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1 New techniques and technology for cancer treatment with a proton beam. V. Balakin

2 Approximately (20÷30)% of inhabitants of the Earth suffer from oncological diseases. Taking into account close relatives it is possible to say that this trouble touches every family. Today’s medicine cures at about 50% of patients. Our new beam therapy allows treating the majority of patients with efficiency of 90% and more.

3 The purpose of beam therapy is to “strike” the tumor with minimal damage to surrounding healthy tissue.

4 The picture of “hitting” ability of beams with different energy released from the accelerator into the fluorescent substance compared to the γ-beams of the electron accelerator with energy of 18 MeV.

5 1. By Philip P. Connell, Lani Ignacio, Daniel Haraf, Azhar M. Awan et al. Equivalent Racial Outcome After Conformal Radiotherapy for Prostate Cancer: A Single Departmental Experience. Journal of Clinical Oncology, Vol 19, No 1 (January 1), 2001: pp 54-61 2. Anthony V. D’Amico, MD, Judith Manola, MS, Marian Loffredo, RN, OCN, Andrew A. Renshaw, MD et al. 6-Month Androgen Suppression Plus Radiation Therapy vs Radiation Therapy Alone for Patients With Clinically Localized Prostate Cancer A Randomized Controlled Trial. JAMA, August 18, 2004—Vol 292, No. 7 3. Stephanie T.H. Peeters, Wilma D. Heemsbergen, Peter C.M. Et al Dose- Response in Radiotherapy for Localized Prostate Cancer: Results of the Dutch Multicenter Randomized Phase III Trial Comparing 68 Gy of Radiotherapy With 78 Gy. JOURNAL OF CLINICAL ONCOLOGY 2006 MAY 1 4. Karel A. Hinnen, Jan J. Battermann, Joep G.H., et al. Long-term biochemical and survival outcome of 921 patients treated with I-125 permanent prostate brachytherapy. Int.J.Radiat.Oncol.Biol.Phys. 2010;76(5):1433-8. 5. Lagerwaard FJ, Senan S, van Meerbeeck JP, Graveland WJ. Has 3-D conformal radiotherapy (3D CRT) improved the local tumour control for stage I non-small cell lung cancer? Radiother Oncol. 2002May;63(2):151-7. 6. Kenneth E. Rosenzweig, Sonal Sura, Andrew Jackson, and Ellen Yorke. Involved-Field Radiation Therapy for Inoperable NonSmall-Cell Lung Cancer. JOURNAL OF CLINICAL ONCOLOGY 2007 dec. 10 7. Miyamoto T, Baba M, YamamotoN et al. Curative treatment of stage I nonsmall- cell lung cancer with carbon ion beams using a hypofractionated regimen. Int J Radiat Oncol Biol Phys 2007;67:750 –758 8. Onishi H, Shirato H, Nagata Y, Hiraoka M, Fujino M, Gomi K, Niibe Y, Karasawa K, Hayakawa K, et al. Hypofractionated stereotactic radiotherapy (HypoFXSRT) for stage I non-small cell lung cancer: updated results of 257 patients in a Japanese multi-institutional study. J Thorac Oncol. 2007 Jul;2(7 Suppl 3):S94-100 1 - 3D CRT 2 - 3D CRT 3 - 3D CRT 4 - Brachytherapy 5 - 3D CRT 6 - 3D CRT 7 – Carbon ion 8 – Stereotactic radiotherapy Clinical data showing transition necessity to high total doses

6 The concept difference of our approach from the existing one is: Not a new hospital around the huge proton installation, But a compact proton installation in the existing hospital. Not several huge proton centers in a country, But one proton installation in each hospital with oncological department.

7 We were working in three directions: I To make proton sources (accelerators) cheap to the limit, compact, economic etc. II To develop the system of quick immobilization of a patient and quick verification which is much cheaper then existing Gantry systems. III The irradiation technology should provide maximum dose in tumor with minimal damage to healthy tissue (optimized IMPT).

