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 Naši Vrhunski Liječnici,
Tehnologija i Rezultati

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"Proton therapy allows patients to live a quality life after treatment",

says MUDr. Kateřina Dědečková, chief physician for the treatment of malignant lymphomas

The Highest Chance
 of Being Cured

Proton Therapy for Malignant Lymphomas

Malignant lymphomas are a condition which very often affect people at a young age. A high percentage of patients is cured after cancer treatment; therefore, it is desirable to prevent any treatment-related side effects to the maximum extent.

Our procedures for treating this diagnosis have been included in official treatment protocols and have been adopted by other centers around the world. These procedures enable us to considerably reduce the radiation exposure to important organs, such as the heart and lungs, and thus significantly eliminate the risk of the development of cardiac and pulmonary diseases (such as cardiac infarction, heart rhythm abnormalities, pulmonary fibrosis, etc.). Proton therapy is also able to substantially eliminate exposure of the spinal cord to radiation, thus reducing the risk of it being damaged.

 

Benefits of Proton Therapy

  • Reduction in doses of undesirable radiation to which the cardiac muscle is exposed, and lower risk of the occurrence of late radiotherapy consequences such as valvular defects, ischaemic heart disease and arrhythmia.
  • Reduction in doses to the pulmonary tissue with a lower risk of post-radiation pulmonary fibrosis (tissue thickening) and pulmonary inflammation.
  • Reduction in doses to the spinal cord with a lower risk of occurrence of post-radiation myelopathy (motor and sensory deficits).
  • Reduction in doses to the mammary glands with a lower risk of occurrence of secondary tumors of the mammary gland.

More than 14 studies have confirmed that proton radiotherapy significantly reduces exposure of most high-risk organs to radiation. Proton radiotherapy is most beneficial for patients who need irradiation of the mediastinum. Proton radiotherapy should be considered for selected patients whose radiation doses would expose their high-risk organs (heart, lungs, spinal cord, etc.) to radiation, where excess radiation could thus be considerably decreased.

At the Proton Therapy Center in Prague, over 220 lymphoma patients have been irradiated so far, of which 90% have undergone irradiation of the mediastinum. PTC physicians and physicists are engaged in preparing domestic and foreign recommendations for the treatment of lymphomas. 

Thanks to the concentrated experience with proton therapy of lymphomas, the Center of Excellence for Radiotherapy of Malignant Lymphomas was set up in 2019. It aims to further promote specialised scientific cooperation in the Czech Republic and abroad, rationalise proton radiotherapy indications for patients with lymphomas, inform experts, physicians, and last but not least, patients and the general public about therapeutic options and results.

Proton Therapy Reduces Damage to the Heart

Cardiotoxicity

One substantial reason to choose proton radiotherapy would be radiation induced heart disease (RIHD). Heart disease caused by radiation is one of the most serious and best-documented very late effects of radiation. Therefore, in the treatment of malignant lymphomas, when radiation is recommended, experts seek to minimize the radiation dose to the heart. Thanks to the proton beam, we are able to significantly reduce the risk of the occurrence of cardiac infarction, cardiac complaints, or the risk of development of pulmonary fibrosis.

Proton Therapy for the Treatment of Central Nervous System Leukemia

Central nervous system leukemia is one of the newest diagnoses suitable for proton therapy. Irradiation of the craniospinal axis is beneficial especially for those patients who have, despite intensive systemic treatment, a positive finding of leukemic cells in the cerebrospinal fluid. It is also suitable for patients who had a positive finding in the cerebrospinal fluid already at the time of diagnosis and those who are high-risk in terms of damage to the central nervous system in the future. It is also beneficial for patients with tumorous leukemic lesions in the brain or spinal cord. The objective is to get rid of leukemic cells in these hard-to-access areas, including those that are not sensitive to chemotherapy or biological treatment.

Proton Therapy in Combination with Controlled Breathing

As respiratory movements may impair the correct and precise execution of proton irradiation, in the treatment of lymphoma we also use the method of controlled breathing. This is achieved by the Dyn'R. The Dyn'R is a special spirometer which not only serves to monitor the breath, as is the case with a conventional spirometer, but also allows triggering of the radiation (radiation beam) only when inhaled to a certain breath level. The controlled breathing method has been chosen because it is important that the irradiated area of the body and the target volume of the tumor are irradiated the same way during each fraction. Since this irradiated volume varies depending on breathing, we need to ensure that the patient's body is always in the same position. This is best done by holding their breath at a certain level. To determine this level, the patient first undergoes a controlled breathing training (Dyn'R training).

The controlled breathing training is done lying down on the back after being connected to the spirometer, using an antibacterial filter and a mouthpiece. The patient´s nose is held closed by a pin so that all exhaled air flows through their mouth. The patient also wears special glasses, where they see the breathing pattern to follow. The training is conducted by an experienced assistant and the patient has nothing to worry about.

 

dynr.png (511 KB)

Zašto Protonoski
centar u Pragu?

Surađujemo s više osiguravajućih kuća

Cijena liječenja je individualna i ovisi o protokolu liječenja i/ili odabranom broju frakcija koje odrede naši liječnici. Na temelju pregleda vaše medicinske dokumentacije možemo potvrditi koji je vjerojatan broj frakcija koje ćete trebati, te stoga i trošak liječenja, još prije nego dođete u Prag na savjetovanje. Procjena je besplatna.

