Indications

Especially those patients, whose tumors can’t be treated adequately with conventional radiation therapy or whose tumors are located near radio-sensitive organs or tissues, will immensely profit from ion beam therapy. Particle therapy is generally considered to be established for many indications and is routinely used in numerous cases. More than 170,000 patients worldwide have already been treated with particle therapy - with excellent results. Our knowledge of the types of diseases and patient groups that benefit from particle therapy is constantly increasing.

Below you can find a list of the indications that are currently predominantly treated at MedAustron. As our range of treatments is constantly expanding, we kindly ask you to contact us for any further clarification.

Note: Ion beam therapy and particle therapy are used synonymously in the descriptions.

    CNS & Skull Base Tumors

    The physical advantage of protons over photons is particularly pronounced in the area of the CNS and the base of the skull, since tumors in this area are often anatomically close to critical, radiation-sensitive normal tissue structures such as the brain stem or optical apparatus. Therapy-related long-term consequences can be neurological and/or cognitive changes as well as the induction of secondary malignancies. These chronic side effects can result in a reduction in the quality of life of the individual patient.

    The advantage of proton radiation over photon radiation in the case of low-grade tumours in the CNS and skull base area is that a significant reduction in side effects can be achieved with the same dose and tumour control.

    Symptomatic low-grade menigeomas are a frequent indication for proton therapy. Patients with low-grade menigeomas have a good prognosis and the maintenance of Health-related Quality of Life has top priority. Proton irradiation takes place both in the primary therapy approach (e.g. opticus sheath menigeomas) and in progressive residual tumors without further neurosurgical intervention. The aim is to stop the growth and thus counteract possible tumor-related restrictions.

    In the case of low-grade gliomas with a low risk profile, particle irradiation can be considered with a good long-term prognosis, since only low-grade, reversible acute toxicity is observed in the context of proton irradiation and the degree of neuro-cognitive changes is also significantly reduced. In Acusticus neurinomas, fractionated proton irradiation can be performed as an alternative to Gamma Knife or stereotactic LINAC-based irradiation. Especially in large neurinomas close to the brain stem, fractionated proton irradiation can reduce possible toxicity at the cranial nerves and the brain stem.

    In the area of the skull base and the CNS, such as pituitary macroadenomas, craniopharyngeomas, germinomas or paragangliomas, proton irradiation in the sense of a significantly reduced side effect profile is beneficial if it is indicated in the primary or adjuvant setting.

    For other aggressive or radioresistant skull base tumors such as solitary fibrous tumors / hemangioperizytomas, higher grade menigeomas, paranasal carcinomas with infiltration of the skull base and esthesioneuroblastoma / olfactory neuroblastoma, promising data for high dose proton irradiation are available in the literature. However, this form of therapy has not yet been established and has yet to be confirmed in dose escalation studies. This also applies to other rare tumors such as those in the base of the skull.

    For aggressive CNS tumors, such as high grade gliomas, the published data are not yet convincing. However, so far only conventional therapy approaches with protons have been published. In the future, MedAustron will offer protocols for these tumours, which will be applied in clinical studies.

    For re-irradiations in the second potentially curative approach, especially for field edge relapses, particle therapy may be beneficial due to a steeper dose decrease.

     

    Tumors of the Upper Gastrointestinal Tract

    As a part of the oncological multimodal-treatment, radiotherapy plays an important role in selected cases of pancreatic carcinoma. The benefits are: reduction of the tumor size and making the disease operable, consolidation of the general oncological treatment after the surgery and as a definitive oncological treatment in combination with chemotherapy. Particle therapy in comparison to photon therapy can apply much higher dose without compromising the sensitive organs at risk such as small intestine- (especially duodenum), stomach, liver, spleen and kidneys.

    Therefore, particle therapy can be used in case of preoperative, postoperative and definitive irradiation with potential advantages over photon radiotherapy. Moreover, re-irradiation of isolated local recurrence from pancreas cancer can be performed with particle therapy even though it is rarely considered an indication in photons radiotherapy. On the other hand treatment with particle therapy of disseminated disease (metastatic patients) offers no advantages over photons as the symptomatic effect requires lower doses and can be achieved equally well by both modalities.

