Low-energy X-rays in the range 10 - 50 keV have a wide application. One important application in radiological diagnostics is mammography, whereas, in radiotherapy, they are used for irradiation of superficial tumours, in brachytherapy and photon activation therapy. The importance of soft X-rays for fundamental radiobiological research is based on the fact, that all species of ionizing radiation produce a wide spectrum of secondary electrons, mainly responsible for the primary damage to be transformed into an observable radiobiological effect. By variation of the primary soft X-ray energy, a variation in the secondary electron spectra and therefore in the local energy deposition is provided. However, up to now no definitive conclusions about the relative biological effectiveness (RBE) of soft X-rays can be made due to its dependence on the photon energy, biological endpoint and dose range and the consequent large spread of the published data. The superconducting electron linear accelerator of high brilliance and low emittance (ELBE) at the Forschungszentrum Rossendorf with an electron energy up to about 40 MeV is used, among all, to generate X-rays in a wide energy range. One method for production of intensive, quasi-monochromatic X-rays in the energy range 10 - 100 keV tunable in energy, is by channeling of electrons in a perfect crystal. This X-ray source has many advantages over the most widespread X-ray source, which is the X-ray tube. Although the physical basis of the channeling effect has been previously investigated, the feasibility of an X-ray source based on channeling radiation (CR) for radiobiological studies has been for the first time theoretically and experimentally studied and a dedicated CR source built and optimised in the frame of this thesis. CR has been theoretically characterised in order to estimate its applicability for radiobiological studies. A good agreement between the theoretical predictions and the measured data has been found. The intrinsic properties of the CR source have led to the conclusion that monochromatisation is necessary. A monochromator based on HOPG mosaic crystals, was designed and manufactured. The dosimetrical methods have been investigated at the CR source as well as at an X-ray tube. Absolute dose measurements using an ionisation chamber and spectral dose distribution determination using semiconductor detectors have been performed. In addition, an unconventional system based on thermally stimulated exoelectron emission (TSEE) detectors, allowing to measure dose in a small volume and in the real cell environment has been tested and has proven itself appropriate in a variable dose range and in a liquid environment, in cases where reproducible laboratory conditions are provided. The biological endpoints clonogenic cell survival and micronucleus induction have been optimised for two established cell lines. The human mammary epithelial cells MCF-12A have been chosen due to the importance of RBE of soft X-rays for determination of risk from mammography. On the other hand, the use of the widespread mouse fibroblast cell line NIH/3T3 allows to compare the results with previously published data. The influence of the specific irradiation procedure at ELBE on the control level of cell survival and micronucleus induction has been tested and an irradiation system was developed and constructed. In addition, the RBE for soft X-rays was determined by X-ray tube irradiation at the Medical Department of Technische Universität Dresden. The RBE of 10 kV and 25 kV X-rays relative to 200 kV X-rays was determined. The RBE was found to be in the range from 1.0 to 1.4, depending on the used radiation quality, cell line and the biological endpoint, in agreement with previously published data for the same radiation qualities. These results confirm that systematical studies of RBE dependence on photon energy at the ELBE CR source are necessary and feasible.