Centar za protonsku terapiju je sklopio ugovor s češkim osiguravajućim kućama, a surađujemo i sa slovačkim i stranim osiguravajućim društvima. Ako ste građanin EU a i vaše osiguravajuće društvo nije jedan od naših ugovornih partnera, mi ćemo vam pomoći u pregovorima za ishođenje odobrenja vašeg liječenja kod nas u skladu s trenutačno mjerodavnim zakonima i propisima.

  • Jeste li pokriveni češkim zdravstvenim osiguranjem?
    Zakonski, protonska terapija je pokrivena javnim zdravstvenim osiguranjem i na nju ima pravo svaka osoba koja ima važeće češko zdravstveno osiguranje. Vaš koordinator liječenja će pripremiti zahtjev i poslati ga na odobrenje vašem osiguravajućem društvu. Taj postupak prosječno traje dva do tri tjedna, ali u slučaju većine bolesnika osiguravajuće društvo odluku donese brže.
  • Jeste li iz Europe?
    Mi prihvaćamo S2 (ili E112) plaćanje prema kojem možete imati pravo na državno plaćeno liječenje u drugoj državi Europskog gospodarskog prostora ili Švicarskoj.
  • Živite li u Ujedinjenom Kraljevstvu?
    Surađujemo s nekoliko privatnih zdravstvenih osiguranja, uključujući BUPA i WPA. S tim partnerskim odnosima, bolesnici koji dolaze u Centar za protonsku terapiju imaju mogućnost povrata troškova.

Ako nijedna od gorenavedenih opcija ne odgovara vašoj situaciji, molimo vas da nam se javite, a mi ćemo vam vrlo rado pomoći pronaći postupak koji je vama najprikladniji. Možete nam pisati e-poštom na patient@ptc.cz ili nas nazvati na +420 222 999 000.

Suvremena dijagnostika ne samo za naše bolesnike

Preglede nudimo ne samo našim onkološkim bolesnicima, već i ostalim pacijentima koji imaju uputnice za preglede iz drugih ustanova. Centar za protonsku terapiju u Pragu nudi vam dijagnostičke preglede magnetske rezonancije (MR) i pozitronske emisijske tomografije u kombinaciji s računalnom tomografijom (PET/CT) s kratkim vremenima čekanja. 

 

Naručit se možete na telefonskom broju  +420 222 999 070 ili na e-mailu zadanky@ptc.cz

Contact
 Us

You can send your medical documentation for assessment of the suitability of proton therapy by e-mail to patient@ptc.cz. Alternatively, you can contact our treatment coordinators, who are prepared to answer all of your questions related to proton therapy. You can call them at +420 222 999 000.

The only thing YOU need to do is to come to US in time. WE are ready to help you.

How To Choose
 The Optimal Treatment

In order to select the optimal treatment, it is imperative to get comprehensive and comprehensible information.

Ask not only about the most advanced treatment methods but also treatment-related side effects. They may significantly affect the quality of your life during and after treatment.

Our physicians have many years of experience in radiotherapy. Moreover, they are experienced in both standard (photon) and proton radiation therapy; therefore, they will be able to answer all your questions pertaining to your decision on your treatment.

  • What treatment has my attending physician recommended?
  • Has the physician informed me about the risks and complications associated with currently used treatments?
  • Has the physician informed me about proton therapy?
  • Has the physician informed me about the risks and complications associated with standard radiation methods

Together, we will find a solution and prepare an individual treatment plan for you.

How
 Proton Therapy Works

How Proton Therapy Works

Proton therapy is an effective, accurate and gentle cancer treatment method with minimal side effects. Thanks to the precise targeting of the proton beam directly to the tumor, the occurrence of side effects is significantly reduced. This gives proton therapy patients a chance to enjoy a quality life even after cancer treatment without an increased risk of late toxicity, which can appear several years after irradiation (10, 15 or even 20 years).

Proton Therapy Provides a High Chance of Being Cured

The goal of modern oncological treatment is to ensure the maximum chance of recovery for patients while minimising adverse effects related to the treatment. Currently, this can be achieved by proton therapy. Unlike conventional radiotherapy, which uses photons for tumor cell irradiation and destruction, proton therapy is more advanced and uses protons. These particles give proton therapy its many advantages. The biggest advantage, compared to conventional radiotherapy, is its accuracy and its ability to protect healthy tissues.

The commonly used photon beam goes through the body and emits a significant portion of its energy in the regions in front of and behind the tumor.

Protons have a certain physical property called the Bragg peak, which means they emit significantly lower amounts of energy on their way to the tumor, thus minimising their impact on healthy tissues behind the tumor.

How We Treat You

Few patients are aware of the complexity of the technology hidden below the Proton Therapy Center, which ultimately allows us to treat cancer gently. Protons, the positively charged elementary nuclei of the hydrogen atom, are accelerated in the cyclotron to approximately half the speed of light. This provides them with energy to destroy tumours up to 30 centimetres deep. Then the protons are directed via a strong magnetic field into a very narrow beam and transferred to the tumour with high precision. As protons impact tumour tissue, they release energy, ionise, and damage the DNA of the affected cell. When the protons damage the tumour repeatedly, the cancer cells stop dividing or immediately die.

 

​

 

Pencil Beam Scanning (PBS) marks the exact distribution of the proton beam dose and is currently the absolute peak in proton therapy technology. PBS irradiates the target area with millimeter accuracy with minimal damage to surrounding healthy tissues and organs. With this irradiation method, the thin (pencil) beam is directed to the appropriate point of the target volume by means of a magnetic field. Highly precise control of this magnetic field achieves gradual irradiation of the entire tumor site.