    Never the less it can be very challenging to deliver the dose given the tissue inhomogeneity that is constantly changing due to the motion of the intestine and the organ motion caused by breathing.

    There are many different modalities (surgery, trans catheter arterial embolization=TAE, radiofrequency ablation=RFA, hepatic transplantation) that can successfully treat hepatocellular cancer and particle therapy provides an excellent alternative in selected cases providing an astonishing local control (more than 80% after 5 years) with low toxicity. Particle therapy is safe, effective and noninvasive making this modality suitable for treating less favorable cases, such as elderly patients and those with large tumors, portal vein thrombosis and poor liver function. The choice of fractionation schedule should be based on the proximity of the dose limiting structures such as GI tract and porta hepatis.

     

    Head & Neck Tumors

    Tumors in the head and neck area represent a major challenge for treatment: due to the proximity of many organs, surgery with the prospect of total removal of the tumor, particularly in the area of the nasal cavity, paranasal sinuses and nasopharynx, is often not possible. At the same time, these tumors are considered radiation-resistant (i.e. a comparatively high dose is required to heal the tumor).

    Therefore, radiotherapy is often the only curative option for the patient. However, many radiation-sensitive organs (such as the brain stem, the spinal cord, the optic nerves and the optic nerve intersection, the salivary glands, etc.) are located in the immediate vicinity of the tumors. Therefore, with conventional radiation, there is a possibility that the tolerance doses of these organs (i.e. the doses where the risk of serious damage to the organ is not considered possible) may be exceeded during treatment.

    If this is the case, these organs may suffer serious permanent damage. The consequences of this damage would be serious, such as paralysis if the spinal cord is damaged, loss of vision if the visual system is damaged, etc.

    Proton therapy is used for tumors of the nasal cavity and paranasal sinuses as well as of the nasopharynx in order to reduce the dose in the area of the radiation-sensitive organs in the vicinity of the tumor as much as possible and thus to reduce the risk of serious late side effects.

    Proton therapy is also used for tumors of the salivary glands, as these are considered to be extremely resistant to radiation and an extremely high dose is required for successful treatment of the tumor. Also in this case the healthy organs and tissues in the environment are better protected by the more advantageous dose distribution of the protons.

    Reducing the risk of serious late side effects means a better quality of life for patients with significantly less serious symptoms that could affect everyday life.

     

    Pediatric Tumors

    Proton therapy is indicated in the majority of all solid tumors of infancy, childhood and adolescence where radiotherapy is part of therapy management. Proton therapy can significantly reduce unnecessary radiation of surrounding organs and tissues that are still in the developmental phase, or in some cases completely avoid it. Examples of indications (no complete list): brain tumors (=CNS tumors), e.g. ependymomas, craniopharyngiomas, gliomas of the optical nerve / optical chiasm, medulloblastomas, aggressive neuroepithelial tumors, and others. Skull base tumors, e.g. chordomas, chondrosarcomas. Benign and malignant tumors of the head neck. Rhabdomyosarcomas of the entire body, tumors involving the orbit, retinoblastomas, Hodgkin's lymphomas, Ewing's sarcomas, osteogenic sarcomas, etc...

    Infants who require sedation or anesthesia for treatment are also treated at MedAustron. MedAustron collaborates with the Pediatric Neuro-Oncology and Neurosurgery Department of the University of Vienna (General Hospital, AKH) as well as with the St. Anna Children's Hospital in Vienna to ensure continuity of pediatric oncology care and integration with disease-dependent, necessary chemotherapy or other systemic therapy.

    In the case of selective tumors, the treatment will only be available in the future, due to the current further development of the technical functionality (details on request).

     

    Pelvic Tumors

    Various pelvic tumors are reasonable and recommended indications for ion beam radiotherapy: In sacral chordomas, soft tissue sarcomas and osteogenic sarcomas, where high total irradiation doses are mandatory for the local tumor control, minimizing doses to the healthy surrounding tissues and organs (e.g. nervous system, gastrointestinal system, genitourinary system) is a major issue: With the favorable dose distribution of ion beams (protons and carbon ions) a better sparing of these organs can be realized. This translates directly into a probability reduction of severe side effects. .

    Local recurrent tumors (e.g. colorectal cancer, gynecological malignancies) with or without pre-irradiation are typical indications for ion therapy. In this situations patients benefit exceedingly from the physical-technical characteristics of ion beams with regard to severe side effect limitation. .

