Carbon ion therapy within an Italian ‘luogo di bellezza’ – place of beauty

The RCR established the ‘RCR–Cyclotron Trust Visiting Fellowships’ to provide opportunities for a limited number of Consultant and post-FRCR Specialist Registrar clinical oncologists to visit Particle Treatment Centres abroad. The purpose of the visits is to enable successful applicants to achieve a greater understanding of the role of particle therapy in the wider spectrum of advanced radiotherapy.

Dr Harshani Green, Clinical Oncology Research Fellow, The Royal Marsden NHS Foundation Trust, visited Centro Nazionale di Adroterapia Oncologica (CNAO), Pavia, Italy.
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In April 2023, following years of delays due to the Covid-19 pandemic, my colleague Orla Byrne (physicist) and I were incredibly fortunate to travel to the Centro Nazionale di Adroterapia Oncologica (CNAO) in Pavia, Italy.  

Pavia is an ancient university town located 30 minutes south of Milan and one hour from Lake Como. Steeped in natural beauty, it has cobbled lanes as well as idyllic parks and vineyards. A must-see includes the Duomo di Pavia dome, the design of which Leonardo Da Vinci reportedly contributed to. Pavia has been home to the likes of Albert Einstein as well as Alessandro Volta, who developed the first electrical battery. 

Centro Nazionale di Adroterapia Oncologica (CNAO)

CNAO is a particle therapy centre based on the outskirts of Pavia town. ‘Hadrontherapy’ or particle therapy, inclusive of protons and carbon ions, is an advanced form of radiotherapy, which has possible benefits with respect to photon or ‘X-ray’ radiotherapy, through potentially reducing the dose to surrounding healthy tissues, minimising total body dose and/or allowing improved dose coverage to the tumour. Carbon ions can be used as a form of high-linear energy transfer (LET) particle therapy, with a relative biological effectiveness of 2-5 in comparison with photons. Through direct cluster DNA damage, it is likely to be more effective at causing cell death as opposed to indirect DNA damage with low-LET radiation. As such, clinicians at CNAO reserve this treatment for more radioresistant histology. 

Currently, there are 14 carbon ion centres open worldwide, with CNAO opening in 2010. In 2022, they treated just over 450 patients (44% carbon ion, 56% proton, and 18% ocular protons). CNAO has a fixed beam synchrotron system which can deliver both protons and carbon ion treatment over three treatment rooms. They are undergoing an expansion project for a proton gantry and a new accelerator system.

Clinicians at this fantastic institution refer to their ‘CNAO family’ and I certainly received a very warm welcome. Although consultations and multidisciplinary discussions were generally in Italian, clinicians, physicists, bioengineers and radiation therapists spent time explaining their treatment pathways with us through a clear timetabled programme of activities. They tailored these to our interests, which enabled us to carry out our carbon ion planning project alongside their highly experienced team of physicists. 

CNAO is both leading on and contributing to prospective data collection and international collaborative research to help build the evidence for this promising treatment modality. This visiting fellowship has enabled me to learn from their clinical, pre-treatment and physics planning processes. It has also helped me form international links with the aim of developing collaborative work to further optimise patient care. I aim to share the potential benefits and challenges of carbon ions with my multidisciplinary colleagues in the UK. 

To the CNAO team: ‘Grazie amici’, thank you my friends. With utmost thanks to the RCR and The Cyclotron Trust for this excellent educational opportunity.