To illustrate how PBS works, imagine the task of colouring in a circle on a piece of paper with a pencil. As you fill in the circle, you will focus on making sure that you do not cross the borders. PBS also focuses on staying within the borders of the area being treated. That is why side effects with proton therapy are minimal.

Why Choose
 Proton Therapy?

Advantages of Proton Therapy over Conventional Radiotherapy

Proton therapy allows us to:

  • apply a sufficient dose to the entire target area and, at the same time, better protect the surrounding healthy tissue;
  • in the head and neck, reduce the undesirable radiation dose to the eye structures, spinal cord, brain stem, and oral cavity;
  • in the chest, reduce the undesirable dose of radiation to the mammary glands, lungs, heart, and spinal cord;
  • in the abdomen and pelvis, reduce the undesirable radiation dose to the intestinal villi, kidneys, liver, ovaries and uterus, urinary bladder, and rectum.

At present, malignant lymphomas are irradiated by photon or proton radiotherapy. The difference rests with the physical properties of individual types of radiation and related behaviour in tissues.

The photon radiation dose produced by the linear accelerator falls off gradually in the tissue. The surrounding healthy tissues are thus more "contaminated" (greater and undesirable irradiation of surrounding healthy tissues).

When protons are used, the radiation dose falls off steeply behind the radiation focus. Proton therapy makes it possible to target the tumor with the radiation dose and, therefore, irradiation of healthy organs and tissue around the tumor (by high, medium, and low radiation doses) is reduced.

 

lymphoma.png (406 KB)

 

Proton radiotherapy represents a very promising and gentle radiotherapy technique for a significant portion of patients with lymphomas (mainly with the mediastinal location of the irradiated volume).

How
 Proton Therapy is Conducted

Malignant lymphomas rank among tumors highly sensitive to radiotherapy. Radiotherapy targets areas with the highest risk of failure (the places of initial tumor development, initially bulky tumors). Irradiation of malignant lymphomas rests in most cases with a reduction in the dose to which the surrounding high-risk organs are exposed. In the long-term, patients are threatened especially by the development of secondary malignancies and cardiovascular diseases after treatment. 

It is essential to carefully consider the choice for irradiation. The need to include radiotherapy in the treatment scheme is confirmed by clinical studies. In the Czech Republic, we follow the recommendations of the Czech Lymphoma Study Group (CLSG), which reflect the latest results of those clinical studies and are updated regularly. When carrying out radiotherapy, we also follow the recommendations of the International Lymphoma Radiation Oncology Group (ILROG).

 

Initial Assessment

In order for our medical team to assess a patient for suitability, we require some medical information from you. Your treatment coordinator will inform you of exactly what information we require. Usually, we will also request to see scans, such as an MRI, CT or PET scan. This information can be requested from the hospital or clinic and is often given to the patient on a CD. We can provide you with login details to upload the CD to our secure server. Alternatively, you can mail it to us.

Any information you already have about your diagnosis and previous treatments is very helpful and it is a good idea to provide us with as much information as possible in your initial enquiry. Your case will then be reviewed by our medical team at the daily indication board meeting. Your treatment coordinator will get back to you with the outcome, or possibly a request for more information if the oncologists require it to make their final decision.

You do not need to travel to Prague for the assessment.

 

Treatment Planning

When you come to Prague for treatment, you will first have a consultation to discuss the side effects and outcomes of treatment in your specific case, as well as the concrete treatment plan. The doctor also explains what to expect during and after the treatment. Finally, all of your questions are answered.

The first stage of treatment involves the diagnostic scans here at the Proton Therapy Center (MRI and/or CT, preparation of the fixation device, etc.). Precise treatment planning is crucial for treatment success. Therefore, a team of clinical physicists and physicians prepares a radiation plan tailored to each patient according to which proton therapy will take place. The irradiation plan also determines from which directions and with what intensity the proton beam will irradiate the tumor. This process is very complex and it typically takes one week to finalise before treatment can commence.

 

k-14996-full.jpg (8.62 MB)

 

The treatment is outpatient, and you come to the Proton Therapy Center for radiation and regular check-ups during treatment. One visit takes about 60 minutes while the radiation is a matter of a few minutes. Prior to each radiation session, we carefully check your position using X-ray scans and carry out certain other checks necessary to commence irradiating. At least once a week, you undergo check-ups with the physician who will go through the treatment progress with you and check your condition.

Individual treatment doses are given each day, Monday to Friday. Treatment cannot be interrupted except for serious health reasons.

 

We Use the Pencil Beam Scanning Technology

Pencil Beam Scanning (PBS) marks the exact distribution of the proton beam dose and is currently the absolute peak in proton therapy technology. PBS irradiates the target area with millimeter accuracy with minimal damage to surrounding healthy tissues and organs.

 

brozura-pbs-obr.png (1.11 MB)

 

The Controlled Breathing Method

As respiratory movements may impair the correct and precise execution of proton irradiation, in the treatment of lymphoma we also use the method of controlled breathing. Patients whose tumor position changes due to respiratory movements are irradiated using a controlled breathing method. For this, we use the Dyn'R.

The controlled breathing method has been chosen because it is important that the irradiated area of the body and the target volume of the tumor are irradiated the same way during each fraction. Since this irradiated volume varies depending on breathing, we need to ensure that the patient's body is always in the same position. This is best done by holding their breath at a certain level. To determine this level, the patient first undergoes a controlled breathing training (Dyn'R training).

The controlled breathing training is done lying down on the back after being connected to the spirometer, using an antibacterial filter and a mouthpiece. The patient´s nose is held closed by a pin so that all exhaled air flows through their mouth. The patient also wears special glasses, where they see the breathing pattern to follow. The training is conducted by an experienced assistant and the patient has nothing to worry about.

