thus Prague became our home for two months. We didn’t imagine that treating such a disease could go so smoothly!

Before going to Prague for Luca’s treatment, I had never left Romania. I didn’t know any foreign language but Susanna, the treatment coordinator who was assigned to our case, helped us with all the details. Susanna found the accommodation most suitable for us, she informed us in detail and patiently explained each step of the process, always making sure we understood. Moreover, the PTC organised for a car to pick us up at the airport as well as take us back to the airport at the end of Luca’s treatment.

Luca loves the Proton Therapy Center and the people here. He didn’t experience any side effects, hair loss, or nausea. In addition Luca began to love walking because of the many beautiful places Prague has to offer!

Easter Traditions in the Czech Republic

Easter, known as Velikonoce, in the Czech Republic is a celebration of the arrival of spring. Celebrated on Monday, not Sunday, Easter has many unusual traditions that may vary depending on the region. Some of the most popular Easter traditions and symbols include:

Kraslice (Easter eggs) – girls decorate Easter eggs using a variety of techniques. The eggs will be given to the boys on Easter Monday.

Pomlázka (Pussywillow) – it is thought that by whipping someone with pussywillow twigs you bring them health and youth. Boys will collect twigs and braid them to create whips, which will then be used to whip the girls while reciting a short Easter poem. The girls reward the boys with candy, a painted egg or a ribbon to tie around his whip.

Lamb shaped cake – a staple of any Czech Easter meal. Other dishes that are common for Easter include potato salad, gingerbread and in many households, slivovice which is homemade plum brandy.

The colour red – symbolising the energy of new life, which is what spring brings. Many people will dye their eggs red or wear a red outfit during Easter.

The warning off of Judas – during holy week, for three days, boys will travel around their village shaking wooden rattles to scare off Judas. On Saturday, the third day, the boys will make their rounds to houses where they will make noise with their rattles until they are given a present.

Proton Beam Therapy vs Intensity-Modulated Radiation Therapy for Locally Advanced Oesophageal Cancer

Radiation therapy has become an important component in the curative management of oesophageal cancer worldwide. Since most of the oesophageal cancers seen in the Western hemisphere (i.e., Europe and the United States) are located in the mid- to distal-oesophageal locations, heart and lungs invariably receive significant radiation doses. Much of the normal tissue exposure could be reduced with the utilisation of advanced radiation technologies such as intensity modulated proton therapy. Proton beam therapy (PBT) provides the ability to reduce normal tissue exposure (compared to conventional treatments) due to its lack of exit dose, which enables medical teams to provide clinically meaningful benefits to oesophageal cancer patients.

A Randomized Trial of Proton Beam Therapy Versus Intensity-Modulated Radiation Therapy for Locally Advanced oesophageal Cancer found that proton beam therapy was associated with less toxicity and similar progression-free survival vs intensity-modulated radiation therapy in patients with locally advanced oesophageal cancer.

In the trial, 145 patients were randomly assigned to proton beam therapy or intensity-modulated radiation therapy. Median follow-up was 44.1 months. The posterior mean total toxicity burden was 2.3 times higher in the intensity-modulated radiation therapy group vs the proton beam therapy group. The mean postoperative complication score was 7.6 times higher in the intensity-modulated radiation therapy group vs the proton beam therapy group (2.5, 95% highest posterior density interval = 0.3–5.2). At 3 years, overall survival was 51.2% vs 50.8% and median overall survival was 42.1 months vs 73.6 months.

The investigators concluded: “For locally advanced oesophageal cancer, proton beam therapy reduced the risk and severity of adverse events compared with intensity-modulated radiation therapy while maintaining similar progression-free survival.”

Treating oesophageal cancer with an adequate dose of radiation can be difficult because of the close proximity of the oesophagus to critical structures, such as the heart, lungs and spinal cord. Because protons deposit their highest dose of radiation at the tumor or area of concern, proton therapy can be an excellent choice for treating patients with oesophageal cancer.

