Hadron Therapy Proposal Tata Memorial Centre Parel, Mumbai July 2012

Radiation Therapy Photons – Diagnostic X-rays - 20 to 150 kV – Superficial X-rays - 50 to 200 kV – Orthovoltage X-rays -200 to 500 kV – Supervoltage X-rays to 1000 kV – Megavoltage X-rays - 1 to 25 MV Electrons Hadron – Proton MeV – Neutron (Fast Neutron) - >50 Mev – Heavy Ions (Carbon, Neon, Oxygen, Helium) – MeV

Historical image showing Gordon Isaacs, the first patient treated with linear accelerator radiation therapy (in this case an electron beam) for retinoblastoma in Gordon's right eye was removed January 11, 1957 because the cancer had spread. His left eye, however, had only a localized tumor that prompted Henry Kaplanto try to treat it with the electron beam Radiation therapy of the pelvis Lasers and a mould under the legs are used to determine exact position Neutron Therapy: Comparison of Low LET electrons and High LET electrons Patient treating room for neutron radiation therapy

Advantages: Superior Dose Localization: Heavy ion therapy can severely damage the tumor while minimizing damage to surrounding tissues. Heavy ion therapy has less toxicity (adverse effects) than conventional radiotherapy. Effective Against Cancers which are Resistant to Conventional Radiation: Heavy ion beams have stronger biological effects than X-ray. For example, heavy ion therapy is more effective against tumors such as osteosarcoma, which are difficult to cure with conventional X-ray radiotherapy. Short Treatment Time: The treatment time for heavy-ion radiotherapy is relatively short (3 weeks on average). Compared to conventional X-ray radiotherapy, which requires 6-7 weeks, the treatment time can be reduced dramatically.

- Head & Neck Cancers - Occular tumors - Prostate Cancers - Gastrointestinal tumors -Esophagus -Hepatocellular cancer -Pancreatic cancer - Non Small Cell Lung Cancers - CNS tumors - Sarcomas - Pelvic tumors - Cervix cancer - Bladder cancer Cancers Treated

Results of Proton Clinical Trials Tumors where protons are superior to photons are: – Skull-base chordoma and chondrosarcoma – Arteriovenous malformations – Uveal melanoma Tumors where more research is needed are: – Skull-base meningioma, craniopharyngioma, pituitary adenoma – Lung – Esophageal – Liver – Uterine cervix – Prostate (pages 174, 178) – Wet macular degeneration Reference: Petti and Lennox, Hadronic Radiotherapy, Ann. Rev. Nuclear & Particle Science, :

Hadron at TMH Highly skilled and talented staff Expertise with modern state-of-the-art equipments 3D-CRT, IMRT, IGRT, Electrons, Teaching Experience with latest techniques ; IMRT, IGRT Large experience with clinical trials available

Societal aspect First of its kind facility Proven efficacy in some cancers Expected superior control in some cancers Large number of patients will benefit Known sites and experimental patients Opportunity for patients from all over India Opening new research avenues

Significance Service: – National Centre for Hadron – Several patients treated on challenging sites Education/Training: – Centre will act as the national HUB for training – Suitable training programmes and fellowships Research: – Will potentially generate landmark information. – Will collect unique physics, dosimetric and clinical data in a prospective fashion – To evaluate the role of hadron/charged particle therapy in clinical practice, phase II and well devised RCT to generate LEVEL 1 evidence – Studies performed will be unique to address a important question of assessing highest end technology as per strict world class scientific rigour.

Schedule Phase-I (12-18 months) – Setting-up facilities – Visits to centres Phase-II (6 months) – Physics QA – Training of staff – Treatment of patient Phase-III (24-36 months) – Implementation of techniques – Clinical Trials Local control Functional outcome Quality of Life

Hadron Therapy at Gunma, Japan Outline of the Physical Facilities: Gunma University Showa Campus, Maebashi, Japan Structure Reinforced concrete, partially steel-framed 1 below and 2 above ground Built-up area: 3130 ㎡ (~0.7 Acre) 45Mx65M Total Area: 6280 ㎡ (~1.6 Acre) Lobby, waiting room, control hall, irradiation room 1 (horizontal port), irradiation room 2 (horizontal and vertical ports), irradiation room 3 (vertical port), irradiation room 4 (vertical, R&D port), dispensary room, CT simulator room, staff room, conference room, accelerator room, machine room.

Finances Total budget: Rs. 450 Crores Procurements: – Indigenous 150 Crores – Import 300 Crores Land: 8 Crores Human Resource requirement 89 personnels Patient to be treated from March 2017