 

The treatment is outpatient and, in most cases, lasts from 16 to 25 business days, according to the regime determined by the physician on the basis of the initial assessment and other diagnostic tests.

About
 Malignant Lymphomas

Malignant lymphoma is a general term for cancer of the lymphatic system. Malignant lymphomas refer to tumors that originate from one type of white blood cells – lymphocytes. They are manifested in particular by an increase in the size of the lymph nodes. Malignant lymphoma is divided into two groups: Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL), which represents a significantly more heterogeneous subgroup.

Malignant lymphomas are conditions which very often affect people at a young age. There are approximately 1,800 new cases per year in the Czech Republic. The prognosis of the disease is often very good.

The therapeutic procedure is established by a specialist – hematologist-oncologist. At present, promising treatment of malignant lymphomas is a systemic (whole-body) treatment represented by chemotherapy or biological treatment and/or a combination of both. Radiotherapy serves primarily as a complementary treatment designed to reduce the risk of disease relapse in the originally affected areas, or as a curative treatment before the next planned systemic treatment, for example, in the case of relapsed lymphomas. It is a local treatment limited to a certain location or area of the body.

For this diagnosis, radiotherapy is used for early and moderately advanced stages of Hodgkin’s lymphoma, high-risk non-Hodgkin’s lymphoma (large initial finding, involvement of bones or finding outside the nodes) and in patients with an inadequate therapeutic response to a previous systemic therapy. Combined treatment (systemic treatment + radiotherapy) often means a higher chance of recovery from the lymphoma.

Due to the excellent efficacy of radiotherapy, it is not usually necessary to use radiation doses exceeding the tolerance limits for surrounding healthy tissues. Nonetheless, even lower radiation doses may be potentially harmful, particularly, in the time horizon of ten or more years after oncological therapy. This often occurs without any relation to the acute toxicity of radiotherapy. With a longer period of time elapsed after the completion of cancer therapy, the risk of development of late toxicity rises. Such risks should be considered especially in patients with a very good long-term prognosis. They include, in particular, young patients with Hodgkin’s lymphoma and B-cell non-Hodgkin’s lymphoma with favourable prognosis (mainly the subtypes of diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma). These patients should always be treated with awareness of the long-term risks of cancer treatment.

 

 Adverse Effects Related to Radiation

Irradiation may cause immediate adverse effects. They occur during radiotherapy and maximum up to 6 weeks after its completion.

Possible symptoms of acute radiation toxicity (related to the irradiated area) include:

  • mucosal: aphthae, swallowing difficulties (when irradiating the head and neck);
  • salivary glands: dryness in the mouth (when irradiating the head and neck);
  • skin: redness or even peeling skin in the radiation field;
  • pulmonary: post-radiation inflammation of the lungs (when irradiating the mediastinum). 

Furthermore, in the context of radiotherapy, we can encounter late radiation consequences which may occur even without prior difficulties within an interval of several decades after radiotherapy (most frequently after 10 years or more). In the treatment of lymphomas, it is vital, and physicians exert great effort to minimise such late consequences and the risk of their occurrence. Possible symptoms of late toxicity depending on the location of the irradiated area:

  • cardiac and vascular diseases (myocardial infarction, valvular defects);
  • other malignant tumors (breast cancer, lung cancer, non-Hodgkin’s lymphoma, leukemia);
  • impaired thyroid gland function (decreased activity);
  • involvement of the spinal cord (Lhermitte's syndrome – an electric shock-like sensation in the upper and lower extremities exacerbated by neck flexion);
  • involvement of the musculoskeletal system;
  • involvement of the bone marrow (myelofibrosis).

It is essential to carefully consider the choice for irradiation. The need to include radiotherapy in the treatment scheme is confirmed by clinical studies. In the Czech Republic, we follow the recommendations of the Czech Lymphoma Study Group (CLSG), which reflect the latest results of those clinical studies and are updated regularly. When carrying out radiotherapy, we also follow the recommendations of International Lymphoma Radiation Oncology Group (ILROG).

Proton radiotherapy represents a very promising and gentle radiotherapy technique for a significant portion of patients with lymphomas (mainly with the mediastinal location of the irradiated volume).

 

Patient stories, blogs (in Czech):

https://www.lymfomhelp.cz/projekty/pribehy-pacientu/karolina-o/
https://nas-zivot-s-hodgkinem.webnode.cz/blog/
https://pisujakoozivot.blogspot.com/
http://www.hlavuvzhuru.cz/blog/diagnoza-Hodgkinuv-lymfom

Center Of Excellence
 for Lymphomas

The aim of the Center of Excellence is to deepen the professional and scientific cooperation in the Czech Republic as well as abroad, rationalize indication of proton radiotherapy for lymphoma patients, inform about the possibilities and results of scientific activities and to share results and experience of lymphoma treatment with professionals, doctors of other specialities as well as with patients and the general public.

More than 200 patients with lymphoma diagnosis have been treated at the Prague Proton Therapy Center (PTC), located within Na Bulovce hospital. The very first patient was treated in spring 2013. Since then, a unique group of patients treated with proton radiotherapy using the pencil beam scanning technique has been established.