Proton therapy offers patients and their doctors a unique option for effectively treating oesophageal cancer while reducing damage to other critical organs and tissues. The Prague Proton Therapy Center is one of the few centres of its kind treating oesophageal cancer with proton technology.

Latest proton therapy study shows hypofractionated proton therapy as safe and effective for patients with low-risk prostate cancer

A study published in August 2019 in the International Journal of Particle Therapy by Dr. Slater and his team, highlights the results of their latest phase I/II hypofractionated proton therapy study at Loma Linda University Hospital.

Prostate cancer is the most commonly diagnosed cancer in men, and many of these patients have low-risk, early disease. Prostate cancer at these stages remains highly treatable with local control rates over 90% and very low rates of late morbidity commonly reported for a variety of treatment modalities. The focus then turns to the avoidance of unnecessary negative treatment-related side effects that can occur, particularly through the use of conventional treatments such as surgery and x-ray (conventional) radiotherapy.

Proton radiation therapy has demonstrated itself to be an excellent option for low-risk prostate cancer as it delivers high control rates with very little toxicity. Proton beam thereby enhances the physician’s opportunity to minimise risks for the patient.

Hypofractionation is the process of delivering higher doses of radiation per fraction, but using fewer daily fractions. Doctors and physicists at Loma Linda University have successfully used hypofractionated proton therapy for several diseases, including cancers of the breast, lung, and liver. In each instance, control and survival rates have been maintained and unwelcome side effects have not increased. This experience prompted the medical team at Loma Linda to investigate hypofractionation for prostate cancer.

The purpose of the study was to determine whether a hypofractionated proton radiotherapy regimen can control early-stage prostate cancer while maintaining low rates of side effects similar to results obtained using standard-fraction proton radiotherapy.

A cohort of 146 patients with low-risk prostate cancer (Gleason score 7, prostate-specific antigen 10, tumor stage of T1–T2a) received 20 fractions of proton therapy (3.0 Gy per fraction over 4 weeks). Patients were evaluated at least weekly during treatment, at which time documentation of treatment tolerance and acute reactions was obtained. Follow-up visits were conducted every 3 months for the first 1 years, every 6 months for the next 3 years, then annually. Follow-up visits consisted of history and physical examination, PSA measurements, and evaluation of toxicity.

The 3-year biochemical progression-free survival rate was 99.3%, and the 5-year biochemical progression-free survival was 97.9%.

In conclusion, this study showed that hypofractionated proton therapy (60 Gy in 20 fractions) was safe and effective for patients with low-risk prostate cancer. A prospective multi-institutional randomised study is currently being conducted to confirm these results.

Sources:

Kil WJ, Nichols RC Jr, Hoppe BS, Morris CG, Marcus RB Jr, Mendenhall W, Mendenhall NP, Li Z, Costa JA, Williams CR, Henderson RH. Hypofractionated passively scattered proton radiotherapy for low- and intermediate-risk prostate cancer is not associated with post-treatment testosterone suppression. Acta Oncol. 2013;52:492–7

Mendenhall NP, Hoppe BS, Nichols RC, Mendenhall WM, Morris CG, Li Z, Su Z, Williams CR, Costa J, Henderson RH. Five-year outcomes from 3 prospective trials of image-guided proton therapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2014;88:596–602

Mendenhall NP, Li Z, Hoppe BS, Marcus RB Jr, Mendenhall WM, Nichols RC, Morris CG, Williams CR, Costa J, Henderson R. Early outcomes from three prospective trials of image-guided proton therapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2012;82:213–21

Shipley WU, Verhey LJ, Munzenrider JE, Suit HD, Urie MM, McManus PL, Young RH, Shipley JW, Zietman AL, Biggs PJ, Heney NM, Goitein M. Advanced prostate cancer: the results of a randomized comparative trial of high dose irradiation boosting with conformal protons compared with conventional dose irradiation using photons alone. Int J Radiat Oncol Biol Phys. 1995;32:3–12

