Monaco 5.10 Training Guide [PDF]

Zitiervorschau

Monaco® Training Guide

IMPAC Medical Systems, Inc. Document ID: LTGMON0510 Part Number: C#98961-EN Language: English

Revision History Revision LTGMON0500

Version 1.0

Date December 2013

LTGMON0510

1.0

April 2015

LTGMON0510

2.0

September 2015

Changes New sections and content due to 3D planning New section for Stereotactic Planning New section for Siemens mARC New sections for Physics course Workflow and icons changed due to Ribbons Merging of QA Activity Planning process changes due to Prescription and Planning Control New MR Planning exercises and updates for Oblique MR images New Frozen Dose content. New Multiple Prescriptions exercise and updates. New Forward Planning exercise and updates. New Anatomical Sites content. New DICOM Import content and DICOM Export updates. New IMRT/VMAT planning improvement content. New content for Isodose Templates for the 5.1 patch. New content for Rescale Doses and Physician’s Intent for the 5.1 patch. Clarified Arc Rotation information after review of Version 1.0.

Trademarks All terms mentioned in this manual that are known trademarks, registered trademarks, or service marks have been appropriately labeled as such. Other products, services, or terms that are referred to in this manual may be trademarks, registered trademarks, or service marks of their respective owners. IMPAC Medical Systems, Inc. makes no claim to these trademarks. Use of a term in this manual should not be regarded as affecting the validity of any trademark, registered trademark, or service mark. XiO® is a registered trademark of IMPAC Medical Systems, Inc. Monaco™ is a registered trademark of IMPAC Medical Systems, Inc. Adobe™, Acrobat™, and the Acrobat logo are trademarks of Adobe Systems Incorporated, which may be registered in certain jurisdictions. Hewlett-Packard™ is a trademark of Hewlett-Packard Corporation. Netscape® and Netscape Navigator® are registered trademarks of Netscape Communications Corporation in the United States and other countries. Netscape's logos and Netscape product and service names are also trademarks of Netscape Communications Corporation, which may be registered in other countries. UNIX® is a registered trademark in the United States and other countries, licensed exclusively through X/Open Company Ltd. Red Hat and all Red Hat-based trademarks and logos are trademarks or registered trademarks of Red Hat, Inc. in the United States and other countries. Microsoft®, Windows®, and Windows NT® are registered trademarks of Microsoft Corporation in the United States and other countries. Copyright © 2015 by IMPAC Medical Systems, Inc. All rights reserved. Performance characteristics given in this manual are for reference only and are not intended as guaranteed specifications.

Document Number. LTGMON0510 Part Number. C#98961-EN

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Table of Contents Volume I of IV – Monaco Sim Section 1. Overview

Monaco Products...................................................................................................................................... 1-1 Disclaimer .................................................................................................................................................. 1-2 System Activities ....................................................................................................................................... 1-2 Planning Activity ...................................................................................................................................... 1-3 Fusion Activity .......................................................................................................................................... 1-4 Plan Review Activity................................................................................................................................. 1-5 Conditions that Prevent Opening Studysets ......................................................................................... 1-5 Conditions that Prevent Plans from Being Available .......................................................................... 1-6 Entering and Editing the Monaco License ............................................................................................ 1-7 Online Help ............................................................................................................................................... 1-8 Keep the Online Help Window in an Open Status while Performing Functions....................... 1-9 User Authorization Database .................................................................................................................. 1-9 Other Training Resources ..................................................................................................................... 1-10

Section 2. General Operation and Navigation

Overview .................................................................................................................................................... 2-1 Open the Monaco Application and Log In ...................................................................................... 2-1 Patient Management ................................................................................................................................ 2-2 Open the Patient .................................................................................................................................. 2-2 Local Patient Tab.......................................................................................................................... 2-3 Remote XiO Patient Tab (not available for standalone Monaco users) ............................... 2-3 Remote Focal Patient Tab ........................................................................................................... 2-3 Selecting, Filtering and Loading a Patient ................................................................................ 2-3 Treatment Couch Library .................................................................................................................. 2-5 Open Treatment Couch Library................................................................................................. 2-6 Remove Couches from Treatment Couch Library .................................................................. 2-6 Import New Data................................................................................................................................. 2-7 Recalculate DICOM Plan ................................................................................................................. 2-11 Enter or Edit DICOM Export Settings................................................................................................. 2-14 Setup your DICOM File Export Data Location............................................................................. 2-14 Setup Storage of Incoming Images for Future Export........................................................... 2-15 Setup DICOM Export Locations .............................................................................................. 2-15 Export Patient via DICOM.................................................................................................................... 2-16 Exporting via DICOM ...................................................................................................................... 2-17 Delete a Patient (Standalone Users Only) ...................................................................................... 2-21 Patient Workspace Control.............................................................................................................. 2-22

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Table of Contents Section 2. General Operation and Navigation (cont.)