    Taking all tumors irradiated with proton therapy into account, non-metastatic prostate cancer of all risk groups is the most frequently treated entity within the last 25 to 30 years. In every country, where proton therapy centers are available, prostate cancer patients are treated with protons. At MedAustron Ion Therapy Center we can offer proton radiotherapy for prostate cancer based on the existing international long-term evidence. .

    Due to technical limitations, we currently cannot offer treatments of very large volumes (e.g. high risk prostate cancer with an indication for irradiation of the lymphatic pathways), because of an unreasonable overlong daily irradiation time for the individual patients. However, with the ongoing technical improvement these treatments will also be possible in the near future. .

    In summary there is a large variety of different pelvic tumors, which benefit from a proton or carbon ion therapy. .

    Please feel free to contact us for further evaluation and for detailed information according to your individual situation.

     

    Re-Irradiation

    Re-irradiation is the delivery of radiotherapy in an already irradiated area. Particle therapy can significantly reduce the volume of non-target tissues that receive intermediate and low doses. This benefit can be more or less important in first line treatments but becomes much more relevant for re-irradiation because the previously irradiated organs “remember” the dose they have received and are therefore at higher risk of radiation induced toxicity. Particle therapy is an ideal tool for re-irradiation.

    Re-irradiation can be necessary either because a previously irradiated tumor was not entirely killed by the first course of radiotherapy, and therefore starts to grow again (local progression or local recurrence), or because a new different tumor develops in an area that was previously irradiated for a completely different disease. The first case typically occurs from several months to a few years after the first radiotherapy, the second can happen also decades after the first course of radiation. The new tumor can be in the middle of the previously treated area (in field re-irradiation) or at the border of the previously treated area (marginal re-irradiation). Irradiation of a new tumor in a different organ is not considered as a re-irradiation (e.g. a patient that received radiotherapy for a breast cancer and must subsequently be irradiated in the skull for a meningioma is not considered a re-irradiation case).

    Re-irradiation can be done either with curative or palliative intent. “Curative” means that a high dose of radiotherapy is applied in order to achieve a long lasting control of both the macroscopic and microscopic component of the tumor. “Palliative” means that a lower dose is delivered with the purpose of controlling the symptoms (such as pain, bleeding, compression of vessels or neural structures or stenosis of hollow organs) and or prevent the risks (pathologic bone fracture) caused by the tumor. In some cases, as for example when multiple distant lesions are present and not controlled, a curative re-irradiation may be not beneficial for a patient, whereas a palliative re-irradiation may significantly improve quality of life.

    The first course of radiotherapy always produces damages that may or may not be clinically evident. A previously irradiated organ can tolerate a lower dose in the second course of radiotherapy because part of its tolerance has been already exhausted. Re-irradiation is therefore intrinsically more dangerous. Particle therapy can significantly reduce this intrinsically higher risk. Cases that could be treated with photons radiotherapy can be treated with particles with a lower risk of toxicity. Some patient that would not be considered a candidate for photons re-irradiation at all can be offered re-irradiation with particle therapy.

    Particle therapy is successfully used for re-irradiation in the brain, skull base , head and neck area, spinal column retroperitoneal area, sacral bone, pelvic wall and para-aortic region. Re-irradiation with particle therapy can also be performed for isolated local recurrences of liver and pancreas tumors.

    The decision to offer or not re-irradiation must be based on a careful and personalized evaluation of the risk benefit ratio. The dose already received by organs at risk, the time interval between the first and second radiotherapy, the presence of concomitant risk factors such as other therapies (chemotherapy and surgery), local pathological process (infections or necrosis), other diseases ( inflammatory bowel disease, connective tissue diseases) must be considered. The intent of the treatment is also relevant: if the purpose of re-irradiation is strictly limited to symptom control and a progressing systemic disease is present the theoretical advantage of particle therapy does not translate into any real benefit for the patient.

    It is of paramount importance to reconstruct with the highest possible precision the dose delivered in the previous radiotherapy. This requires a direct contact with the institution that performed the treatment and the transfer of the previous radiotherapy plan. Unfortunately re-irradiation, even with particle therapy, has always a higher risk of toxicity. The patient attitude and the patient’s set of values must be carefully consider. Ultimately, the decision to offer or not re-irradiation must be made together with the patient and depends significantly upon his will to accept the risk of severe side effects. It is important to consider that the expected toxicity of re-irradiation must be compared with the expected toxicity of treatment abstention and tumor progression. In cases candidate to re-irradiation it is often necessary to evaluate several other treatment possibility such as surgery, chemotherapy, systemic therapy with new drugs or enrollment in experimental trials. To explore all these possibilities it may be necessary to obtain a second opinion from other specialists.

    In summary, particle therapy can be offered for re-irradiation but indication must be necessarily based upon a personalized evaluation of each case.

     

    Sarcomas

    Sarcomas are an inhomogeneous group of malignant diseases of the musculoskeletal system. They account for 1% of malignancies in adults and 12% of malignancies in children. The majority of sarcomas (80%) originate in soft tissue (connective tissue, vascular structures, fatty tissue), the rest originate in bone structures (e.g. osteosarcoma or Ewing sarcoma).

    Sarcomas can occur throughout the axial skeleton, i.e. along the spine, retroperitoneally, in the pelvis and extremities. The radicality of the surgery is crucial for local control and prognosis. However, this cannot be done to the same extent in different body locations, such as paraspinal, in the pelvis or in the retroperitoneum. There are many sensitive organs such as the spinal cord, bone, intestines, kidneys, bladder, lungs and heart.

    Radiotherapy is the only therapeutic option for inoperable or incompletely resected tumors. With conventional photon radiation therapy techniques, the necessary doses can only be applied to a limited extent due to the expected toxicity. The possibility of using ion therapy improves the protection of healthy tissue. This allows higher doses to be applied, which considerably improves local control rates, especially in the case of tumors that have not undergone radical surgery. Thus, local control rates of 70-80 % can be achieved.

     

    Skull Base Tumors

    In the skull base region the following tumor entities are regarded as a possible indication to proton therapy:

    Several cases of meningioma, chordoma, chondrosarcoma, neurinoma, and schwannoma. Moreover rare tumors like craniopharyngioma, esthesioneuroblastoma etc. and specific cases of pituitary gland adenoma can possibly be treated with ion beam therapy. Selected cases of head and neck tumors which infiltrate the scull base region might also be treated with proton therapy.

    In all cases histology is one parameter in order to decide on proton therapy. Other factors like operational options, general health status, previous treatments etc. have to be taken into consideration in order to finally decide on the indication to proton therapy.

    See also the section on „CNS“.

     

    Paraspinal Tumors

    Primary paraspinal tumors are rare diseases (3% of all spinal lesions, 10% of all soft tissue sarcomas). Some of the tumors most frequently found in this location are osteosarcoma, Ewing’s sarcoma, chordoma and chondrosarcoma; less common ones include: neurinomas, malignant peripheral nerve sheath tumors (MPNST), glomus tumors and others. Their treatment requires complex surgical procedures, often involving removal of whole vertebral bodies and neighboring soft tissues with extensive stabilizing implants used. All inoperable primary paraspinal tumors and many of the resected ones require radiation therapy. However, it can be difficult to deliver with photons due to proximity to critical organs like the spinal cord, nerve roots and many others depending on which level of the spine is affected (esophagus and larynx for cervical, heart and lungs for thoracic, bowels for lumbosacral tumors, etc.).

    Proton therapy can help deliver the required high doses of radiation often exceeding 70 Gy without compromising the dose to the tumor and at the same time keeping the nearby healthy tissues within the safe limits. This is possible due to special physical properties of the proton beam which only deposits its maximum dose at a precisely programmed depth. As the whole radiation treatment comprises of thousands of such single beams, the effect is that the critical organs near the spine and even the spinal cord itself get almost cut out from the high dose delivered to the tumor. Depending on the tumor type, proton therapy can be used with combination of surgery (before, after or both before & after) as well as a standalone treatment.

    The result for the patient is a controlled tumor (for chordoma and chondrosarcoma, the success rate after proton treatment described in the literature well exceeds 90%) and long survival without a severe functional deficit of the critical organs affected. Paraspinal tumors in children can be also treated with proton therapy, with an additional gain of likely less risk to develop a secondary, radiation-induced tumor in the future.

     

     

     

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