Slater JD, Rossi CJ Jr, Yonemoto LT, Bush DA, Jabola BR, Levy RP, Grove RI, Preston W, Slater JM. Proton therapy for prostate cancer: the initial Loma Linda University experience. Int J Radiat Oncol Biol Phys. 2004;59:348–52

Slater JD, Rossi CJ Jr, Yonemoto LT, Reyes-Molyneux NJ, Bush DA, Antoine JE, Miller DW, Teichman SL, Slater JM. Conformal proton therapy for early-stage prostate cancer. Urology. 1999;53:978–84

Slater JD, Yonemoto LT, Rossi CJ Jr, Reyes-Molyneux NJ, Bush DA, Antoine JE, Loredo LN, Schulte RW, Teichman SL, Slater JM. Conformal proton therapy for prostate carcinoma. Int J Radiat Oncol Biol Phys. 1998;42:299–304

Slater JM, Slater JD, Kang JI, et al. Hypofractionated Proton Therapy in Early Prostate Cancer: Results of a Phase I/II Trial at Loma Linda University. Int J Part Ther. 2019;6(1):1–9. doi:10.14338/IJPT-19-00057

Zietman AL, Bae K, Slater JD, Shipley WU, Efstathiou JA, Coen JJ, Bush DA, Lunt M, Spiegel DY, Skowronski R, Jabola BR, Rossi CJ. Randomized trial comparing conventional-dose with high-dose conformal radiation therapy in early-stage adenocarcinoma of the prostate: long-term results from Proton Radiation Oncology Group/American College of Radiology 95-09. J Clin Oncol. 2010;28:1106–11

Proton Therapy for Central Nervous System Leukaemia

The guidelines issued by the International Lymphoma Radiation Oncology Group (ILROG) open up new opportunities for the use of proton radiotherapy in leukaemia.

ILROG’s recommendations newly apply also to patients with initial involvement of CNS (positive finding in the cerebrospinal fluid) or patients with a relapsed disease related to CNS who are planned for allogeneic transplantation or have CNS involvement and do not respond to chemotherapy or biological treatment. If patients diagnosed with leukaemia have infiltration of their central nervous system (CNS) or extramedullary involvement (myelosarcoma) and their attending hematologist-oncologist recommends radiotherapy, proton therapy is a suitable choice. This is confirmed both by the newly updated recommendations of the international expert group ILROG, and dosimetric comparisons of the existing forms of available radiotherapy.

In such cases, proton radiotherapy has substantial benefits when compared with other forms of radiotherapy. These include no radiation strain on organs in front of vertebral bodies and minimal systemic toxicity (reduced occurrence of nausea, vomiting, diarrhoea). Proton radiotherapy is suitable for highly pre-treated patients (patients after a few rounds of chemotherapy) with necessary reduction of the dose to which the lungs, intestinal villi, heart and other organs are exposed.

Interview with Dr Kateřina Dědečková on the possibilities of treatment of hematologic diseases with proton radiotherapy

According to the latest recommendations of the International Lymphoma Radiation Oncology Group (ILROG), radiotherapy is also suitable for some patients diagnosed with leukaemia. Which patients specifically?

ILROG is very active in raising awareness on the benefits of radiation in the treatment of hematological malignancies, i.e. blood tumours. Over the past few years, ILROG has issued recommendations for the use of radiation in most haematologic cancers such as lymphomas, leukemias, myelosarcomas, myelomas, and others. For leukemias, in particular patients with central nervous system (CNS) involvement, it is now recommended to use radiation more frequently and to a greater extent.

Why is it now advisable to irradiate the central nervous system (CNS) also in patients with leukaemia?