In April 2015, the PTC started to use a treatment combination with the deep inspiration breath hold (DIBH) method for patients with mediastinal disease. This technology is one of the gentlest radiation options for mediastinal tumours. In some cases, the treatment is further combined with attention to other movements unrelated to breathing, such as major blood vessels pulsation or heart movements (rescanning). These options secure safe irradiation of problematic areas, such as the mediastinum and the upper abdominal area (below liver). Such technologically advanced treatment is offered by only a few proton centres worldwide. Thanks to this experience of ours, we are a member of the international ILROG team that has created consensual recommendations for proton radiotherapy for mediastinal lymphomas in adults.

PTC doctors and physicists cooperate on local and foreign recommendations for lymphoma treatment, they lecture on local and international congresses and take part in clinical studies related to lymphoma radiotherapy, such as analysis of dosimetric and radiobiological models comparing modern technologies of photon radiotherapy with proton radiotherapy.

Counselling for Patients

If the hematooncologist has recommended radiation treatment to you or a loved one, and you would like to consult about the different possibilities of irradiation, please do not hesitate to contact our client service at patient@ptc.cz.

Proton therapy is suitable especially for patients with:

  • mediastinal disease, where the irradiated area (the original disease) is located in the area below the left coronary artery, i.e. below Th7 level;
  • young women with axillar disease, where proton radiotherapy can spare the breast gland and thus reduces the risk of developing a secondary breast carcinoma;
  • highly pre-treated patients (after several types of chemotherapy or bone marrow transplant), who are at a higher risk of developing radiation toxicity (esp. lung, cardiovascular toxicity and bone marrow disease);
  • patients with localized disease which has not responded to systematic treatment (esp. PET positive mediastinal residual) and where the total radiation dose needs to be increased;
  • patients after previous radiotherapy within the same or surrounding area;
  • patients with a pre-existing serious health problem (condition after myocardial infarction, valve defect, lung involvement, etc.) and the need to irradiate this area.

 

Counselling for Professionals

The Center of Excellence provides counselling for relevant specialists. Consultations are provided mostly in situations when radiotherapy indication is considered or to choose an optimal radiation method. The response time is 5 business days.

If you are a doctor and you are interested in counselling services, please contact us at poradna.lymfom@ptc.cz. Please provide a medical report for the case being consulted and send up-to-date images. Consultation is also possible in English.

 

Open Lymphoma Indication Seminar

If you are a doctor and you are interested in consulting a possible indication of a patient with lymphoma, the Center of Excellence offers the opportunity to participate in a multidisciplinary lymphoma indication seminar, which takes place at the PTC once a week. For such participation, prior personal agreement is required electronically or by the telephone number provided. In general, relevant scan image documentation (ePACS available) and epicrisis is required in order to provide a consult of the patient.

For preliminary orientation, we inform you that proton therapy is suitable especially for patients with:

  • mediastinal disease, where the irradiated area (the original disease) is located in the area below the left coronary artery, i.e. below Th7 level;
  • young women with axillar disease, where proton radiotherapy can spare the breast gland and thus reduces the risk of developing a secondary breast carcinoma;
  • highly pre-treated patients (after several types of chemotherapy or bone marrow transplant), who are at a higher risk of developing radiation toxicity (esp. lung, cardiovascular toxicity and bone marrow disease);
  • patients with localized disease which has not responded to systematic treatment (esp. PET positive mediastinal residual) and where the total radiation dose needs to be increased;
  • patients after previous radiotherapy within the same or surrounding area.

Proton radiotherapy cannot be indicated in patients:

  • with pacemakers – absolute contraindication;
  • with metal in the irradiated area.

Additional proton therapy indication for malignant lymphomas:

A major group of patients indicated for RT of lymphoma are patients with a very good long-term prognosis. These patients shall be treated knowing the long-term risks of oncology therapy. These are especially young patients with Hodgkin lymphoma and B-cell non-Hodgkin lymphoma, which has a favourable prognosis (esp. aggressive subtypes of diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma). For these patients, the approach of “limit doses” shall not be used. The RT technique with the least burden shall always be considered. Proton radiotherapy is the most beneficial for the mediastinal area. Currently, a recommendation by the International Lymphoma Radiation Oncology Group (ILROG) for proton radiotherapy for adults with mediastinal lymphoma has been published: Dabaja BS(1), Hoppe BS(2), Plastaras JP(3). PROTON THERAPY FOR ADULTS WITH MEDIASTINAL LYMPHOMAS: THE INTERNATIONAL LYMPHOMA RADIATION ONCOLOGY GROUP (ILROG) GUIDELINES. Blood. 2018 Aug 14. pii: blood-2018-03-837633. Patients with maximum benefits from proton RT have been identified. These are especially patients in the following situations:

  • Mediastinal irradiation, when the irradiated volume (original disease) is in the area below the level of the left coronary artery
  • Young women with axillar disease, where proton radiotherapy can spare the breast gland and therefore reduces the risk of developing a secondary breast carcinoma
  • Highly pre-treated patients, who are at a higher risk of developing radiation toxicity (esp. lung, cardiovascular toxicity and bone marrow disease)

A smaller group consists of patients with refractory or relapsing lymphomas with localized disease, more frequently with a finding of a larger volume in the mediastinum: Rates of Toxicity and Outcomes After Mediastinal Proton Therapy For Relapsed/Refractory Lymphoma Tseng, Y.D. et al. International Journal of Radiation Oncology • Biology • Physics , Volume 99 , Issue 2 , S62 – S63.

Due to the disease being more aggressive, it is necessary to increase the total radiation dose and the standard photon RT has a high risk of post-radiation complications. In this situation, proton RT can be used as a separate curative method or as “debulking” (reduction of the tumour mass) before planned additional systemic treatment (e.g. allogeneic transplantation). Thus, for some patients, proton RT may be part of a curative treatment approach in situations that were previously thought to be “incurable”.

