Ten years of Proton Therapy in Trento as part of 70 years of high-tech radiotherapy in Trentino

Radiotherapy is an important pillar of modern multidisciplinary tumor treatment and is an essential element for tumor cure in more than 50% of all oncologic patients.

While advanced radiotherapy was established in Trentino more than 70 years ago in 1953 with the first European Telecobalt radiotherapy unit in Borgo Valsugana and later in Trento, the Trento Proton Center has now provided 10 years of clinical service as part of the Radiotherapeutic Network in Trentino-Alto Adige (RadioterapiaOncologica di Trento, Protonterapia di Trento, Radioterapia di Bolzano, which, together, provide all available types of high tech radiation oncology) and is fully integrated in all oncological activities in Trentino and national and international networks.

The center as the only fully public center in Italy serves patients from Trentino and Alto Adige with 20% of its capacity and also serves 70% of its patients that are coming from outside the region and 10% of international patients.

To date, the center has treated more than 2400 patients (25% of which being pediatric), all of which fall into the categories covered by the LivelliEssenziali di Assistenza (LEA) and are currently authorized for patients outside Trentino on an individual basis with the TariffarioNomenclatoreNazionale now expected to be activated in January 2025.

These include “classic” indications for proton therapy where the physical characteristics of protons translate into favorable clinical results, such as chordomas, chondrosarcomas and other soft tissue tumors as well as certain particular head and neck tumors such as a subset of parotid and paranasal sinus cancers, certain brain tumors, pediatric malignancies and malignancies in young adults such as lymphomas and other mediastinal tumors where proton therapy is increasingly considered a favorable option. Increasingly, proton therapy is also used in situations of retreatment, as for example in breast or lung cancer for individual patients. A significant number of high-quality clinical data currently being published or in arrival may expand the number of situations where protons are clinically useful, further strengthening the overall situation of radiotherapy as a determining factor in tumor cure.

After the clinical go-live of the center in 2014 with the first treatment of a pediatric patient in 2015, physicists, physicians and TSRMs in collaboration with radiologists, anesthetists and nursing staff of the center have introduced several new treatment techniques that had previously been game-chaning in photon radiation oncology such as near-line treatment verification, on-line imaging, respiratory gating to permit the treatment of moving tumors, radiosurgery and most recently quasi-rotational treatments for the first time worldwide.

This has resulted in several firsts on a national and international level and permitted the center to become one of the few worldwide that can perform treatments, when indicated, everywhere in the body at maximum quality, in optimal integration with photon radiotherapy and systemic oncologic treatments.

Those results permitted APSS, in a collaborative effort between different Operative Units, to enter a potentially practice changing international trial in a subgroup of patients with esophageal cancer as well as promoting a national multicenter trial on treatment of malignant heart arrhythmias where proton therapy might be beneficial for patients with large lesions. Both trials will start at the beginning of 2025.

The Trento Proton center is unique also on an international level as it disposes of two clinical treatment rooms as well as an experimental beam that offers the possibility, in collaborationfor example with the Trento Institute for Fundamental Physics and Applications (TIFPA) and UniTN, to perform preclinical studies that will prepare for the clinical application of new biological treatment paradigms such as ultrafast Radiotherapy (FLASH) and inhomogeneous dose application, both of which may also further improve the immune response against tumors and their metastases together with systemic immunotherapy.

Recently approved investments by the autonomous province as well as CariTRO will, on one hand, establish fast online imaging on a clinical gantry, further facilitating the treatment of moving tumors, and on the other hand permit to provide preclinical experiments on the experimental beam with the same characteristics as the clinical beam (beam scanning) to further improve the transfer from preclinical experiments into clinical data.

The center will then be the only Italian center with full rotational gantriesandalsopretreatment volume Imaging, and one of the few centers worldwide with the abovementioned treatment possibilities on the experimental beam and will be well prepared for further improvements of oncological outcome in a multidisciplinary setting in the next decade.