8 The first clinic in the world with proton therapy equipment. (USA, Loma Linda,1990) For comparison the room size for our device of the same efficiency is shown in white.

9 The scheme of the Proton therapy complex in Protvino Control room Power supplyWater cool system Technical room

10 Proton accelerator in the hospital of Protvino

11 Basic technical characteristics of synchrotron: Beam energy 70-250 MeV±0.15% Beam energy in tomography mode – 330 MeV ±0.15%; Intensity of the emitted beam – 1·10 9 ; Acceleration time to 330Мэв – 1 sec.; Slow emission of the beam in the range – 0.1-1 sec.; 100% of the emitted beam reaches the tumor; Average power consumption ~ 50 кWt; Diameter of synchrotron – 5м; Total weight – 25 tonn.

12 The dose rate for different volumes of tumor (spherical tumor independently from the location depth) (Optimized algorithm with IMPT) №= 1·10 9 per cycle, T= 1,5 sec V DR 50 cm 3 – 8.3 GY/min 200cm 3 – 3.1 GY/min 500 cm 3 – 1.5 GY/min

13 Inscription on the luminophore screen made by the proton pencil-beam to demonstrate the possibility of the extracted beam intensity and position control during its slow extraction.

14 Amplitude (mm) of internal organs’ movement during respiration. horizontal vertical horizontal vertical Left kidneyRight kidney

15 Our irradiation technology provides synchronization of accelerator’s working cycles - synchrotron with patient’s breathing cycle which considerably increases irradiation accuracy. Nevertheless, it is better to have less movements of internal organs during respiration which means that the best patient’s position is vertical!!! Our irradiation system doesn’t require huge and expensive Gantry which makes it more affordable for people.

16 System of quick immobilization of a patient in standing, sitting and lying positions. 21


18 The example of tumor irradiation by means of new technology. The irradiation is given from 36 directions with modulation of intensity. Such technology is used for a long time in y-rays therapy (Gamma-knife, Cyber-knife etc) but protons will have an advantage due Bregg’s pick. (In others existing proton installations the irradiation is usually given from 2-3 directions.)

19 Example plan of tumor exposure considering sensitive zones and metastases (exposure plan is calculated by the program using the unique optimizing algorithm). (OIMPT – concept analogue of IMRT)

20 The plan of irradiation for prostate cancer: left - the electron accelerator; right - the proton irradiation (optimized IMPT).


22 The scheme of the biological experiment on measurement of efficiency of treatment 28

23 20 Therapy during movement of internal organs due to respiration Phase I measurement of (~ 30 sec) Phase II synchronization (~ 30 sec) Phase III therapy (1 ÷ 5 min) Accelerator cycle Extracted beam

24 ------------------------------------------------------------------------------------------------ Protvino, Moscow region. Ruzomberok (Slovakia) Pushchino, Moscow region. Accelerator only Flint, Michigan, USA. Our centers of proton therapy under construction.

25 Vertical MRI tomographs. Except for built-in the system computer tomograph, the magnetic tomograph for vertical position diagnostics is supposed to be in complectation.

26 In our opinion, the beam therapy during 10-20 years will mostly use proton installations. Large centers will contain 2-3 and more proton accelerators. In some percentage of cases (children, gravely ill patients etc) it is necessary to equip accelerators with Gantry system. For the most radio resistant tumors it is necessary to have ion (carbon) installations. We work in all these directions.

27 Many years ago we set a goal – to make a proton therapy installation as affordable as electron ones which will allow beam therapy to take right course of development. This will increase treatment efficiency from today’s 50% to 90%, as well as broaden the field of application of beam therapy from 70% to 90% due to irradiation of tumors closely located to sensitive organs and irradiation of radio resistant tumors as well.

28 Assemblage of first installations mass produced by industrial companies of RF

29 Thanks for attention!

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