1. Medical requirements for FFAG as proton beam sources Jacques BALOSSO, MD, PhD Radiation oncologiste UJF / INSERM / ETOILE FFAG 2007, April 12-17, 2007 Grenoble

2. Plan Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

3. Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

4. The protons Bragg peak The 200 MeV Bragg peak of the CPO (Orsay, France)

5. The protons Spread Out Bragg Peak (SOBP) The inside structure of the proton SOBP

6. Comparison of the « efficient » dose according to the depth for photons, a proton SOPB and a carbon ion SOBP. (GSI, Darmstadt, Germany)

7. PSI Villigen

11. Comparison of the « efficient » dose according to the depth for photons, a proton SOPB and a carbon ion SOBP. (GSI, Darmstadt, Germany)

12. X-Rays Protons Carbone Neutrons RBE  1 RBE >> 1

13. Protons and Carbon ions are not offering the same advantages Protons are representing a crude and important ballistic improvement for any type of radiotherapy… providing they are affordable ! Carbones are an innovative kind of radiations with particular radiobiological properties suitable for certain indications only.

14. Indication for a fractionated radiotherapy of RBE  1 Indication for particle therapy having an RBE >> 1 Survival

15. Consequently … Protons indications are not limited Protons can, with the time, replace X- Rays Carbon ions should have a definitive and limited number of indications These indications are a number of therapeutic spots present in different groups of tumors.

16. Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

17. Indications for protontherapy in Loma Linda (1) Brain and spinal cord –Isolated brain metastases –Pituitary adenomas –Arteriovenous malformations (AVMs) Base of skull –Meningiomas –Acoustic neuromas –Chordomas and chondrosarcomas Eye –Uveal melanomas In red: indications treated in France

18. Indications for protontherapy in Loma Linda (2) Head and neck –Nasopharynx –Oropharynx (locally advanced) Chest and abdomen –Medically inoperable non-small-cell lung cancer –Chordomas and chondrosarcomas Pelvis –Prostate –Chordomas and chondrosarcomas Tumors in children –Brain –Orbital and ocular tumors –Sarcomas of the base of skull and spine

19. Uvea melanoma treated by protons

20. Chondrosarcoma of the skull base

21. Chordoma

22. Meningioma

23. Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

24. Indications for protontherapy in Loma Linda (1) Brain and spinal cord –Isolated brain metastases +++ –Pituitary adenomas –Arteriovenous malformations (AVMs) Base of skull –Meningiomas –Acoustic neuromas –Chordomas and chondrosarcomas Eye –Uveal melanomas In red: indications treated in France

25. Indications for protontherapy in Loma Linda (2) Head and neck –Nasopharynx +++ –Oropharynx (locally advanced) Chest and abdomen –Medically inoperable non-small-cell lung cancer +++ –Chordomas and chondrosarcomas Pelvis –Prostate +++ –Chordomas and chondrosarcomas Tumors in children –Brain –Orbital and ocular tumors –Sarcomas of the base of skull and spine

26. Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

27. Technical requirements Depth: 2 to 30 cm in water Size: at least 10 x 10 cm up to 20 x 20 Dose rate: at least one Gy / min / liter Precision of size & position: 1 mm Precision of the dose: +/- 2 to 3% Operability: > 97% Session time: < 30 min Beam control: active +++ (rapid change of energy ??) better than passive

28. Exemple of a single proton beam

29. Exemple of the set-up with a gantry

30. Why to use protons in radiotherapy ? What kind of tumors are presently treated by protons ? What kind of tumors would be treated by widely available proton beams? Requirement for a medical proton source Prospective for a radiotherapy of the future

31. Toward the future of radiotherapy 100% hadrontherapy: – with 95% proton – and 5% light-ions (carbon…) High precision and small volume of early diagnozed tumors Few sessions of >> « 2 Gy » Fast shot RT to reduce immobilization and to favor precision of moving target treatment (lung, lever, prostate…) About 5000 treatments / 10 6 inhabitants per year in 20 years

32. Open questions What type of machine for the generalized availability of protons ? What are the radiobiological characteristic of very high dose rates ? What could be the organization and the economical conditions of very short but highly sophisticated treatments ? Could FFAG be an answer?