Proton radiotherapy: a therapeutic opportunity for pediatric brain tumor patients

Proton radiation therapy is a form of external radiation that uses charged particles which have distinct physical advantages to deliver the majority of its dose in the target while minimizing the dose of radiation to normal tissues. In children who are particularly susceptible even at low and medium doses of radiation, the significant reduction of integral dose can potentially mitigate the incidence of side effects and improve quality of life. The aim of the first part of the thesis is to describe the physical and radiobiological properties of protons, the Proton Therapy Center of Trento (TCPT) active for clinical purpose since 2014, which use the most recent technique called active pencil beam scanning. The second part of the thesis describes the preliminary clinical results of 23 pediatric patients with central nervous system tumors as well as of two aggressive pediatric meningiomas treated with pencil beam scanning. All the patients were particularly well-suited candidates for proton therapy (PT) for possible benefits in terms of survival and incidence of acute and late side effects. We reported also a multicentric experience of 27 medulloblastoma patients (median age 6 years, M/F ratio 13/14) treated between 2015 and 2020 at TPTC coming from three Pediatric oncology centers: Bologna, Florence, and Ljubljana, with a focus on clinical results and toxicities related to radiotherapy (RT). Proton therapy was associated with mostly mild acute and late adverse effects and no cases of CNS necrosis or high grade of neuroradiological abnormailities. Comparable rates of survival and local control were obtained to those achievable with conventional RT. Finally, we performed a systematic review to specifically address the safety of PT for pediatric CNS patients, late side effects and clinical effectiveness after PT in this patient group.

Shaping transverse beam distributions by means of adiabatic crossing of resonances

Non-linear effects are responsible for peculiar phenomena in charged particles dynamics in circular accelerators. Recently, they have been used to propose novel beam manipulations where one can modify the transverse beam distribution in a controlled way, to fulfil the constraints posed by new applications. One example is the resonant beam splitting used at CERN for the Multi-Turn Extraction (MTE), to transfer proton beams from PS to SPS. The theoretical description of these effects relies on the formulation of the particle's dynamics in terms of Hamiltonian systems and symplectic maps, and on the theory of adiabatic invariance and resonant separatrix crossing. Close to resonance, new stable regions and new separatrices appear in the phase space. As non-linear effects do not preserve the Courant-Snyder invariant, it is possible for a particle to cross a separatrix, changing the value of its adiabatic invariant. This process opens the path to new beam manipulations. This thesis deals with various possible effects that can be used to shape the transverse beam dynamics, using 2D and 4D models of particles' motion. We show the possibility of splitting a beam using a resonant external exciter, or combining its action with MTE-like tune modulation close to resonance. Non-linear effects can also be used to cool a beam acting on its transverse beam distribution. We discuss the case of an annular beam distribution, showing that emittance can be reduced modulating amplitude and frequency of a resonant oscillating dipole. We then consider 4D models where, close to resonance, motion in the two transverse planes is coupled. This is exploited to operate on the transverse emittances with a 2D resonance crossing. Depending on the resonance, the result is an emittance exchange between the two planes, or an emittance sharing. These phenomena are described and understood in terms of adiabatic invariance theory.

Development and Implementation of the Plasma Focus Technology for Radiation Therapy Applications

A Plasma Focus device can confine in a small region a plasma generated during the pinch phase. When the plasma is in the pinch condition it creates an environment that produces several kinds of radiations. When the filling gas is nitrogen, a self-collimated backwardly emitted electron beam, slightly spread by the coulomb repulsion, can be considered one of the most interesting outputs. That beam can be converted into X-ray pulses able to transfer energy at an Ultra-High Dose-Rate (UH-DR), up to 1 Gy pulse-1, for clinical applications, research, or industrial purposes. The radiation fields have been studied with the PFMA-3 hosted at the University of Bologna, finding the radiation behavior at different operating conditions and working parameters for a proper tuning of this class of devices in clinical applications. The experimental outcomes have been compared with available analytical formalisms as benchmark and the scaling laws have been proposed. A set of Monte Carlo models have been built with direct and adjoint techniques for an accurate X-ray source characterization and for setting fast and reliable irradiation planning for patients. By coupling deterministic and Monte Carlo codes, a focusing lens for the charged particles has been designed for obtaining a beam suitable for applications as external radiotherapy or intra-operative radiation therapy. The radiobiological effectiveness of the UH PF DR, a FLASH source, has been evaluated by coupling different Monte Carlo codes estimating the overall level of DNA damage at the multi-cellular and tissue levels by considering the spatial variation effects as well as the radiation field characteristics. The numerical results have been correlated to the experimental outcomes. Finally, ambient dose measurements have been performed for tuning the numerical models and obtaining doses for radiation protection purposes. The PFMA-3 technology has been fully characterized toward clinical implementation and installation in a medical facility.