In a similar indication, we can recommend proton RT for repeated irradiation, where the organs at risk have already been burdened with a dose from the previous RT. Again, long-term disease control can be achieved in limited disease.

 

Professional Team of the Center of Excellence for Radiotherapy of Malignant Lymphomas

The Center of Excellence for proton RT of malignant lymphomas is led by MUDr. Kateřina Dědečková, leading expert for this type of treatment in the Czech Republic.

 

Radiation Oncologists

MUDr. Kateřina Dědečková, Proton Therapy Center & Oncology clinic 2nd Faculty of Medicine, Charles University & Motol University Hospital

prim. MUDr. Jiří Kubeš, Proton Therapy Center & Oncology clinic 2nd Faculty of Medicine, Charles University & Motol University Hospital

MUDr. Simona Zapletalová, Proton Therapy Center

 

Haematooncology:

MUDr. Heidi Móciková, Intern haematology clinic 3rd Faculty of Medicine, Charles University & University Hospital Vinohrady

MUDr. Ľubica Gahérová, Intern haematology clinic 3rd Faculty of Medicine, Charles University & University Hospital Vinohrady

MUDr. Kateřina Kopečková, Oncology clinic 2nd Faculty of Medicine, Charles University & Motol University Hospital

MUDr. Jindřich Polívka MHA, TŘI o.p.s., Hospice Good Shepherd Čerčany, Haematology & paliative medicine

 

Nuclear Medicine:

prim. MUDr. Lucie Kaliská, Proton Therapy Center

 

Radiodiagnostics:

prim. MUDr. Daniel Klika, Proton Therapy Center

 

Radiological Physicists:

Mgr. Vladimír Vondráček, Head of Physicists Proton Therapy Center

Ing. Michal Andrlík, Proton Therapy Center

 

Posters

  • Pencil Beam Scanning Proton Therapy for Lymphoma Patients with Mediastinal Involvement: A Dosimetric Study and Preliminary Clinical Data Authors: Katerina Dedeckova  13th International Conference on Malignant Lymphoma, 17-20 June 2015 Lugano
  • Pencil beam scanning proton therapy for lymphoma patients with mediastinal involvement: Prague´s single institution experience K. Dedeckova  1 , J. Stokucova  2 , H. Mocikova  3 , J. Markova  3 , L. Gaherova  3 , I. Kantorova  4 , B. Ondrova  1 , V. Vondracek  2 , P. Vitek  1 , J. Kubes  PTCOG COnference, Prague 2016
  • Predicted Cardiac and Second Cancer Risks in Hodgkin Lymphoma Patients Treated With Advanced Proton Beam Therapy Compared to Photon Radiation Therapy Ntentas, G. , Dedeckova, K. et al. International Journal of Radiation Oncology
  • Biology
  • Physics , Volume 99 , Issue 2 , S181 ASTRO Annual Meeting, San Diego, 2017

 

Clinical Studies

Participation in professional studies in the Czech Republic and abroad.

  • Intern haematology clinic FN Královské Vinohrady
    Oncology clinic 2nd LF UK & FN Motol (modern photon RT-technique IMRT, VMAT) – participation in IESLG 37 study (the role of consolidation RT in patients with primary mediastinal B-lymphoma)
  • Nuffield Department of Population Health Oxford University (dr.Ntentas)
    International Lymphoma Radiation Oncology Group (ILROG)
    Cooperation with the Univesity of Florida, the Univesity of Washington (joint database of patients with relapsed/refractory lymphomas, who have undergone proton RT)

 

Publications

Overview of published work and relevant studies of PTC experts:

  • Shbib Dabaja, B., Hoppe, B., Plastaras, J., Newhauser, W., Rosolova, K., Flamour, S., Mohan, R., Mikhaeel, G., Kirova, Y., Specht, L., Yahalom, J. (2018). Proton therapy for adults with mediastinal lymphomas: the international lymphoma radiation oncology group (ilrog) guidelines. Blood. Retrieved from bloodjournal.org.
    Summary: The deciding factor in the choice of treatment modality for Hodgkin and non-Hodgkin lymphoma patients with mediastinal tumors depends on if the dose of excess radiation to organs at risk (OAR) can be minimized. Proton therapy may help to reduce the radiation dose to the OARs and reduce toxicities, especially the risk of cardiac morbidity and secondary cancers.
  • Ntentas, G., Dědečková K., Andrilik, M., Aznar, M.C., George, B., Darby, S.C., Cutter, D. (2017). Predicted cardiac and second cancer risks in hodgkin lymphoma patients treated with advanced proton beam therapy compared to photon radiation therapy. S181 ASTRO Annual Metting. International Journal of Radiation Oncology, Biology, Physics, 99(2). doi: doi.org.
    Summary: A comparison between proton radiotherapy and photon radiotherapy in the treatment of Hodgkin lymphoma patients using deep inspiration breath hold. Proton therapy using pencil beam scanning was found to reduce the risk of future cardiovascular diseases and secondary cancers when compared to 3D-CRT and PartArc RT.
  • Dedeckova, K., Stokucova J., Mocikova, H., Markova, J., Gaherova, L., Kantorova, I., Ondrova, B., Vondracek, V., Vitek, P., Kubes, J. (2016). Pencil beam scanning proton therapy for lymphoma patients with mediastinal involvement: Prague´s single institution experience. PTCOG Conference. Retrieved from www.czech-in.org.
    Summary: Proton radiotherapy using pencil beam scanning in deep inspiration breath hold offers a promising and safe possibility for patients who are indicated for mediastinal radiotherapy.
  • Dedeckova K., Markova J., Gaherova, L., Kantorova, I., Ondrova, B., Vondracek, V., Vitek, P., Kubes, J. (2016). Proton radiotherapy for mediastinal Hodgkin lymphoma: single institution experience. 10th International Symposium on Hodgkin Lymphoma. Retrieved from hodgkinsymposium.org.
    Summary: The treatment of mediastinal Hodgkin lymphoma using proton radiotherapy results in low acute toxicity and a potential to decrease the risk of significant late toxicity.
  • Kubeš, J., Dědečková, K., Kohlová, T., Vitek, P., Vondráček, V., Ondrová, B. (2015). Protonová chemoradioterapie technikou pencil beam scanning v léčbě nádorů hlavy a krku s nutností ozařování bilaterálních krčních uzlin (Proton chemoradiotherapy with pencil beam scanning in the treatment of head and neck tumors with the need for irradiation of bilateral cervical nodes). 2015 XXXIX. Brněnské onkologické dny a XXIX. Konference pro nelékařské zdravotnické pracovníky (2015 XXXIX. Brno Oncology Days and XXIXth Conference for non-medical healthcare professionals). Retrieved from linkos.cz.
    Summary: Proton Radiotherapy for head and neck tumors using Pencil Beam Scanning allows for excellent dose coverage for large, complex target volumes while minimizing the dose to nearby organs.
  • Dedeckova, K., Mocikova, H., Markova, J., Gaherova, L., Koren, J., Backova, B., Vondracek, V., Sindelar, D., Kohlova, T., Ondrova, B., Kantorova, I., Vitek, P., Pytlik, R., Kubes, J. (2015). Pencil Beam Scanning Proton Therapy for Lymphoma Patients with Mediastinal Involvement: A Dosimetric Study and Preliminary Clinical Data. Hematological Oncology, 33, 191. Retrieved from lymphcon.ch.
    Summary: When compared to standard photon radiotherapy, proton radiotherapy using pencil beam scanning for mediastinal lymphoma patients significantly reduces the dose of radiation to nearby organs.
  • Ondrová, B., Vinakurau, S., Kubeš, J., Dědečková, K., Kohlová, T., Sepeši, B., Vitek, P. (2014). Protonová radioterapie chordomů a chondrosarkomů – proveditelnost, akutní toxicita a časné výsledky: zkušenosti PTC Praha (Proton radiotherapy of chordomas and chondrosarcomas – feasibility, acute toxicity and early results: PTC Prague experience). 2014 XXXVIII. Brněnské Onkologické Dny a XXVIII. konference pro nelékařské zdravotnické pracovníky (2014 XXXVIII. Brno Oncological Days and XXVIII. conferences for non-medical healthcare professionals). Retrieved from linkos.cz.
    Summary: Intensity-modulated proton therapy is a safe technique for chordoma and chondrosarcoma patients due to its low acute toxicity.
  • Vitek, P., Kubeš, J., Vinakurau, S., Ondrová, B., Dědečková, K. (2014). Protonová radioterapie nádorů pankreatu, regionální lymfatika a “setrvalá beznaděj“? (Proton radiotherapy of pancreatic tumors, regional lymphatics and "persistent hopelessness"?). 2014 XXXVIII. Brněnské Onkologické Dny a XXVIII. konference pro nelékařské zdravotnické pracovníky (2014 XXXVIII. Brno Oncological Days and XXVIII. conferences for non-medical healthcare professionals). Retrieved from linkos.cz.
    Summary: The use of proton radiotherapy to treat pancreatic cancer is well tolerated and highly efficient due to its great dosimetric parameters.
  • Kubeš, J., Vítek, P., Dědečková, K., Ondrová, B. (2014). Velmi pozdní následky radioterapie – limitující faktor současných radioterapeutických Technik (Very late side effects of radiotherapy - limiting factor of current radiotherapeutic techniques). Klinicka onkologie Journal, 27(3), 161-165. doi: linkos.cz.
    Summary: The risk of developing very late side effects from radiotherapy must be considered in all young patients who are exposed to radiation. This paper summarizes the most common very late side effects of radiotherapy, including cardiotoxicity, CNS toxicity, pneumotoxicity, renal toxicity and secondary malignancies.
  • Dědečková K, Móciková H, Belada D, Janíková A, Dolečková M, Malinová B, Feltl D, Vošmik M, Svoboda T, Marková J, Trněný M. (2013). The role of radiotherapy in the treatment of malignant lymphomas - recommendations of the Czech Lymphoma Study Group. Klinicka onkologie Journal, 26(2), 99-109. Retrieved from ncbi.nlm.nih.gov. PubMed PMID: 23718668.
    Summary: This paper is regarding the consensus between hematologist-oncologists and radiation oncologists defining the role of radiotherapy in lymphoma treatment and specific recommendations on total doses of radiotherapy in lymphoma treatment.