The CNS (i.e. brain and spinal cord) is separated from the bloodstream by a safety barrier, called blood–brain barrier (BBB), which prevents materials from the blood from entering the brain. Thus, some molecules, including drugs, reach the CNS with limited or no effect. For this reason, in some cases, the CNS may be a source of disease recurrence because part of the cells escape the effects of chemotherapy or biological therapy, leading to a re-spread of cancer cells in the body.

What benefits do patients have from using proton radiotherapy?

Due to the limited possibilities of systemic treatment, irradiation of the entire CNS area is advantageous. This consists of the irradiation of the brain, spinal cord, spaces where cerebrospinal fluid circulates, and craniospinal axis. The aim is also to get to the hard-to-reach leukaemia cells, as well as those that are no longer sensitive to chemotherapy or biological therapy.

Patients who benefit the most from proton radiotherapy are the ones who, despite intensive systemic treatment, have a positive finding of leukemic cells in the cerebrospinal fluid, a positive cerebrospinal fluid at the time of diagnosis, or leukemic lesions in the brain or spinal cord. Also, patients who are at risk of involvement of the central nervous system future.

Therefore, according to the new recommendations, these patients should preferably be irradiated in the whole area of ​​the craniospinal axis.

Is radiotherapy commonly indicated in these patients or is it a new recommendation?

Previously, because of the high toxicity, it was preferable to irradiate only the skull area. However, thanks to the use of proton radiotherapy instead of classical radiation, it is possible to reduce the adverse effects of treatment that previously impaired quality of life, such as nausea, vomiting, fatigue, swallowing pain, and aphthae in the oral cavity. Therefore, radiotherapy has not been commonly used in these patients and, if so, less extensive exposure has been used, mainly because of concerns about toxicity associated with older exposure techniques, as I have mentioned. Irradiation of the CNS as a risk area has been found to improve the outlook for cure in risk patients. According to the new ILROG recommendation, groups of patients have already been identified who will benefit from the inclusion of craniospinal axis irradiation in their treatment plan.

How does the treatment work?

The patient is placed in supine position with their arms along the body, while the head is fixed with a special thermoplastic mask. A CT scan is done over the entire irradiation range, i.e. the entire head and spine to the coccyx. These CT images then show the areas that are the target of radiation and also the areas that we want to protect from radiation, called organs at risk (OAR). Then, the doctors and physicists collaborate to carefully calculate the irradiation plan. This plan is then checked multiple times, as well as directly in the gantry to confirm its accuracy. Then, the actual treatment begins. Leukaemia is typically treated in 9 to 12 sessions (fractions), applied to the entire craniospinal axis. In some patients, we also irradiate the riskiest areas, such as apparent tumor lesions, up to a total of 15-18 fractions. Irradiation takes place every weekday and may be associated with mild swallowing difficulties, fatigue and a decrease in the number of blood cells.

Is there a difference if a patient is irradiated with photon or proton techniques?

Yes, the difference is that when using proton radiotherapy, the patient is less exposed to radiation. There is less irradiation to the organs in front of the tumor, minimal irradiation to lungs, heart, oesophagus, intestinal loops, kidneys, liver, and bladder, which significantly reduces the possibility of late toxicity of these organs. The patient also better tolerates irradiation of the craniospinal axis.

Do you have any recent experience with this form of treatment? If so, how did the patients tolerate the treatment?

At the Proton Therapy Center in Prague we already have experience with this irradiation technique for hematological malignancies, although there has been a relatively small number of patients (around 10 so far). Our experience so far has so far been very positive, both in terms of toxicity and preliminary treatment outcomes. In some of these patients, radiotherapy was the last treatment option and even here we managed to successfully destroy CNS tumor cells. From our point of view this is a very promising method of treatment, but a longer follow-up of patients and evaluation of a larger group of patients will be required.

Dr Kateřina Dědečková

In 1998-2001 Dr Dědečková worked at the radiotherapy department of the District Hospital in Jičín. Then, from 2001 to 20017, she worked at the Institute of Radiation Oncology of the University Hospital Na Bulovce. In 2009 Dr Dědečková gained specialised competence in the field of radiation oncology. Since 2012, she has been working as a radiation oncologist at the Proton Therapy Center in Prague. Since 2019, Dr Dědečková also leads the interdisciplinary Center of Excellence for Proton Radiotherapy of Malignant Lymphomas at the Proton Center in Prague.

Dr Dědečková specialises in radiation treatment of malignant lymphomas and other hematological tumours, urological tumours and head and neck tumours. She has participated in international clinical trials with independent quality control of radiotherapy (GHSG, ESTRO Equal, QARC) in the treatment of malignant lymphomas and head and neck tumours. Dr Dědečková is a member of the Council of the International Lymphoma Radiation Oncology Group (ILROG) and a member of the Lymphoma Sub-Committee of the Particle Therapy Co-Operative Group (PTCOG). Dr Dědečková publishes professional medical press and lectures at congresses, both domestically and internationally. Dr Dědečková is co-author of the “Diagnostic and Treatment Guidelines in Patients with Malignant Lymphoma” of the Lymphoma Cooperative Group (chapter on lymphoma radiotherapy). Dr Dědečková deals with new techniques of lymphoma radiotherapy, such as proton radiotherapy of mediastinal lymphomas using the pencil beam scanning technique in maximum inhalation.

New study shows proton therapy more effective than conventional radiotherapy in the treatment of intrahepatic cholangiocarcinoma (ICC)

In a recent study by the Massachusetts General Hospital Department of Radiation Oncology, the use of proton therapy for intrahepatic cholangiocarcinoma (ICC) was shown to more effectively control the cancer and improve the chances of survival – particularly in comparison to conventional (photon) radiotherapy.

Cholangiocarcinoma is a cancer that develops in the cells within the bile ducts; both inside and outside the liver. The terms cholangiocarinoma and bile duct cancer are often used to refer to the same condition. This condition occurs slightly more often in males than females and usually affects people who are between 50-70 years old. Signs and symptoms of intrahepatic cholangiocarcinoma include jaundice, abdominal pain, fever, weight loss, weakness and itching. Treatment options may include surgery (when possible) to remove the bile duct and parts of the liver, chemotherapy and radiation.

In certain cases cholangiocarcinoma is an unresectable form of cancer. Unresectable cancer is defined as a cancer or tumour that cannot be removed completely through surgery. In these cases, radiotherapy and chemotherapy offer the best chances of survival.

The aim of this study was to evaluate outcomes for patients with unresectable intrahepatic cholangiocarcinoma (ICC) treated with hypofractionated proton or photon radiation therapy.

66 patients with unresectable intrahepatic cholangiocarcinoma were treated with hypofractionated proton (32 patients) or photon (34 patients) radiation therapy. Median radiotherapy (RT) dose was 58.05 Gy, all delivered in 15 daily fractions. On multivariate analysis for overall survival (OS), compared with photon RT, there was a trend towards improved survival with proton RT (HR 0.50; p = 0.05).

Median follow-up times from diagnosis and RT start were 21 months and 14 months, respectively. In total, five patients (7.6%) developed local failure. The 2-year outcomes were 84% local control (LC) and 58% OS. Among the 51 patients treated with definitive intent, the 2-year LC rate was 93% and the OS rate was 62%.

The study concluded that hypofractionated radiation therapy yields high rates of local control and is an effective modality to optimize biliary control for unresectable/locally recurrent ICC.

At the ESMO World Congress on Gastrointestinal Cancer 2019, it was identified that high dose radiotherapy in unresectable ICC should be considered as a viable treatment option, in combination with systemic therapy.

This study adds to the growing body of evidence suggesting proton beam therapy as a safe and effective treatment for patients with unresectable ICC. It is proposed therefore, that – pending further research – proton therapy be utilised as a curative treatment for ICC.

Sources:

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