Load a Patient/Plan from Patient Workspace Control ................................................................ 2-23 Load a Studyset ........................................................................................................................... 2-23 Load a Primary and Secondary Studyset ................................................................................. 2-24 Load an Existing Plan ................................................................................................................ 2-25 Unload an Existing Studyset and/or Plan ............................................................................... 2-25 Activate a Loaded Studyset and/or Plan ................................................................................. 2-26 Load Existing Plan(s) Into a Specific Activity ........................................................................ 2-26 Delete a Plan ............................................................................................................................... 2-26 Studyset Info ............................................................................................................................... 2-26 Frozen Dose ....................................................................................................................................... 2-27 QA Plans...................................................................................................................................... 2-28 Multiple Prescription Plans ...................................................................................................... 2-28 Patient Workspace Control Tooltip ............................................................................................... 2-28 Navigating Monaco ................................................................................................................................ 2-29 Ribbons ............................................................................................................................................... 2-29 Styles.................................................................................................................................................... 2-30 Planning Control ............................................................................................................................... 2-30 Save a Plan .......................................................................................................................................... 2-31 Save a Template ................................................................................................................................. 2-33 Autosave Contours............................................................................................................................ 2-34 Close a Patient ................................................................................................................................... 2-34 Image Navigation and View Types ...................................................................................................... 2-35 Transverse, Sagittal, Coronal, and Oblique Views ........................................................................ 2-35 Oblique Views.................................................................................................................................... 2-35 Navigate Through T/S/C/O Images......................................................................................... 2-35 Use the Color-coded T-bars ..................................................................................................... 2-36 Use the Scroll Wheel on the Mouse ......................................................................................... 2-37 Use the Quick Locator Method ................................................................................................ 2-37 Use the Slice Navigator Toolbar ............................................................................................... 2-38 Use the Reference Plane Values ............................................................................................... 2-38 Use the Display Image Plane Option....................................................................................... 2-39 Use the Jump to Point Option .................................................................................................. 2-39 Use the Page Up/Page Down keys (Transverse Images Only) ............................................. 2-39 Adjust Window and Level......................................................................................................... 2-39 Adjust Window and Level Using the Mouse .......................................................................... 2-40 Adjust Window and Level from the Window and Level on Tools tab ............................... 2-40 Select an Image Set/View in the Window/Level Affects Drop-Down Menu ..................... 2-41 Link W/L Affect to Image Sets ................................................................................................. 2-41 Adjust Window and Level Using User-Definable Window Level Presets.......................... 2-42 Non-Editable Window/Level Presets ...................................................................................... 2-42

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Table of Contents Section 2. General Operation and Navigation (cont.)

Zoom and Pan T/S/C/O and 3D Images ............................................................................... 2-43 Zoom .......................................................................................................................................... 2-43 Zoom Continuously ........................................................................................................................ 2-43 Reset Zoom and Pan ....................................................................................................................... 2-43 Magnifying Glass ............................................................................................................................. 2-44 Zoom Area of Interest .................................................................................................................... 2-45 Pan.............................................................................................................................................. 2-46 Screen Layout ........................................................................................................................................ 2-47 Layouts .............................................................................................................................................. 2-47 Save Layout as Preset Option.................................................................................................. 2-47 Manage Layouts........................................................................................................................ 2-48 User Defaults ............................................................................................................................ 2-49 User Layouts ............................................................................................................................. 2-50 Global Layouts .......................................................................................................................... 2-51 Side-by-Side Layout ........................................................................................................................ 2-52 Side-by-Side: Planning Activity.............................................................................................. 2-53 Side-by-Side: Plan Review Activity ........................................................................................ 2-53 3D View ............................................................................................................................................ 2-54 3D Rotate ................................................................................................................................... 2-55 3D Translate.............................................................................................................................. 2-56 Reset 3D Image Navigation Functions ......................................................................................... 2-56 Reset 3D Functions .................................................................................................................. 2-56 4D Imaging Overview .......................................................................................................................... 2-57 4D Imaging....................................................................................................................................... 2-57 Import 4D Data ........................................................................................................................ 2-57 Multiple Structure Sets ............................................................................................................ 2-58 Create a Specialty Image.......................................................................................................... 2-58 Measurement Grid ................................................................................................................... 2-60 Use Grid to Measure Movement ............................................................................................ 2-60 4D Margin ................................................................................................................................. 2-63 Print 4D Auto Margin Report ................................................................................................ 2-64 Cine View .................................................................................................................................. 2-65 DRR Views ....................................................................................................................................... 2-66 Show MIP (Maximum Intensity Projection)........................................................................ 2-67 Show Grid (Reticule) ............................................................................................................... 2-68 Jaw Labels .................................................................................................................................. 2-68 DRR Volume of Interest Tool ................................................................................................ 2-69 Display Synth. CT............................................................................................................................ 2-70 Room’s Eye View ............................................................................................................................. 2-71 Room’s Eye View-Display Options........................................................................................ 2-72

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Table of Contents Section 2. General Operation and Navigation (cont.)

Room’s Eye View-Menu.......................................................................................................... 2-72 Additional Navigation and Screen Customization Tools ............................................................... 2-74 Maximize and Restore a Window ................................................................................................. 2-74 Patient Orientation Icon ................................................................................................................ 2-74 Move Control Dialog Box .............................................................................................................. 2-75 Printing Options ................................................................................................................................... 2-77 Print/Export a Transverse, Sagittal, Coronal, Oblique, or 3D Image....................................... 2-77 Print or Export the Screen.............................................................................................................. 2-78 Print DRRs ....................................................................................................................................... 2-79 Select the Print Type ................................................................................................................ 2-80 Select Options and Copies ...................................................................................................... 2-81 Print or Export Monaco IMRT Plan Reports .............................................................................. 2-82 Print/Export Individual Reports ............................................................................................ 2-82 Print/Export Custom Reports ................................................................................................ 2-83 Additional IMRT Plan Report Options................................................................................. 2-85 Print DICOM Coordinates on reports instead of the proprietary system ....................... 2-85 Include Base Dose on Reports for Bias Dose plans ............................................................. 2-85 Print DICOM Plan Report ............................................................................................................. 2-85

Section 3. CT Simulation Options

CT Simulation Options .......................................................................................................................... 3-1 Determine the Shifts to a Structure Center, Interest Point, Marker, or Beam Isocenter ......... 3-1 Determine the Shift using Virtual Fluoroscopy ............................................................................ 3-4 Determine Shifts in Absolute Coordinates .................................................................................... 3-6 Determine Setup Reference Coordinates ....................................................................................... 3-6 Assign CT-to-ED to Patient .................................................................................................................. 3-8 Create and Edit a CT-to-ED File (Standalone Users Only) .............................................................. 3-8 Create and Edit a CT-to-ED File (Monaco with XiO Users) ............................................................ 3-8 Create and Edit a CT-to-ED File .......................................................................................................... 3-9 Create a New CT-to-ED File ............................................................................................................ 3-9 Edit an Existing CT-to-ED File to Create a New CT-to-ED File .............................................. 3-11 Assign CT-to-ED to Studyset ........................................................................................................ 3-11 Planning on MR Studysets ............................................................................................................. 3-12

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Table of Contents Section 4. Fusion Activity

Overview .................................................................................................................................................. 4-1 Open a Primary and Secondary Studyset ............................................................................................ 4-1 Studyset Volume Toolbar................................................................................................................. 4-2 Select How to Show the Primary and/or Secondary Studysets ............................................ 4-2 Apply a colormap to a Studyset ................................................................................................ 4-2 Masking Options (Optional) ................................................................................................................. 4-3 Patient Contours ............................................................................................................................... 4-3 Shape/Intensity Model ...................................................................................................................... 4-4 RE Segmentation ............................................................................................................................... 4-4 No Mask (default) ............................................................................................................................. 4-4 Create a Registration .............................................................................................................................. 4-5 Create a Registration Manually ....................................................................................................... 4-5 Point Registration.............................................................................................................................. 4-6 Add Points in Point Registration ............................................................................................. 4-6 Delete an Individual Point in Point Registration................................................................... 4-8 Delete Multiple Points ............................................................................................................... 4-8 Create a Registration using Auto Registration .............................................................................. 4-8 Use the VOI Masking Tool ..................................................................................................... 4-10 Verify the Results of the Alignment ................................................................................................... 4-12 Fusion Display Options .................................................................................................................. 4-12 Blended Display ........................................................................................................................ 4-12 Transition between Primary and Secondary Images ........................................................... 4-13 Horizontal, Vertical and Checkerboard Display.................................................................. 4-14 Pan/Reset Fusion Display Options ........................................................................................ 4-15 View/Edit the Transformation Matrix ......................................................................................... 4-16 (Optional) Registering Multiple Studysets ........................................................................................ 4-18

Section 5. Contouring Tools

Overview .................................................................................................................................................. 5-1 Draw Contour ......................................................................................................................................... 5-2 Replace (Contour Editing Tool) ........................................................................................................... 5-4 Contour Editing Tips ........................................................................................................................ 5-6 Guide Radius ...................................................................................................................................... 5-7 Reshape Contour (Contour Editing Tool) .......................................................................................... 5-8 Contour by Shapes.................................................................................................................................. 5-8 Paintbrush................................................................................................................................................ 5-9 Contour Using the Paintbrush Tool ............................................................................................... 5-9 Smoothing Contours Using the Paintbrush Tool ....................................................................... 5-10 Change the Transparency of the Painted Area............................................................................ 5-11

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Table of Contents Section 5. Contouring Tools (cont.)

Erase the Painted Contour ............................................................................................................. 5-11 Paintbrush Enhancement Tools .................................................................................................... 5-12 Edge Detection Tool ................................................................................................................ 5-12 Structure Avoidance Tool ....................................................................................................... 5-12 Edge Detection Sensitivity ...................................................................................................... 5-12 Considerations When Using Paintbrush Enhancement Tools .......................................... 5-13 Desirable Image Characteristics of Structures:..................................................................... 5-13 Less Desirable Image Characteristics of Structures: ............................................................ 5-13 Using Structure Avoidance with Paintbrush Tool............................................................... 5-14 Using Structure Avoidance with Edge Detection ................................................................ 5-16 Auto Contouring .................................................................................................................................. 5-19 EZ Sketch Tool................................................................................................................................. 5-19 EZ Sketch – Initial Creation ................................................................................................... 5-19 EZ Sketch Edit Mode – Refine Contour................................................................................ 5-21 EZ Sketch Edit Mode – Global Edit ....................................................................................... 5-23 EZ Sketch – Quick Scheme ..................................................................................................... 5-23 Using Other Editing Tools ...................................................................................................... 5-23 Copy Structure ...................................................................................................................................... 5-24 Copy Superior/Inferior, Anterior/Posterior or Right/Left .............................................................. 5-26 Transverse View .............................................................................................................................. 5-26 Sagittal View..................................................................................................................................... 5-27 Coronal View ................................................................................................................................... 5-28 Interpolation.......................................................................................................................................... 5-29 Auto Threshold ..................................................................................................................................... 5-30 Auto Segmentation ............................................................................................................................... 5-31 Auto Margin .......................................................................................................................................... 5-32 Create an Auto Margin ................................................................................................................... 5-33 Common Margin Templates ......................................................................................................... 5-36 Save a Template ........................................................................................................................ 5-36 Apply a Template ..................................................................................................................... 5-37 Using Advanced Margins ............................................................................................................... 5-38 Create an Advanced Margin .......................................................................................................... 5-40 Save an Advanced Margin Template ............................................................................................ 5-43 Apply an Advanced Margin Template .................................................................................. 5-43 Print a Margin Report..................................................................................................................... 5-44 EZClean.................................................................................................................................................. 5-44 Select and Group Contours and Structures....................................................................................... 5-46 Anatomical Groups .............................................................................................................................. 5-48 Create an Anatomical Group ......................................................................................................... 5-48 Copy Anatomical Group ................................................................................................................ 5-48

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Table of Contents Section 5. Contouring Tools (cont.)

Delete Anatomical Group .............................................................................................................. 5-49 Apply Anatomical Groups ............................................................................................................. 5-49 PET Tools .............................................................................................................................................. 5-50 SUV Calculation .............................................................................................................................. 5-50 DICOM Editor for SUV .......................................................................................................... 5-52 PET Threshold Contouring ........................................................................................................... 5-54 Click on RAW icon to select PET Image Type............................................................................ 5-57 Import Treatment Couchtop .............................................................................................................. 5-58 Prerequisites ..................................................................................................................................... 5-58 Generate Bolus ...................................................................................................................................... 5-62 Generate Bolus – Fill VOI .............................................................................................................. 5-65 Bolus – Editing Tools ...................................................................................................................... 5-66 Structure Planning Control ................................................................................................................. 5-66

Section 6. Planning Tools

Overview .................................................................................................................................................. 6-1 Start a Sim Plan using Templates ......................................................................................................... 6-1 Save a Template ...................................................................................................................................... 6-3 Manipulate Beams .................................................................................................................................. 6-4 Beam Toolbar..................................................................................................................................... 6-4 Beam Visibility ........................................................................................................................... 6-5 Move the Beam Isocenter .......................................................................................................... 6-5 Move the Beam Isocenter .......................................................................................................... 6-6 Move a Single Beam ................................................................................................................... 6-6 Move Multiple Beams as a Group (for all types of plans) ..................................................... 6-6 Change the Gantry or Collimator Using the Mouse ............................................................. 6-7 Rotate the Gantry or Collimator Using the Mouse ............................................................... 6-7 Edit/Change Values on the Beam Spreadsheet ............................................................................. 6-8 Beam Spreadsheet – Sim Plans ............................................................................................................. 6-9 Beam Spreadsheet for Sim Plans – General Tab............................................................................... 6-10 Add/Edit/Delete Beams .................................................................................................................. 6-11 Copy a Beam .................................................................................................................................... 6-11 Delete a Beam................................................................................................................................... 6-11 Renumber Beams ............................................................................................................................ 6-12 Reorder Beams ................................................................................................................................. 6-12 Number Beams Consecutively....................................................................................................... 6-12 Link Machine ID and/or Isocenter Location ............................................................................... 6-12 Beam Spreadsheet for Sim Plans – Geometry Tab ........................................................................... 6-14 Beam Spreadsheet for Sim Plans – Treatment Aids Tab ................................................................. 6-15 Beam Spreadsheet for Sim Plans – All Tab ....................................................................................... 6-15

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Table of Contents Section 6. Planning Tools (cont.)

Print a Beam Summary Report ...................................................................................................... 6-15 Feet First Sim Plans .............................................................................................................................. 6-16 Create a Feet First Sim Plan ........................................................................................................... 6-16 Change Treatment Orientation for Monaco IMRT Plan ................................................................ 6-17 Create a Feet First IMRT Plan ....................................................................................................... 6-17 Port Tools .............................................................................................................................................. 6-19 Auto Conform a Port ...................................................................................................................... 6-19 Draw a Port ...................................................................................................................................... 6-21 Edit a Port or MLC .......................................................................................................................... 6-21 Replace a Segment of the Port/MLC...................................................................................... 6-22 Resize the Port/MLC................................................................................................................ 6-23 Move the Port/MLC................................................................................................................. 6-24 Edit Individual MLC Leaves ................................................................................................... 6-24 Use the Leaf Table to edit the port ......................................................................................... 6-25 Edit the Close Leaf Position .................................................................................................... 6-26 Delete a Port.............................................................................................................................. 6-26 Maintain Field Borders ................................................................................................................... 6-27 Measure Tool......................................................................................................................................... 6-27 Use the Measure Tool .......................................................................................................................... 6-27 Remove the Measurement Rulers ....................................................................................................... 6-27 Interest Points and Markers ................................................................................................................ 6-28 Place Interest Points or Markers ................................................................................................... 6-28 Verify an Interest Point or Marker ............................................................................................... 6-30 Locate an Interest Point or Marker ............................................................................................... 6-30 Delete an Interest Point or Marker ............................................................................................... 6-31 Print the Interest Point and Marker Report ................................................................................ 6-31 Dose Reference Points (Plans from Monaco IMRT only) ......................................................... 6-31 Image Statistics...................................................................................................................................... 6-32

Section 7. Plan Review Activity

Overview .................................................................................................................................................. 7-1 Open Plan(s) into Plan Review ............................................................................................................. 7-1 Change the Isodose Display .................................................................................................................. 7-2 Change the Transparency of the Dose Display................................................................................... 7-3 Save an Isodose Template ...................................................................................................................... 7-4 (Optional) Transition between Two Studysets ................................................................................... 7-5 Beam Visibility Control ......................................................................................................................... 7-6 Beam Summary ....................................................................................................................................... 7-7

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Table of Contents Section 7. Plan Review Activity (cont.)

Structure Control .................................................................................................................................... 7-8 Toggle Structure On and Off ........................................................................................................... 7-8 View Images from XiO .......................................................................................................................... 7-9 Change the DVH Display Properties ................................................................................................. 7-10 DVH Statistics-Statistics Tab ......................................................................................................... 7-10 % in Volume ............................................................................................................................. 7-10 Is in SS........................................................................................................................................ 7-11 Edit the Reference Doses and % Volumes on the DVH Statistics Dialog Box................. 7-11 Edit the Reference Doses and % Volumes on the DVH Graph ......................................... 7-12 DVH Statistics – Display Tab ........................................................................................................ 7-14 Heterogeneity Index ................................................................................................................ 7-14 Conformity Index..................................................................................................................... 7-15 Print/Export the DVH Statistics ............................................................................................ 7-16 DVH Color Setup ............................................................................................................................ 7-17 DVH Properties Setup .................................................................................................................... 7-18 Create Structure Combinations for the DVH................................................................................... 7-20 Add Structures ................................................................................................................................. 7-20 Export the DVH Values .......................................................................................................... 7-21 Print or Export the DVH View .............................................................................................. 7-22 Measure Dose Intensity at a Point...................................................................................................... 7-22 Set the Normalization Parameters...................................................................................................... 7-24 Show Dose Extents ............................................................................................................................... 7-25 Measure and Interest Points Tools ..................................................................................................... 7-25 Dose Reference Points.......................................................................................................................... 7-25 Single Plan Display and Multiple Plan Display ................................................................................ 7-26 Measure and Interest Points Tools ..................................................................................................... 7-27 Switch from Single Plan Mode to Multiple Plan Mode.............................................................. 7-27 Navigation Tools in Multiple Plan Mode..................................................................................... 7-27 Show the Dose Difference or Dose Summation between Plans ..................................................... 7-28 Modify the Dose Difference or Dose Summation Display.............................................................. 7-29 lsoDose Summation ........................................................................................................................ 7-29 Dose Difference ............................................................................................................................... 7-30 Save the Summation or Difference Plan....................................................................................... 7-30 Review the Patient in 3D ..................................................................................................................... 7-31 Convert Isodose to Structure ......................................................................................................... 7-32 Approve a Calculated Plan .................................................................................................................. 7-35 Rescale Number of Fractions .............................................................................................................. 7-37 Rescale by modifying Fractional Dose ............................................................................................... 7-37 Practice Exercise – Plan Review Tools ............................................................................................... 7-39

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Table of Contents Section 8. Practice Exercises

Practice Exercise 1. General Operation and Navigation ................................................................... 8-1 Practice Exercise 1. General Operation and Navigation .............................................................. 8-1 Practice Exercise 2. Fusion, Contouring, and Beam Manipulation ............................................ 8-2 Fusion .......................................................................................................................................... 8-2 Contouring .................................................................................................................................. 8-3 Beam Manipulation ................................................................................................................... 8-3 Miscellaneous.............................................................................................................................. 8-3 Practice Exercise 3. Plan Review ........................................................................................................... 8-4

Section 9.Treatment Couchtop Inclusion Task 1. Import a Treatment Couch Structure..................................................................................... 9-1 Task 2. Edit and Save a Treatment Couch........................................................................................... 9-2 Task 3. Add Couch to a Plan, a Studyset or a Phantom .................................................................... 9-3

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Table of Contents Volume II of IV – Planning Section 1. 3D Planning

Features of 3D Plans ................................................................................................................................. 1-1 Create a 3D Treatment Plan .................................................................................................................... 1-1 Planning Control – Structures ................................................................................................................ 1-4 Planning Control – Prescription Tab:.................................................................................................... 1-4 Physician’s Intent ................................................................................................................................ 1-5 Rx ID .......................................................................................................................................................... 1-6 Add Rx ....................................................................................................................................................... 1-7 Delete Rx .................................................................................................................................................... 1-8 Rescale Dose .............................................................................................................................................. 1-8 Beam Weighting .................................................................................................................................. 1-9 Prescription: Segments Tab ............................................................................................................. 1-10 Segment Light Field Projection ....................................................................................................... 1-13 Planning Control – Dose Reference Points......................................................................................... 1-14 Planning Control – Beams Tab............................................................................................................. 1-14 Planning Control – Treatment Aids .................................................................................................... 1-15 Wedges................................................................................................................................................ 1-15 Port /MLC .......................................................................................................................................... 1-16 Applicator ID .............................................................................................................................. 1-16 Couch .................................................................................................................................................. 1-16 Bolus .................................................................................................................................................... 1-17

Section 2. Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup

Overview .................................................................................................................................................... 2-1 Monaco Workflow.................................................................................................................................... 2-3 Contouring and Beam Manipulation..................................................................................................... 2-4 Contour all Targets and Organs at Risk (OARs) ............................................................................ 2-4 3D Auto-Margin Generation ...................................................................................................... 2-4 Consideration of Contours outside the Patient ....................................................................... 2-4 Beam Manipulation Tools.................................................................................................................. 2-5 Using Templates ....................................................................................................................................... 2-6 Start a Plan Using a Template............................................................................................................ 2-6 VMAT .......................................................................................................................................... 2-11 Dynamic Conformal Arcs ......................................................................................................... 2-11 Creating a Customized Template .................................................................................................... 2-12 Deleting a Template .......................................................................................................................... 2-13 Beam Tools .............................................................................................................................................. 2-14

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Table of Contents Section 2. Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup (cont.)