Protonentherapie ist eine wichtige Behandlungsmodalität in der Radioonkologie. Aufgrund einer vorteilhaften Dosisverteilung im bestrahlten Volumen kann diese Bestrahlungsmethode das tumorumgebende Normalgewebe schützen. Dadurch können Nebenwirkungen in bestimmten Patientenpopulationen, zum Beispiel Kindern oder Patienten mit Gehirntumoren, verringert werden. Trotzdem können nach Protonenbestrahlung von Gehirntumorpatienten Normalgewebsschäden auftreten. Gründe dafür können der notwendige klinische Sicherheitssaum im Normalgewebe, der Einfluss der relativen biologischen Wirksamkeit RBE sowie eine erhöhte Strahlensensitivität bestimmter Gehirnregionen sein. Um diese Aspekte zu beleuchten, werden geeignete präklinische Modelle für die Normalgewebsreaktion im Gehirn nach Protonenbestrahlung benötigt. Darüber hinaus kann eine Risikostratifizierung der Patienten durch die Vorhersage von Nebenwirkungswahrscheinlichkeiten oder der Tumorantwort den Behandlungserfolg erhöhen. Auch hier können präklinische Modelle helfen, um neue prädiktive Biomarker zu finden und um die zugrunde liegenden Mechanismen strahleninduzierter Gehirnschäden besser zu verstehen. Das Ziel dieser Dissertation war die Etablierung und Charakterisierung von adäquaten präklinischen Modellen für die Untersuchung von strahleninduzierten Normalgewebsschäden im Gehirn. Diese Modelle bilden die Grundlage für zukünftige Studien zur Untersuchung von RBE Effekten, der spezifische Strahlensensitivität einzelner Gehirnregionen und neuer Biomarker. Die getesteten Modellsysteme waren in vitro Kulturen von adulten organotypischen Gehirnschnitten, Tumorschnittkultur sowie in vivo Bestrahlung von Gehirnsubvolumina, jeweils mit dem Modellorganismus Maus. Die Etablierung eines Bestrahlungssetups in der experimentellen Protonenanlage und dessen dosimetrische Charakterisierung waren von großer Bedeutung für die Durchführung der biologischen Experimente. Ein weiteres Hauptziel war die Definition klinisch relevanter Endpunkte für frühe und späte Nebenwirkungen. Die Gewebsschnitte wurden durch Messungen des Zellüberlebens und der Entzündungsreaktion, sowie mittels in situ Analyse von Zellmorphologie und DNA Schäden untersucht. Als ergänzendes Modell wurde die Tumorschnittkultur etabliert und ähnliche Endpunkte analysiert. Adulte Gehirnschnitte stellten sich als ungeeignet für präklinische Experimente in der Radioonkologie heraus. Die Messungen von Zelltod und Entzündungswerten zeigten eine starke Zellreaktion auf die Inkulturnahme, aber keine auf die Protonenbestrahlung. In der Histologie wurden gestörte Zellmorphologie, reduzierte Vitalität und eingeschränkte Reparaturfähigkeit von DNA Schäden beobachtet. Daher sollten für strahlenbiologische Experimente andere 3D Zellkulturmodelle in Betracht gezogen werden, wie zum Beispiel Organoide oder durch Tissue Engineering hergestellte Kulturen. Durch die Publikation der Daten leistet diese Dissertation einen wichtigen Beitrag zur aktuellen Forschung, da so künftig die limitierten Ressourcen, die für strahlenbiologische Experimente mit Protonen zur Verfügung stehen, auf relevantere Modelle verwendet werden können. Die Bestrahlung von Gehirnsubvolumina in Mäusen wurde mit dem Ziel etabliert, klinisch vergleichbare Felder zu erreichen. Das gewählte Zielvolumen war der rechte Hippocampus; der Protonenstrahl sollte in der Mitte des Gehirns stoppen. Im Rahmen des Projekts wurde ein Arbeitsablauf für präzise und reproduzierbare Bestrahlung entwickelt. Zur Verifizierung wurde der induzierte DNA Schaden ausgewertet und anschließend mit Monte-Carlos Dosissimulationen korreliert. Die Maushirnbestrahlung lieferte wertvolle Ergebnisse für frühe Zeitpunkte (d.h. innerhalb 24 h nach Bestrahlung). Im Verlauf des Projekts wurde ein Algorithmus erstellt, der schnell und zuverlässig die räumliche Verteilung des DNA Schadens in Relation zur Gesamtzellzahl analysiert. Diese Auswertung zeigte, wie bei der Bestrahlungsplanung vorgesehen, ein Stoppen des Protonenstrahls im Gehirn. Eine anschließende Korrelation der Schadensverteilung mit der applizierten Dosis weist nach, dass das Modell einen wichtigen Beitrag zur Untersuchung des RBE leisten kann. In einer darauf folgenden Studie wurde der Dosis-Zeitverlauf der beobachteten Strahlenreaktion des Normalgewebes genauer beleuchtet. Dafür wurden Untersuchungen des Allgemeinzustands der Versuchstiere, regelmäßige Magnetresonanztomografie (MRI) Messungen über einen Zeitraum von sechs Monaten, sowie abschließende Histologie korreliert. Die Volumenzunahme des Kontrastmittelaustritts, die den Zusammenbruch der Blut-Hirn-Schranke anzeigt, wurde konturiert; aus diesen Daten entstand ein prädiktives Dosis-Volumen Modell. Die Pilotstudie konnte eine dosisabhängige Strahlenreaktion nachweisen, die sich im Zusammenbruch der Blut-Hirn-Schranke, einer Hautreaktion mit vorrübergehender Alopezie, Gewichtsabnahme und zelluläre Veränderung äußerte. Das von den MRI Messungen abgeleitete Modell konnte zuverlässig das Eintreten der Nebenwirkungen, den Krankheitsverlauf, sowie die geschätzte Überlebensdauer der Mäuse vorhersagen. Zusätzlich konnte ein Zusammenhang zwischen den MRI Bildänderungen und den pathologischen Gewebsveränderungen beobachtet werden. Durch die außerordentlich homogene Strahlenreaktion der Tiere können aus den vorliegenden Daten künftig zuverlässig geeignete Dosen für spezifische experimentelle Endpunkte bestimmt werden. Zusammenfassend wurden in dieser Arbeit zwei präklinische Modelle für die Protonengehirnbestrahlung etabliert, nämlich organotypische Gewebsschnitte als 3D Zellkulturmodell sowie in vivo Bestrahlung von Gehirnsubvolumina in Mäusen. Während Zellkulturexperimente die Erwartungen nicht erfüllen konnten, stellen sich die Tierexperimente als hervorragendes Modell für translationale Radioonkologie heraus, welches zusätzlich für andere Strahlenqualitäten eingesetzt werden kann. Darauf basierend können aktuelle und zukünftige Studien die Ursachen von strahleninduzierten Normalgewebsschäden im Gehirn beleuchten, RBE Effekte untersuchen und neue prädiktive Biomarker erforschen.:Contents Abstract i Zusammenfassung v Publications ix List of Figures xiii List of Acronyms and Abbreviations xiv 1 Introduction 3 2 Background 5 2.1 Proton therapy for brain cancer treatment 5 2.1.1 Fundamentals of radiobiology 5 2.1.2 Proton therapy 6 2.1.3 Tumors of the central nervous system 8 2.2 Radiation effects on brain cells 8 2.2.1 Neurons and myelin 9 2.2.2 Blood-brain barrier 9 2.2.3 Astrocytes 10 2.2.4 Microglia 10 2.3 Principles of histology 11 2.3.1 Hematoxylin & eosin staining 12 2.3.2 Immunohistochemistry 13 2.3.3 Bioimage analysis 13 2.4 Techniques in medical imaging 14 2.4.1 Projectional radiography 14 2.4.2 Computed tomography 14 2.4.3 Magnetic resonance imaging 15 2.5 Preclinical models for radiation injury 17 2.5.1 Technical requirements 17 2.5.2 In vitro models 17 2.5.3 Small animal models 18 3 Applying Tissue Slice Culture in Cancer Research – Insights from Preclinical Proton Radiotherapy 19 3.1 Aim of the study 19 3.2 Conclusion 19 3.3 Author’s contribution 19 3.4 Publication 21 4 High-precision image-guided proton irradiation of mouse brain sub-volumes 41 4.1 Aim of the study 41 4.2 Conclusion 41 4.3 Author’s contribution 41 4.4 Publication 43 5 Late side effects in normal mouse brain tissue after proton irradiation 51 5.1 Aim of the study 51 5.2 Conclusion 51 5.3 Author’s contribution 52 5.4 Publication 53 6 Discussion 71 6.1 Establishment of preclinical models for radiooncology 71 6.1.1 3D cell culture 71 6.1.2 In vivo irradiation of brain subvolumes 73 6.2 Current applications of the mouse model 75 6.2.1 Ongoing data analysis 75 6.2.2 Innovating on-site imaging 76 6.2.3 RBE investigations 77 6.3 Future studies of radiation-induced brain tissue toxicities 79 Acknowledgement XV Supplementary Material XVII 1 Applying Tissue Slice Culture in Cancer Research – Insights from Preclinical Proton Radiotherapy XVII 2 High-precision image-guided proton irradiation of mouse brain sub-volumes XXVI 3 Late side effects in normal mouse brain tissue after proton irradiation XXXI / Proton therapy is an important modality in radiation oncology. Due to a favorable dose distribution in the irradiated volume, this treatment allows to spare tumor-surrounding normal tissue. Although this protection can lead to reduced side effects in certain patient populations, such as brain tumor or pediatric patients, normal tissue toxicities can occur to some extend. This could be due to clinical safety margins around the tumor that lead to dose deposition in the normal tissue. The underlying causes might also be related to relative biological effectiveness (RBE) variations or elevated radiosensitivity of certain brain regions. To address these issues, suitable preclinical models for normal brain tissue reaction after proton therapy are needed. In addition, patient stratification to predict the tumor response or the probability of side effects will contribute to increased treatment effectiveness. Preclinical models can improve the process of finding new predictive biomarkers and help to understand underlying mechanisms of radiation-induced brain injury. The aim of this thesis was to establish and characterize suitable preclinical models of brain tissue irradiation effects and set the base for future studies designed to reveal RBE effects, brain region specific radiation sensitivities, and novel biomarkers. The tested model systems were in vitro organotypic brain slice culture (OBSC) and in vivo irradiation of brain subvolumes, both on mouse brain tissue. Setup establishment at the experimental proton beam line and subsequent dosimetry built the foundation for conducting the biological experiments. Additionally, one main goal was defining clinically relevant endpoints for both short- and long-term effects. For OBSC, assays for cell death and inflammation, as well as in situ analysis of cell morphology and DNA damage induction were tested. As comparative model to OBSC, tumor slice culture was established and the results were also used for proton investigation. Adult OBSC turned out as inadequate model for preclinical experiments in radiation oncology. The assays measuring cell death and inflammation indicated a severe reaction during the first days in culture, but no response to irradiation. Histology revealed deficient cell morphology, reduced vitality and impaired DNA damage repair. In conclusion, other 3D cell culture models, such as organoids or tissue engineered constructs, should be considered for radiobiological experiments with protons. By publishing the observations, this thesis contributes to conserving the limited resources of proton radiobiology for more meaningful models. A methodology for irradiation of mouse brain subvolumes was established with a focus on creating fields comparable to clinical practice. The chosen target was the right hippocampus and the goal was to stop the proton beam in the middle of the brain. The project included a workflow for this precise irradiation in a robust and reproducible manner. Evaluation of the induced DNA damage and its correlation to Monte Carlo dose simulations were used for verification. Irradiation of mouse brain subvolumes yielded valuable results for early (i.e. within 24 h after irradiation) time points. An evaluation algorithm was designed for fast and robust analysis of spatial DNA damage distribution in relation to the total cell count. This ratio showed that the beam stopped in the brain tissue, in accordance to the treatment planning. Furthermore, the DNA damage could be reliably correlated with the dose simulation, which proves the value of the presented model for future RBE studies. In a follow-up experiment, the dose-time relationship of induced normal tissue reactions was analysed. For this, scoring of the animals' health status was combined with regular MRI measurements over the course of up to 6 months, and final histopathology. The volume increase of contrast agent leakage - representing breakdown of the blood brain barrier (BBB) - was contoured and the data was used to create a dose-volume response model. This pilot study on long-term radiation effects revealed dose-dependent normal tissue toxicities, including breakdown of the BBB, a skin reaction with temporary alopecia, weight reduction and changes on the cellular level. The model derived from MRI data reliably predicts onset of side effects, volume of brain damage as well as the expected animal survival. In addition, MRI image changes could be correlated to underlying tissue alterations by histopathology. Due to the uniform radiation response of the animals this data set enables to determine endpoint-specific dose values in future experiments. In conclusion, two preclinical models for proton brain irradiation were established, namely OBSC as 3D cell culture model and in vivo irradiation of mouse brain subvolumes. While the former could not yield the anticipated results, the latter emerged as excellent model for translational radiooncology, which can also be applied for experiments with other radiation types. Ongoing and future studies will focus on revealing the causes of normal brain tissue toxicities, studying RBE effects, and investigating new predictive biomarkers.:Contents Abstract i Zusammenfassung v Publications ix List of Figures xiii List of Acronyms and Abbreviations xiv 1 Introduction 3 2 Background 5 2.1 Proton therapy for brain cancer treatment 5 2.1.1 Fundamentals of radiobiology 5 2.1.2 Proton therapy 6 2.1.3 Tumors of the central nervous system 8 2.2 Radiation effects on brain cells 8 2.2.1 Neurons and myelin 9 2.2.2 Blood-brain barrier 9 2.2.3 Astrocytes 10 2.2.4 Microglia 10 2.3 Principles of histology 11 2.3.1 Hematoxylin & eosin staining 12 2.3.2 Immunohistochemistry 13 2.3.3 Bioimage analysis 13 2.4 Techniques in medical imaging 14 2.4.1 Projectional radiography 14 2.4.2 Computed tomography 14 2.4.3 Magnetic resonance imaging 15 2.5 Preclinical models for radiation injury 17 2.5.1 Technical requirements 17 2.5.2 In vitro models 17 2.5.3 Small animal models 18 3 Applying Tissue Slice Culture in Cancer Research – Insights from Preclinical Proton Radiotherapy 19 3.1 Aim of the study 19 3.2 Conclusion 19 3.3 Author’s contribution 19 3.4 Publication 21 4 High-precision image-guided proton irradiation of mouse brain sub-volumes 41 4.1 Aim of the study 41 4.2 Conclusion 41 4.3 Author’s contribution 41 4.4 Publication 43 5 Late side effects in normal mouse brain tissue after proton irradiation 51 5.1 Aim of the study 51 5.2 Conclusion 51 5.3 Author’s contribution 52 5.4 Publication 53 6 Discussion 71 6.1 Establishment of preclinical models for radiooncology 71 6.1.1 3D cell culture 71 6.1.2 In vivo irradiation of brain subvolumes 73 6.2 Current applications of the mouse model 75 6.2.1 Ongoing data analysis 75 6.2.2 Innovating on-site imaging 76 6.2.3 RBE investigations 77 6.3 Future studies of radiation-induced brain tissue toxicities 79 Acknowledgement XV Supplementary Material XVII 1 Applying Tissue Slice Culture in Cancer Research – Insights from Preclinical Proton Radiotherapy XVII 2 High-precision image-guided proton irradiation of mouse brain sub-volumes XXVI 3 Late side effects in normal mouse brain tissue after proton irradiation XXXI

Low-energy X-rays in the range 10 - 50 keV have a wide application. One important application in radiological diagnostics is mammography, whereas, in radiotherapy, they are used for irradiation of superficial tumours, in brachytherapy and photon activation therapy. The importance of soft X-rays for fundamental radiobiological research is based on the fact, that all species of ionizing radiation produce a wide spectrum of secondary electrons, mainly responsible for the primary damage to be transformed into an observable radiobiological effect. By variation of the primary soft X-ray energy, a variation in the secondary electron spectra and therefore in the local energy deposition is provided. However, up to now no definitive conclusions about the relative biological effectiveness (RBE) of soft X-rays can be made due to its dependence on the photon energy, biological endpoint and dose range and the consequent large spread of the published data. The superconducting electron linear accelerator of high brilliance and low emittance (ELBE) at the Forschungszentrum Rossendorf with an electron energy up to about 40 MeV is used, among all, to generate X-rays in a wide energy range. One method for production of intensive, quasi-monochromatic X-rays in the energy range 10 - 100 keV tunable in energy, is by channeling of electrons in a perfect crystal. This X-ray source has many advantages over the most widespread X-ray source, which is the X-ray tube. Although the physical basis of the channeling effect has been previously investigated, the feasibility of an X-ray source based on channeling radiation (CR) for radiobiological studies has been for the first time theoretically and experimentally studied and a dedicated CR source built and optimised in the frame of this thesis. CR has been theoretically characterised in order to estimate its applicability for radiobiological studies. A good agreement between the theoretical predictions and the measured data has been found. The intrinsic properties of the CR source have led to the conclusion that monochromatisation is necessary. A monochromator based on HOPG mosaic crystals, was designed and manufactured. The dosimetrical methods have been investigated at the CR source as well as at an X-ray tube. Absolute dose measurements using an ionisation chamber and spectral dose distribution determination using semiconductor detectors have been performed. In addition, an unconventional system based on thermally stimulated exoelectron emission (TSEE) detectors, allowing to measure dose in a small volume and in the real cell environment has been tested and has proven itself appropriate in a variable dose range and in a liquid environment, in cases where reproducible laboratory conditions are provided. The biological endpoints clonogenic cell survival and micronucleus induction have been optimised for two established cell lines. The human mammary epithelial cells MCF-12A have been chosen due to the importance of RBE of soft X-rays for determination of risk from mammography. On the other hand, the use of the widespread mouse fibroblast cell line NIH/3T3 allows to compare the results with previously published data. The influence of the specific irradiation procedure at ELBE on the control level of cell survival and micronucleus induction has been tested and an irradiation system was developed and constructed. In addition, the RBE for soft X-rays was determined by X-ray tube irradiation at the Medical Department of Technische Universität Dresden. The RBE of 10 kV and 25 kV X-rays relative to 200 kV X-rays was determined. The RBE was found to be in the range from 1.0 to 1.4, depending on the used radiation quality, cell line and the biological endpoint, in agreement with previously published data for the same radiation qualities. These results confirm that systematical studies of RBE dependence on photon energy at the ELBE CR source are necessary and feasible.

Protonen töten Zellen wirksamer ab als Photonen. Die klinisch verwendete konstante relative biologische Wirksamkeit (RBW) für Protonen vernachlässigt jedoch erste klinische Evidenz einer RBW-Variabilität, die vom linearen Energietransfer (LET) abhängt. Diese Arbeit trägt dazu bei, die RBW-Variabilität in Protonen-Bestrahlungsplänen zu berücksichtigen, um potenzielle Nebenwirkungen zu vermindern. Zuerst wurde ein erhöhtes Risiko für RBW-induzierte Nebenwirkungen bei Hirntumorpatienten festgestellt. Dies konnte jedoch nicht systematisch durch klinische Planungsstrategien reduziert werden. Zweitens ergab eine multizentrische europäische Studie, dass die zentrums-spezifischen, nicht standardisierten LET-Berechnungen erheblich voneinander abweichen. Eine harmonisierte LET-Definition wurde vorgeschlagen und reduzierte die Variabilität zwischen den Zentren auf ein klinisch akzeptables Niveau, was künftig eine einheitliche Dokumentation des Therapieergebnisses ermöglicht. Abschließend wurden vier Strategien zur RBW-Reduktion in der Planoptimierung bei Hirntumorpatienten angewandt, die das Risiko für Nekrose und Erblindung erheblich reduzierten. LET-Optimierung in Hochdosisregionen erscheint besonders geeignet, um die Sicherheit der Patientenbehandlung künftig weiter zu verbessern.:List of Figures vii List of Tables viii List of Acronyms and Abbreviations ix 1 Introduction 1 2 Theoretical background 3 2.1 Proton interactions with matter 4 2.2 Biological effect of radiation 8 2.2.1 Linear-quadratic model 8 2.2.2 Relative biological effectiveness 9 2.3 Proton beam delivery and field formation 13 2.4 Treatment planning 14 2.4.1 Patient modelling and structure definition 15 2.4.2 Treatment plan optimisation 16 2.4.3 Treatment plan evaluation 19 2.5 Proton therapy uncertainties and mitigation strategies 22 2.5.1 Clinical mitigation strategies 23 2.5.2 Optimisation approaches beyond absorbed dose 26 3 Variable biological effectiveness in PBS treatment plans 29 3.1 LET and RBE recalculations of proton treatment plans with RayStation 30 3.1.1 Monte Carlo dose engine 30 3.1.2 Monte Carlo scoring extensions 32 3.1.3 Graphical user interface 33 3.2 LET assessment and the role of range uncertainties 36 3.2.1 Patient cohort and treatment plan creation 37 3.2.2 Simulation of range deviations 38 3.2.3 Treatment plan recalculation settings 39 3.2.4 Resulting impact of range deviations 40 3.3 Patient recalculations in case of side effects 46 3.3.1 Image registration and range prediction 48 3.3.2 Retrospective treatment plan assessment 49 3.4 Benefit of an additional treatment field 50 3.4.1 Patient and treatment plan information 50 3.4.2 Results of variable RBE recalculations 51 3.5 Discussion 51 3.6 Summary 59 4 Status of LET and RBE calculations in European proton therapy 61 4.1 Study design 62 4.1.1 Treatment planning information 64 4.1.2 Data processing and treatment plan evaluation 67 4.2 Treatment plan comparisons in the water phantom 68 4.2.1 Absorbed dose evaluation 69 4.2.2 Centre-specific LET calculations 69 4.2.3 Harmonised LET calculations 71 4.3 Treatment plan comparisons in patient cases 72 4.3.1 Dose-averaged linear energy transfer for protons 73 4.3.2 Centre-specific RBE models and parameters 76 4.4 Discussion 77 4.5 Summary 82 5 Biological treatment plan optimisation 83 5.1 Treatment plan design 84 5.1.1 Clinical goals 86 5.1.2 Novel treatment plan optimisation approaches 87 5.2 Treatment plan quality assessment with a constant RBE 90 5.3 Assessment of NTCP reductions with a variable RBE 90 5.4 Discussion 95 5.5 Conclusion 100 6 Summary 103 7 Zusammenfassung 107 Bibliography 111 Danksagung 137 / Protons are more effective in cell killing than photons. However, the clinically applied constant proton relative biological effectiveness (RBE) neglects emerging clinical evidence for RBE variability driven by the linear energy transfer (LET). This thesis aims to safely account for RBE variability in proton treatment plans to mitigate potential side effects. First, an elevated risk for RBE induced overdosage was found in brain tumour patients. However, this could not be mitigated systematically by clinical planning strategies. Second, a multicentric European study revealed that centre-specific non-standardised LET calculations differed substantially. A harmonised LET definition was proposed which reduced the inter-centre variability to a clinically acceptable level and allows for future consistent outcome reporting. Finally, four strategies to include RBE variability in treatment plan optimisation were applied to brain tumour patients, which considerably reduced the estimated risk for necrosis and blindness. Of these, LET optimisation in high dose regions may be suited for clinical practice to further enhance patient safety in view of a variable RBE.:List of Figures vii List of Tables viii List of Acronyms and Abbreviations ix 1 Introduction 1 2 Theoretical background 3 2.1 Proton interactions with matter 4 2.2 Biological effect of radiation 8 2.2.1 Linear-quadratic model 8 2.2.2 Relative biological effectiveness 9 2.3 Proton beam delivery and field formation 13 2.4 Treatment planning 14 2.4.1 Patient modelling and structure definition 15 2.4.2 Treatment plan optimisation 16 2.4.3 Treatment plan evaluation 19 2.5 Proton therapy uncertainties and mitigation strategies 22 2.5.1 Clinical mitigation strategies 23 2.5.2 Optimisation approaches beyond absorbed dose 26 3 Variable biological effectiveness in PBS treatment plans 29 3.1 LET and RBE recalculations of proton treatment plans with RayStation 30 3.1.1 Monte Carlo dose engine 30 3.1.2 Monte Carlo scoring extensions 32 3.1.3 Graphical user interface 33 3.2 LET assessment and the role of range uncertainties 36 3.2.1 Patient cohort and treatment plan creation 37 3.2.2 Simulation of range deviations 38 3.2.3 Treatment plan recalculation settings 39 3.2.4 Resulting impact of range deviations 40 3.3 Patient recalculations in case of side effects 46 3.3.1 Image registration and range prediction 48 3.3.2 Retrospective treatment plan assessment 49 3.4 Benefit of an additional treatment field 50 3.4.1 Patient and treatment plan information 50 3.4.2 Results of variable RBE recalculations 51 3.5 Discussion 51 3.6 Summary 59 4 Status of LET and RBE calculations in European proton therapy 61 4.1 Study design 62 4.1.1 Treatment planning information 64 4.1.2 Data processing and treatment plan evaluation 67 4.2 Treatment plan comparisons in the water phantom 68 4.2.1 Absorbed dose evaluation 69 4.2.2 Centre-specific LET calculations 69 4.2.3 Harmonised LET calculations 71 4.3 Treatment plan comparisons in patient cases 72 4.3.1 Dose-averaged linear energy transfer for protons 73 4.3.2 Centre-specific RBE models and parameters 76 4.4 Discussion 77 4.5 Summary 82 5 Biological treatment plan optimisation 83 5.1 Treatment plan design 84 5.1.1 Clinical goals 86 5.1.2 Novel treatment plan optimisation approaches 87 5.2 Treatment plan quality assessment with a constant RBE 90 5.3 Assessment of NTCP reductions with a variable RBE 90 5.4 Discussion 95 5.5 Conclusion 100 6 Summary 103 7 Zusammenfassung 107 Bibliography 111 Danksagung 137

No description available.

The aim of this thesis was to develop user interface in LabVIEW to make typical measurements with spectral analyzer HP89410A There is introduced the theory of operation of an analogue heterodyne and a digital FFT spectral analyzer. It is explained the background of the Fast Fourier Transform. There are discussed the key settings in measuring with FTT analyzer, like window function, bandwidth, number of frequency points, or the averaging. Further is described the program, which was developed for measuring frequency characteristic by white noise and by stepped measurement. It was also made a module for measuring Signal to Noise Ratio and module for Total Harmonic Distortion. In the last part of this thesis are shown the results of processed exemplar measurements.