  • Dědečková, K., Móciková, H., Belada, D., Obořilová-Janíková, A., Dolečková, M., Malinová, B., Feltl, D., Vošmik, M., Svoboda, T., Marková, J., Trněný, M.(2013). Postavení radioterapie v léčbě maligních lymfomů – doporučení Kooperativní lymfomové skupiny (The Position of radiotherapy in the treatment of malignant lymphomas - recommendations of the cooperative lymphoma group). Klinicka onkologie Journal, 26(2), 99-109. doi: linkos.cz.
    Summary: An overview of indications for radiotherapy in malignant lymphomas, including recommended total doses for RT.
  • Marková J., Kahraman D., Kobe C., Skopalová M., Móciková H., Klásková K., Dědečková, K., Eich H.T., Böll B., Dietlein M., Kozák T. (2012). Role of (18F)-fluoro-2- deoxy-D-glucose positron emission tomography in early and late therapy assessment of patients with advanced Hodgkin lymphoma treated with bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristine, procarbazine and prednisone. Leukemia & Lymphoma, 53(1), 64-70. doi: 10.3109/10428194.2011.603444.
    Summary: A study aimed at defining the prognostic value of positron emission tomography in the assessment of early therapy response after the end of treatment for advanced Hodgkin lymphoma. The study concluded that an interim PET after four cycles of chemotherapy is a strong prognostic marker for progression-free survival in advanced Hodgkin lymphoma patients.
  • Chocenská, E., Móciková, H., Dědečková K. (2010). Průvodce pacienta onkologickou léčbou (Patient's Guide to Cancer Treatment). Retrieved from linkos.cz.
    Summary: A guide that provides information about different types of cancer, the problems caused by tumors, the possibilities of treatment, and the complications associated with this treatment.
  • Marková J., Kobe C., Skopalová M., Klásková K., Dědečková K., Plütschow A., Eich H.T., Dietlein M., Engert A., Kozák T. (2009). FDG-PET for assessment of early treatment response after four cycles of chemotherapy in patients with advanced-stage Hodgkin’s lymphoma has a high negative predictive value. Annals of Oncology, (20)7. 1270-4. doi: 10.1093/annonc/mdn768.
    Summary: Examination of the prognostic value of positron emission tomography after four cycles of combination therapy in advanced-stage Hodgkin’s lymphoma patients.
  • Marková, J., Kobe C., Skopalová, M., Žikavská, L., Vernerová, Z., Klásková, K., Dědečková, K., Eich, H.T., Dietlein, M., Fuchs, M., Engert, A., Kozák, T. (2009). Early and late response assessment with fdg-pet after beacopp-based chemotherapy in advanced-stage Hodgkin lymphoma patients has a high negative predictive value. Haematologica, 94(2). Retrieved from online.haematologica.org.
    Summary:     Positron emission tomography (PET) is a powerful prognostic factor in the treatment of Hodgkin lymphoma. The study analyses the prognostic values of PET for early and late response to BEACOPP-based chemotherapy in patients who are diagnosed with advanced-stage HL.
  • Kubeš, J., Betlachová, L., Dědečková, K. (2008). Radioterapie v léčbě karcinomu prsu (Radiotherapy in the treatment of breast cancer). 2008 16. onkologicko-urologické sympozium a 12. mammologické symposium (2008 16th Cancer and Urology Symposium and 12th Mammological Symposium). Retrieved from linkos.cz.
    Summary: Radiotherapy is essential in the treatment of breast cancer, however, radiation exposure to nearby critical organs, especially the lungs and heart, can lead to late cardiovascular and pulmonary morbidity. This abstract discusses radiotherapy indications at the Institute of Radiation Oncology at University Hospital Bulovka.
  • Dědečková, K., Betlachová, L., Kubeš, J. (2006). Indikace postmastektomické lokoregionální radioterapie v léčbě karcinomu prsu u pacientek s 1 až 3 pozitivními axilárními lymfatickými uzlinami (Indication of postmastectomy locoregional radiotherapy in the treatment of breast cancer in patients with 1 to 3 positive axillary lymph nodes). 2006 11. ročník odborného sympózia na téma Onkologie v gynekologii a mammologii (2006 11th year of the symposium on Oncology in gynecology and mammology). Retrieved from linkos.cz.
    Summary: A summary of three randomized trials evaluating the need for postmastectomy radiotherapy to reduce the risk of locoregional failure.
  • Kubeš, J., Dědečková, K., Pála, M. (2005). Technika concomitant boost v léčbě nádorů ORL oblasti – biologické odůvodnění a vlastní zkušenosti (Concomitant boost technique in the treatment of ENT tumors - biological rationale and our own experience). 2005 2. ročník semináře o brachyterapii a technice IMRT (2005 2nd year seminar on brachytherapy and IMRT technique). Retrieved from linkos.cz.
    Summary: Two techniques can improve the effectiveness of radiotherapy for locally advanced head and neck cancers, applying concomitant chemotherapy, known as concomitant boost (CB), and the use of alternative fractionation modes. For suitable patients, CB has shown to be feasible with acceptable toxicity and promising therapeutic outcomes.

 

Patient Stories

Patient stories, blogs (in Czech):

Experiences of patients treated with proton therapy in the USA:

Videos about proton therapy for lymphoma (in English):

 

Other Resources

Map of oncological and hematooncological centers:

Domestic sources of information (Czech Republic):

Comprehensive information on Hodgkin's lymphoma for doctors and patients, brochure and counseling for patients:

Comprehensive information on the issue of Hodgkin's and non-Hodgkin's lymphoma for doctors and patients. Current recommendations available for the diagnosis and treatment of lymphomas, including radiotherapy:

Comprehensive information and assistance for patients before, during, or after lymphoma treatment:

Website of the Czech Oncological Society:

Psychosocial assistance project, for cancer patients:

 

Foreign Sources

Guidelines for individual types of cancer, including recommended irradiation techniques:

Information on publications related to proton radiotherapy for lymphomas:

Information on the status and implementation of radiotherapy in lymphomas, for professionals:

A self-help project and sharing the experiences of patients who have been or are being treated for cancer: