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Proton therapy comparative planning

 
Background

Radiotherapy plays an important part in the management of cancer in Australia, with half of all cancer patients requiring radiotherapy as part of their disease management. This is most commonly delivered with X-Rays, which have been used therapeutically since the late 19th century. X-ray beams are effective in delivering high doses to the tumour cells they target, but unfortunately also give some of the dose to all healthy tissues in their path.

In the 1950s, proton beams emerged as a new option for radiotherapy. Protons are heavy charged particles and have a unique way of depositing their energy. Rather than causing damage through their whole path, they deposit most of their energy at a distinct depth before stopping completely. When protons are used for radiation therapy this effect allows the largest dose to be delivered where it is needed – in the tumour – with minimal dose and damage to the surrounding healthy tissues.

Early clinical use of proton therapy has focused on paediatric tumours, where damage to healthy tissues can result in long term side effects and growth problems, and adult tumours of the head and neck and central nervous system areas, where tumours are adjacent to organs with distinct radiation tolerances. A comparison of radiotherapy treatment plans created using an X-ray volumetric arc therapy (VMAT) technique and intensity modulated proton therapy (IMPT) technique for a paediatric tumour of the brainstem is shown in Figure 1. The reduction of dose delivered to healthy tissues made possible with proton therapy is demonstrated.

Radiotherapy Treatment Plans Created With Impt And Vmat

Figure 1. Radiotherapy treatment plans created with IMPT(Left) and VMAT (Right). The significant lack of blue in the anterior region of the IMPT plan signifies a much lower exposure of dose to non-target structures, sparing key optic and cognitive structures.

RAH project

While proton therapy has experienced expansion in the United States, Europe and Eastern Asia in the past two decades, there is no clinical facility operating in the Southern Hemisphere. RANZCR has endorsed that particle therapy must be available to patients in Australia and New Zealand. Construction of the Australian Bragg Centre for Proton Therapy and Research commenced in Adelaide in June 2020 and marks the first proton therapy cancer treatment facility in Australia. The $500 million facility is expected to treat its first patients approximately 18 months following the completion of building construction which is scheduled for late 2023. It is estimated that 600-700 patients could be treated at the facility each year—with around half of these expected to be children and young adults. The centre’s development means patients will no longer need to travel overseas to access proton therapy.

At this point in time patients who will benefit from proton therapy have to travel overseas to gain access. Funding for Proton Therapy overseas is available through the Australian Medical Treatment Overseas Programme (MTOP), following referral from the RANZCR Particle Therapy Referral Committee. Comparative planning of proton and photon treatment will help ensure that the referral decision is evidence based and objective and is a pre-requisite for all funding applications.

The Royal Adelaide Hospital (RAH) team have been working on proton planning with multiple treatment planning systems since 2014, whilst gaining international experience through training and collaboration with experts in the field. The team is happy to be able to offer a national comparative planning service to assist in the decision making and referral of patients overseas for proton therapy treatment.

Aims
  1. Produce photon and proton plans for comparative purposes, for patients where a clinical benefit may be predicted from protons.
  2. Inform the decision making process for referral of patients overseas for proton therapy.
  3. Provide evidence to support the application for government funding for overseas treatment.
  4. Build proton planning experience among RAH team and collect local comparative data.
Planning process

For all comparative planning enquiries, referrals or requests please contact the RAH comparative planning team via email.

Please ensure all data entry fields on the referral form are completed.

Once a request for the Comparative Planning service has been received, the RAH comparative planning team will make contact with the referrer with instructions for the data transfer process.

  • A copy of the Comparative Planning Referral form will be sent via email
  • A Share File secure data transfer link will also be included in this email

In order to complete the referral process, referring departments are requested to compile the following for transfer to the RAH team:

  • Completed Referral Form
  • Copies of any diagnostic imaging, pathology and surgical reports
  • Copies of any relevant correspondence and patient histories
  • Radiotherapy planning CT data set (or any diagnostic CT dataset that will be used for plan generation)
  • Structure set associated with the planning CT data set
    • Including all OARs and target volumes
    • Please ensure all structures are labelled clearly for straightforward interpretation by the RAH team
  • Any diagnostic imaging datasets used to guide target delineation (i.e. MRI, PET)
  • Any registration files associated with the fusion of the planning CT and any diagnostic datasets
  • Any dose and plan files relating to any treatment plans the referring department would like the RAH to use in their comparative planning work
Secure data transfer process
  • Ensure all required files for transfer are located in one location to make the transfer process more simple
    • All files should be in DICOM format prior to transfer (i.e. files should have filename extension of .dcm)
    • CT = CT file
    • MR = MRI file
    • PE = PET file
    • RS = Structure set file
    • RP = Plan file
    • RD = Dose file
    • REG = Registration file
  • Click on the link provided by the RAH team
    • This should open a web browser (if this does not work, try copying the link and pasting the link into a different web browser)
  • Open the folder containing the required files
  • Select all of the files for transfer and drag and drop those files into the web browser
    • N.B. you cannot drop folders into the web browser, only individual files – open the folder and select all the files within the folder before dragging into the web browser
    • Include the Referral form & any other documents in PDF form in this transfer. These documents can also be sent via email if required.
  • Once all files are ready for transfer click Upload
  • Send an email to the RAH team (add email here) to advise that the data transfer has been completed
    • If you have any issues during the transfer process please contact the RAH team for assistance

A multidisciplinary conference call with the referring department is undertaken as part of the quality assurance. The purpose is to discuss the planning aims and objectives.

The SecureFile transfer process uses the same ports as web browsing, so it will not be blocked by local hospital network firewalls.

The standard turnaround time is 2 weeks from receipt of request form and DICOM data. Shorter planning time can be negotiated at initial request if clinically required. To ensure a quick turnaround, we request that all relevant imaging is provided, as well as planning structures from the referring Radiation Oncologist.

The RAH will complete photon and proton plans as per request form or comparison can be made with a photon plan from the referring institution if this is the preferred option.

The Plan comparison will be returned as a PDF via email, with the following:

  • Spreadsheet comparison of dose volume statistics
  • Screenshots of Dosimetry, DVH and accumulated dose images
  • Planning report from Radiation Oncologist

Ethics, ownership of data and intellectual property

Ethics approval for this project has been obtained from the Human Research Ethics Committee of the RAH.

The patients’ original radiotherapy planning data will remain the property of the requesting institution, however the RAH will retain de-identified copies in a database that may be used for research and publication purposes. The referring Radiation Oncologist is responsible for ensuring the patient’s consent.

The intellectual property created during the comparative planning process will be owned by the RAH and the requesting institution according to the relevant policies and/or procedures of these institutions.

Comparative plans are produced by the RAH to help guide clinical decision making by the radiation oncology staff of the referring institution. The proton therapy dosimetry generated is indicative only and the patient may receive a different dose distribution if undergoing proton therapy.

Plans are produced in a research environment and are not to be used for treatment. The RAH accepts no responsibility for clinical decisions or outcomes.

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