Die Protonentherapie zeichnet sich durch eine konformale und fokussierte Tumorbestrahlung aus, die es ermöglicht, gesundes Gewebe besser zu schonen als bei der konventionellen Strahlentherapie. Dieses Potential wird jedoch durch Unsicherheiten bei der Vorhersage der Protonenreichweite im Gewebe oder durch anatomische Veränderungen über den Verlauf der Therapie eingeschränkt. In der vorliegenden Arbeit wurde daher der klinische Nutzen eines Reichweiteverifikationssystems auf Grundlage von Prompt-Gamma-Imaging (PGI) zur Behandlungskontrolle untersucht. Dafür wurden Messungen mit einem PGI-System während Prostata- und Kopf-Hals-Tumor-Bestrahlungen durchgeführt und retrospektiv ausgewertet. Einerseits konnte dabei mittels PGI die Genauigkeit verschiedener Methoden zur Reichweitevorhersage überprüft werden. Es zeigte sich, dass die 2019 klinisch eingeführte Methode zur Reichweitevorhersage (DirectSPR) nicht von der mit PGI gemessenen Protonenreichweite in Prostata-Tumor-Bestrahlungen abweicht, wodurch die Reduktion der auf DirectSPR basierenden Reichweiteunsicherheiten unabhängig bestätigt werden konnte. Andererseits konnte die Detektionsfähigkeit von PGI bei der Erkennung relevanter und nicht relevanter anatomischer Veränderungen in applizierten Bestrahlungsfeldern nachgewiesen werden. Insbesondere wurde für die feldweise Klassifizierung der Prostata-Bestrahlungen eine Sensitivität und Spezifität von 74% bzw. 79% festgestellt. Damit konnte in dieser Dissertation erstmals systematisch das klinische Anwendungspotential eines Systems zur PGI-Reichweiteverifikation gezeigt werden. Als zusätzliche Untersuchung wurde in einer Kollaboration mit dem Massachusetts General Hospital zum ersten Mal ein Vergleich zwischen zwei verschiedenen, auf prompter Gammastrahlung basierenden Systemen zur Reichweiteverifikation durchgeführt. Dazu wurde ein standardisiertes Studienprotokoll etabliert, welches die Vergleichbarkeit und die klinische Implementierung von Reichweiteverifikationssystemen generell unterstützen könnte.:1 Einleitung 2 Strahlentherapie mit Protonen 2.1 Physikalische Grundlagen der Protonentherapie 2.2 Behandlungsablauf in der Protonentherapie 2.2.1 Bildgebung zur Therapieplanung 2.2.2 Bestrahlungsplanung 2.2.3 Strahlapplikation 2.3 Genauigkeit in der Protonentherapie 2.3.1 Ursachen für Behandlungs- und Reichweiteunsicherheiten 2.3.2 Aktueller Stand der Behandlungs- und Reichweiteverifikation 3 Methodik der Reichweiteverifikation mittels Prompt-Gamma-Bildgebung (PGI) 3.1 Funktionsprinzip der PGI-Schlitzkamera 3.2 Datenaufnahme und -verarbeitung 3.2.1 Detektoraufbau und Signalaufnahme 3.2.2 PGI-Simulation und Bestimmung der Reichweiteabweichung 3.3 Charakterisierung des PGI-Prototyps 3.3.1 Kalibrierung des Systems 3.3.2 Positionierungspräzision 3.4 Überblick zur PRIMA-Studie 3.5 Experimentelle Studien zur PGI-Simulationsgenauigkeit 3.5.1 Abhängigkeit vom PGI-Sichtfeld und der Protonenenergie 3.5.2 Validierung der erweiterten Simulationssoftware 3.5.3 Abhängigkeit von der Tumorentität 3.5.4 Schlussfolgerungen 4 Validierung der CT-basierten Reichweitevorhersage mittels PGI 4.1 Konzept der Validierung 4.2 Gesamtabschätzung der Validierungsunsicherheit 4.3 Ergebnisse der Validierung 4.4 Diskussion 5 Detektionsfähigkeit anatomischer Veränderungen mittels PGI 5.1 Prinzipieller Aufbau der Studie 5.2 Grundwahrheit auf Basis von CT- und Dosisinformationen 5.2.1 Manuelle Klassifizierung 5.2.2 Klassifizierung auf Grundlage von integrierten Tiefendosisprofilen 5.2.3 Ergebnis der Etablierung einer CT-basierten Grundwahrheit 5.3 Etablierung einer Klassifikation auf Basis von PGI-Daten 5.3.1 Verarbeitung der PGI-Daten mittels Cluster-Algorithmus 5.3.2 Definition von spot- oder clusterbasierten Klassifikationsmodellen 5.4 Ergebnisse der PGI-Detektionsfähigkeit 5.4.1 Auswertung für Patienten mit Prostata-Tumor 5.4.2 Auswertung für Patienten mit Tumoren im Kopf-Hals-Bereich 5.5 Diskussion 6 Genauigkeit zweier Reichweiteverifikationsmethoden – bizentrischer Vergleich 6.1 Material und Methoden 6.1.1 Bildgebung 6.1.2 Bestrahlungsplanung 6.1.3 Durchführung und Auswertung 6.2 Ergebnisse 6.3 Diskussion 7 Zusammenfassung 8 Summary / Proton therapy is a conformal and focused irradiation of the tumor, which allows for a better sparing of healthy tissue than with conventional radiotherapy. However, this potential is limited by uncertainties from the proton range prediction in the patient or anatomical changes over the course of the treatment. Therefore, in this work, the clinical benefit of a range verification system based on the prompt-gamma-imaging (PGI) method for treatment verification was investigated. For this purpose, measurements were carried out with a PGI system during prostate and head and neck cancer irradiations and evaluated retrospectively. On the one hand, PGI was used to review the accuracy of several range prediction methods. The results showed that a specific method for range prediction (DirectSPR), which was clinically introduced in 2019, does not deviate from the PGI-measured proton range in prostate cancer irradiations. This means that the reduction of the range uncertainties with DirectSPR could be independently confirmed. On the other hand, the detection capability of PGI in identifying relevant and non-relevant anatomical changes in delivered treatment fields was demonstrated. In particular, for the fieldwise classification of prostate irradiations a sensitivity and specificity of 74% and 79% was determined, respectively. Thus, the clinical potential of a PGI range verification system was for the first time systematically demonstrated in this thesis. Furthermore, in a collaboration with the Massachusetts General Hospital a first-time comparison of two different range verification systems based on prompt gamma radiation was conducted. Therefore, a standardized study protocol was established, which could generally foster the comparability and clinical implementation of range verification systems.:1 Einleitung 2 Strahlentherapie mit Protonen 2.1 Physikalische Grundlagen der Protonentherapie 2.2 Behandlungsablauf in der Protonentherapie 2.2.1 Bildgebung zur Therapieplanung 2.2.2 Bestrahlungsplanung 2.2.3 Strahlapplikation 2.3 Genauigkeit in der Protonentherapie 2.3.1 Ursachen für Behandlungs- und Reichweiteunsicherheiten 2.3.2 Aktueller Stand der Behandlungs- und Reichweiteverifikation 3 Methodik der Reichweiteverifikation mittels Prompt-Gamma-Bildgebung (PGI) 3.1 Funktionsprinzip der PGI-Schlitzkamera 3.2 Datenaufnahme und -verarbeitung 3.2.1 Detektoraufbau und Signalaufnahme 3.2.2 PGI-Simulation und Bestimmung der Reichweiteabweichung 3.3 Charakterisierung des PGI-Prototyps 3.3.1 Kalibrierung des Systems 3.3.2 Positionierungspräzision 3.4 Überblick zur PRIMA-Studie 3.5 Experimentelle Studien zur PGI-Simulationsgenauigkeit 3.5.1 Abhängigkeit vom PGI-Sichtfeld und der Protonenenergie 3.5.2 Validierung der erweiterten Simulationssoftware 3.5.3 Abhängigkeit von der Tumorentität 3.5.4 Schlussfolgerungen 4 Validierung der CT-basierten Reichweitevorhersage mittels PGI 4.1 Konzept der Validierung 4.2 Gesamtabschätzung der Validierungsunsicherheit 4.3 Ergebnisse der Validierung 4.4 Diskussion 5 Detektionsfähigkeit anatomischer Veränderungen mittels PGI 5.1 Prinzipieller Aufbau der Studie 5.2 Grundwahrheit auf Basis von CT- und Dosisinformationen 5.2.1 Manuelle Klassifizierung 5.2.2 Klassifizierung auf Grundlage von integrierten Tiefendosisprofilen 5.2.3 Ergebnis der Etablierung einer CT-basierten Grundwahrheit 5.3 Etablierung einer Klassifikation auf Basis von PGI-Daten 5.3.1 Verarbeitung der PGI-Daten mittels Cluster-Algorithmus 5.3.2 Definition von spot- oder clusterbasierten Klassifikationsmodellen 5.4 Ergebnisse der PGI-Detektionsfähigkeit 5.4.1 Auswertung für Patienten mit Prostata-Tumor 5.4.2 Auswertung für Patienten mit Tumoren im Kopf-Hals-Bereich 5.5 Diskussion 6 Genauigkeit zweier Reichweiteverifikationsmethoden – bizentrischer Vergleich 6.1 Material und Methoden 6.1.1 Bildgebung 6.1.2 Bestrahlungsplanung 6.1.3 Durchführung und Auswertung 6.2 Ergebnisse 6.3 Diskussion 7 Zusammenfassung 8 Summary

Cadmium (Cd) concentration in the environment has increased in most recent decades, which represents a serious socio-environmental problem, since Cd is toxic to most living beings. Thus, it is important to reduce the concentration of this metal in contaminated environments, and the use of plants properly supplied with sulfur (S) can contribute to this (phytoextraction), since S is a component of metabolites involved in defense responses against stress caused by Cd. Therefore, our aim with this study was to evaluate the effect of S on i) Cd uptake kinetics, ii) root development and nutrient uptake, iii) metabolic profiling and thiol peptides synthesis, and iv) activity of antioxidant and photosynthetic system of Massai grass (Panicum maximum Jacq. cv. Massai) used for Cd phytoextraction. The studies were carried out in a greenhouse conditions using pots of 0.5 and 2.0 L for development of the study about Cd uptake kinetics (treatments represented by combinations of S: 0.1 and 1.9 mmol L-1 and Cd concentrations: 0.1 and 0.5 mmol L-1) and Cd detoxification mechanisms (treatments represented by combinations of S: 0.1, 1.9 and 3.7 mmol L-1 and Cd concentrations: 0.0, 0.1 and 0.5 mmol L-1), respectively. Pots were distributed in randomized blocks, with four replications. Plants used in Cd kinetics study were exposed to treatments for 14 days after they remained in solutions containing only S for 42 days, while plants used in Cd detoxification study were exposed to treatments for 9 days after growing in solutions containing only S for 44 days. At the end of studies, plants used were harvested and sent for analysis. Maximum uptake rate (Vmax) and Cd apoplastic influx of Massai grass exposed to highest Cd concentration was highest when the plants were supplied with highest S concentration. The root development of Massai grass was strongly inhibited when plants were exposed to 0.5 mmol L-1 Cd, but proper (1.9 mmol L-1) S supply allowed highest Cd uptake, while excessive S supply (3.7 mmol L-1) decreased iron plaques formation in the roots of plants. Lysine, cysteine, ornithine, arginine, tryptophan and histidine were accumulated in more than one tissue in plants exposed to Cd, as well as galactinol. Glutathione (GSH), phytochelatins (PCs) and their homologues were strongly induced by Cd, whereas plants supplied with 1.9 and/or 3.7 mmol L-1 S showed the highest concentrations of these peptides. Plants supplied with highest S concentration showed lowest lipid peroxidation and highest photosynthetic rate, which evidences that antioxidant system of these plants was more efficient in mitigating the damages caused by Cd. In view of these results, it is clear that Massai grass properly supplied with S shows greatest Cd tolerance, as well as phytoextraction potential / A concentração de cádmio (Cd) no ambiente aumentou em décadas recentes, o que representa sério problema sócio-ambiental, visto que o Cd é tóxico para a maioria dos seres vivos. Por isso, é importante reduzir a concentração desse metal em ambientes contaminados e o uso de plantas adequadamente supridas com enxofre (S) pode contribuir para isso (fitoextração), uma vez que o S é componente de metabólitos envolvidos no combate ao estresse causado pelo Cd. Assim, o nosso objetivo com esse estudo foi avaliar o efeito do S na i) cinética de absorção do Cd, no ii) desenvolvimento radicular e na absorção de nutrientes, no iii) perfil metabólico e síntese de compostos tiol, e iv) na atividade do sistema antioxidante e fotossintético do capim-massai (Panicum maximum Jacq. cv. Massai), utilizado para fitoextração de Cd. Os estudos foram conduzidos em casa de vegetação utilizando-se vasos de 0,5 e 2,0 L para a condução do estudo de cinética de absorção de Cd (tratamentos representados pelas combinações das doses de S de 0,1 e 1,9 mmol L-1 e Cd de 0,1 e 0,5 mmol L-1) e para o estudo dos mecanismos de detoxificação de Cd (tratamentos representados pelas combinações das doses de S de 0,1; 1,9 e 3,7 mmol L-1 e Cd de 0,0; 0,1 e 0,5 mmol L-1), respectivamente. Os vasos foram distribuídos em blocos ao acaso, com quatro repetições. As plantas utilizadas no estudo de cinética foram expostas aos tratamentos durante 14 dias após as mesmas terem permanecido em soluções contendo apenas S durante 42 dias, enquanto as plantas utilizadas no estudo de detoxificação de Cd foram expostas aos tratamentos pelo período de 9 dias após terem crescido em soluções contendo apenas S por 44 dias. Ao final dos estudos, as plantas utilizadas foram colhidas e encaminhadas para análises. A velocidade máxima de absorção (Vmax) e o influxo apoplástico de Cd do capim-massai exposto à maior dose de Cd foram maiores quando as plantas foram supridas com a maior dose de S. O desenvolvimento radicular do capim-massai foi fortemente inibido quando as plantas foram expostas à dose de Cd de 0,5 mmol L-1, mas o adequado (1,9 mmol L-1) suprimento de S permitiu maior absorção de Cd, enquanto o suprimento excessivo (3,7 mmol L-1) de S diminuiu a formação de placas de ferro nas raízes das plantas. A lisina, cisteína, ornitina, arginina, triptofano e histidina foram acumulados em mais de um tecido nas plantas expostas ao Cd, assim como o galactinol. A glutationa (GSH), as fitoquelatinas (PCs) e seus homólogos foram fortemente induzidos pelo Cd, sendo que as plantas supridas com as doses de S de 1,9 e/ou 3,7 mmol L-1 apresentaram as maiores concentrações desses peptídeos. As plantas supridas com as maiores doses de S apresentaram menor peroxidação lipídica e maior taxa fotossintética, o que demonstra que o sistema antioxidante dessas plantas foi mais eficiente na atenuação dos danos causados pelo Cd. Diante desses resultados, fica claro que o capim-massai suprido adequadamente com S apresenta maior tolerância ao Cd, assim como maior potencial de fitoextração

Cadmium (Cd) concentration in the environment has increased in most recent decades, which represents a serious socio-environmental problem, since Cd is toxic to most living beings. Thus, it is important to reduce the concentration of this metal in contaminated environments, and the use of plants properly supplied with sulfur (S) can contribute to this (phytoextraction), since S is a component of metabolites involved in defense responses against stress caused by Cd. Therefore, our aim with this study was to evaluate the effect of S on i) Cd uptake kinetics, ii) root development and nutrient uptake, iii) metabolic profiling and thiol peptides synthesis, and iv) activity of antioxidant and photosynthetic system of Massai grass (Panicum maximum Jacq. cv. Massai) used for Cd phytoextraction. The studies were carried out in a greenhouse conditions using pots of 0.5 and 2.0 L for development of the study about Cd uptake kinetics (treatments represented by combinations of S: 0.1 and 1.9 mmol L-1 and Cd concentrations: 0.1 and 0.5 mmol L-1) and Cd detoxification mechanisms (treatments represented by combinations of S: 0.1, 1.9 and 3.7 mmol L-1 and Cd concentrations: 0.0, 0.1 and 0.5 mmol L-1), respectively. Pots were distributed in randomized blocks, with four replications. Plants used in Cd kinetics study were exposed to treatments for 14 days after they remained in solutions containing only S for 42 days, while plants used in Cd detoxification study were exposed to treatments for 9 days after growing in solutions containing only S for 44 days. At the end of studies, plants used were harvested and sent for analysis. Maximum uptake rate (Vmax) and Cd apoplastic influx of Massai grass exposed to highest Cd concentration was highest when the plants were supplied with highest S concentration. The root development of Massai grass was strongly inhibited when plants were exposed to 0.5 mmol L-1 Cd, but proper (1.9 mmol L-1) S supply allowed highest Cd uptake, while excessive S supply (3.7 mmol L-1) decreased iron plaques formation in the roots of plants. Lysine, cysteine, ornithine, arginine, tryptophan and histidine were accumulated in more than one tissue in plants exposed to Cd, as well as galactinol. Glutathione (GSH), phytochelatins (PCs) and their homologues were strongly induced by Cd, whereas plants supplied with 1.9 and/or 3.7 mmol L-1 S showed the highest concentrations of these peptides. Plants supplied with highest S concentration showed lowest lipid peroxidation and highest photosynthetic rate, which evidences that antioxidant system of these plants was more efficient in mitigating the damages caused by Cd. In view of these results, it is clear that Massai grass properly supplied with S shows greatest Cd tolerance, as well as phytoextraction potential / A concentração de cádmio (Cd) no ambiente aumentou em décadas recentes, o que representa sério problema sócio-ambiental, visto que o Cd é tóxico para a maioria dos seres vivos. Por isso, é importante reduzir a concentração desse metal em ambientes contaminados e o uso de plantas adequadamente supridas com enxofre (S) pode contribuir para isso (fitoextração), uma vez que o S é componente de metabólitos envolvidos no combate ao estresse causado pelo Cd. Assim, o nosso objetivo com esse estudo foi avaliar o efeito do S na i) cinética de absorção do Cd, no ii) desenvolvimento radicular e na absorção de nutrientes, no iii) perfil metabólico e síntese de compostos tiol, e iv) na atividade do sistema antioxidante e fotossintético do capim-massai (Panicum maximum Jacq. cv. Massai), utilizado para fitoextração de Cd. Os estudos foram conduzidos em casa de vegetação utilizando-se vasos de 0,5 e 2,0 L para a condução do estudo de cinética de absorção de Cd (tratamentos representados pelas combinações das doses de S de 0,1 e 1,9 mmol L-1 e Cd de 0,1 e 0,5 mmol L-1) e para o estudo dos mecanismos de detoxificação de Cd (tratamentos representados pelas combinações das doses de S de 0,1; 1,9 e 3,7 mmol L-1 e Cd de 0,0; 0,1 e 0,5 mmol L-1), respectivamente. Os vasos foram distribuídos em blocos ao acaso, com quatro repetições. As plantas utilizadas no estudo de cinética foram expostas aos tratamentos durante 14 dias após as mesmas terem permanecido em soluções contendo apenas S durante 42 dias, enquanto as plantas utilizadas no estudo de detoxificação de Cd foram expostas aos tratamentos pelo período de 9 dias após terem crescido em soluções contendo apenas S por 44 dias. Ao final dos estudos, as plantas utilizadas foram colhidas e encaminhadas para análises. A velocidade máxima de absorção (Vmax) e o influxo apoplástico de Cd do capim-massai exposto à maior dose de Cd foram maiores quando as plantas foram supridas com a maior dose de S. O desenvolvimento radicular do capim-massai foi fortemente inibido quando as plantas foram expostas à dose de Cd de 0,5 mmol L-1, mas o adequado (1,9 mmol L-1) suprimento de S permitiu maior absorção de Cd, enquanto o suprimento excessivo (3,7 mmol L-1) de S diminuiu a formação de placas de ferro nas raízes das plantas. A lisina, cisteína, ornitina, arginina, triptofano e histidina foram acumulados em mais de um tecido nas plantas expostas ao Cd, assim como o galactinol. A glutationa (GSH), as fitoquelatinas (PCs) e seus homólogos foram fortemente induzidos pelo Cd, sendo que as plantas supridas com as doses de S de 1,9 e/ou 3,7 mmol L-1 apresentaram as maiores concentrações desses peptídeos. As plantas supridas com as maiores doses de S apresentaram menor peroxidação lipídica e maior taxa fotossintética, o que demonstra que o sistema antioxidante dessas plantas foi mais eficiente na atenuação dos danos causados pelo Cd. Diante desses resultados, fica claro que o capim-massai suprido adequadamente com S apresenta maior tolerância ao Cd, assim como maior potencial de fitoextração