Planning Ribbon – Beam Tools ....................................................................................................... 2-14 Beam Control .......................................................................................................................................... 2-16 Add/Edit/Delete Beams in Beam Control ...................................................................................... 2-18 Copy a Beam/Sequence .................................................................................................................... 2-18 Beam Control for IMRT Plans – General Tab .................................................................................... 2-19 Delete a Beam/Sequence................................................................................................................... 2-19 Renumber Beams/Sequences ........................................................................................................... 2-19 Reorder Beams/Sequences ............................................................................................................... 2-19 Number Beams/Sequences Consecutively ..................................................................................... 2-19 Link Machine ID and/or Isocenter Location ................................................................................. 2-20 Beam Control | Geometry Tab.............................................................................................................. 2-22 Split Beams ......................................................................................................................................... 2-23 Fixed Jaws ........................................................................................................................................... 2-25 Beam Control |Treatment Aids Tab..................................................................................................... 2-27 Planning Control – Treatment Aids ............................................................................................... 2-27 Wedges ........................................................................................................................................ 2-28 Port ............................................................................................................................................... 2-28 MLC ............................................................................................................................................. 2-28 Applicator ID .............................................................................................................................. 2-29 Bolus............................................................................................................................................. 2-29 Couch ........................................................................................................................................... 2-30 Add Bolus to Beams ................................................................................................................... 2-30 Beam Control | Setup Beams Tab ......................................................................................................... 2-31 Edit Beam Options Using Mouse ......................................................................................................... 2-31 Print a Beam Control Report ........................................................................................................... 2-32 Definition of Terms as They Apply to Arc Planning ......................................................................... 2-33 Sequence ............................................................................................................................................. 2-33 Direction............................................................................................................................................. 2-33 Gantry ................................................................................................................................................. 2-34 Arc ....................................................................................................................................................... 2-34 Collimator .......................................................................................................................................... 2-34 Increment ........................................................................................................................................... 2-35 Sector................................................................................................................................................... 2-36 Sweep Sequencer ............................................................................................................................... 2-38 Control Point (VMAT only) ............................................................................................................ 2-39 Arc Segment (VMAT only).............................................................................................................. 2-39 Dynamic Segments with Static Gantry (VMAT only) ................................................................. 2-41

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Table of Contents Section 3. 3D Lung Case

Overview .................................................................................................................................................... 3-1 Practice Exercise ....................................................................................................................................... 3-2 Task 1. Select Patient and Open Studyset ........................................................................................ 3-2 Task 2. Create Contours ..................................................................................................................... 3-3 Task 3. Use Auto Margin to Expand the Target Volume .............................................................. 3-3 Task 4. Start a 3D Plan using Templates .......................................................................................... 3-4 Task 5. Create Ports ............................................................................................................................ 3-6 Task 6. Duplicate and Oppose Beam ................................................................................................ 3-7 Task 7. Edit Beam Information ......................................................................................................... 3-8 Task 8. Add Right Posterior Oblique Beam..................................................................................... 3-8 Task 9. (Optional) Edit a Port............................................................................................................ 3-9 Task 10. Add a Wedge ...................................................................................................................... 3-10 Task 11. Add an Interest Point ........................................................................................................ 3-11 Task 12. Enter the Prescription ....................................................................................................... 3-12 Task 13. Dose Calculation Properties ............................................................................................. 3-13 Task 14. Calculate Dose .................................................................................................................... 3-14 Task 15. Evaluate Isodoses and DVH ............................................................................................. 3-14 Task 16. Edit Beam Weights ............................................................................................................ 3-15 Task 17. (Optional) Rescale Dose ................................................................................................... 3-15 Task 18. Save the Plan ....................................................................................................................... 3-15 Task 19. Save a Template.................................................................................................................. 3-16

Section 4. 3D Breast Case

Field in Field Planning ............................................................................................................................. 4-1 Task 1. Open the Patient .................................................................................................................... 4-2 Task 2. Create Contours ..................................................................................................................... 4-3 Task 3. Use Auto Margin to Expand the Target Volume .............................................................. 4-3 Task 4. New Plan from Template ...................................................................................................... 4-4 Task 5. Edit Beam Isocenter ............................................................................................................... 4-6 Task 6. Edit Gantry Angle .................................................................................................................. 4-8 Task 7. Manage Structure Display .................................................................................................... 4-9 Task 8. Edit Field Size ....................................................................................................................... 4-10 Task 9. Create and Edit Port ............................................................................................................ 4-11 Task 10. Duplicate and Oppose Beam to Create Lateral Tangent .............................................. 4-12 Task 11. Edit Beam Descriptions in the Beam Control................................................................ 4-12 Task 12. Line up Superior Edge of the Fields ................................................................................ 4-13 Task 13. Re-evaluate the Ports ......................................................................................................... 4-14 Task 14. Add an Interest Point ........................................................................................................ 4-15 Task 15. Enter Prescription .............................................................................................................. 4-17

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Table of Contents Section 4. 3D Breast Case (cont.)

Task 16. Calculate Dose .................................................................................................................... 4-18 Task 17. Evaluate Dose ..................................................................................................................... 4-18 Task 18. Edit Beam Weighting and Plan Normalization ............................................................. 4-20 Task 19. Display 3D Isodose for Field in Field Planning ............................................................. 4-21 Task 20. Manage MU/Fluence Display .......................................................................................... 4-22 Task 21. Create First Medial Sub-Field .......................................................................................... 4-23 Task 22. Calculate Dose and Adjust Beam Weighting for First Medial Subfield ..................... 4-25 Task 23. Create First Lateral Subfield ............................................................................................. 4-26 Task 24. Calculate Dose and Adjust Beam Weighting for First Lateral Subfield..................... 4-29 Task 25. Calculate Dose and Adjust Beam Weighting for Remaining Subfields ...................... 4-30 Task 26. Add Setup Beams ............................................................................................................... 4-30 Task 27. Save Plan ............................................................................................................................. 4-30 Create a Supraclavicular (SCV) Plan.................................................................................................... 4-31 Task 1. Add another Beam ............................................................................................................... 4-31 Task 2. Save Plan As .......................................................................................................................... 4-31 Task 3. Setup the Beam ..................................................................................................................... 4-31 Task 4. Find Isocenter Location ...................................................................................................... 4-32 Task 5. Edit the Port.......................................................................................................................... 4-33 Task 6. Create a Calculation Point .................................................................................................. 4-34 Task 7. Create a Prescription ........................................................................................................... 4-34 Task 8. Delete Tangent Beams ......................................................................................................... 4-35 Task 9. Calculate Dose ...................................................................................................................... 4-35 Task 10. Evaluate Doses.................................................................................................................... 4-35 Plan Summation ..................................................................................................................................... 4-36 Task 1. Sum Plans.............................................................................................................................. 4-36 Task 2. Plan Summation Review ..................................................................................................... 4-36 Task 3. Save the Plan Summation ................................................................................................... 4-36

Section 5. 3D Prostate Case

Practice Exercise ....................................................................................................................................... 5-1 Task 1. Select Patient and Open Studysets ....................................................................................... 5-2 Task 2. (Optional) Fuse Studysets ..................................................................................................... 5-3 Task 3. (Optional) Import Treatment Couch.................................................................................. 5-4 Task 4. Define the Scan Reference Point .......................................................................................... 5-5 Task 5. Create a New Monaco Plan from Template ....................................................................... 5-7 Task 6. Edit DRR ................................................................................................................................. 5-8 Task 7. Create Anterior Port .............................................................................................................. 5-9 Task 8. Duplicate and Oppose Anterior Beam .............................................................................. 5-10 Task 9. Edit Beams in Planning Activity ........................................................................................ 5-10

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Table of Contents Section 5. 3D Prostate Case (cont.)

Task 10. Add Right Lateral Beam .................................................................................................... 5-11 Task 11. Create Right Lateral Port .................................................................................................. 5-12 Task 12. Duplicate and Oppose Right Lateral Beam .................................................................... 5-13 Task 13. (Optional) Edit a Port ....................................................................................................... 5-14 Task 14. Enter the Prescription ....................................................................................................... 5-15 Task 15. Force Electron Density ...................................................................................................... 5-16 Task 16. Calculate Dose .................................................................................................................... 5-16 Task 17. Evaluate Isodoses and DVH ............................................................................................. 5-17 Task 18. Edit Beam Weights ............................................................................................................ 5-17 Task 19. (Optional) Rescale Dose ................................................................................................... 5-18 Task 20. Save the Plan ....................................................................................................................... 5-19 Task 21. Create 6 Field Boost Plan .................................................................................................. 5-19 Task 22. Add/Edit Additional Beams ............................................................................................. 5-20 Task 23. Create Ports ........................................................................................................................ 5-20 Task 24. Enter the Prescription ....................................................................................................... 5-21 Task 25. Edit Beam Weights ............................................................................................................ 5-21 Task 26. Force Electron Density ...................................................................................................... 5-21 Task 27. Calculate Dose .................................................................................................................... 5-21 Task 28. Evaluate Isodoses and DVH ............................................................................................. 5-22 Task 29. (Optional) Rescale Dose ................................................................................................... 5-22 Task 30. Save the Plan ....................................................................................................................... 5-22 Task 31. Create Plan Summation .................................................................................................... 5-23 Task 32. Plan Summation Review ................................................................................................... 5-23 Task 33. Save the Plan Summation ................................................................................................. 5-23

Section 6. IMRT Tools

Overview .................................................................................................................................................... 6-1 Planning Control ...................................................................................................................................... 6-1 Structures ................................................................................................................................................... 6-2 Prescription ............................................................................................................................................... 6-2 Beams ......................................................................................................................................................... 6-3 IMRT Constraints..................................................................................................................................... 6-4 Dose Reference Points.............................................................................................................................. 6-5 Use the mouse to move a Dose Reference Point ............................................................................. 6-6 Update DRP with Prescribe to Point ................................................................................................ 6-6 Reset All Dose Reference Points to Isocenter .................................................................................. 6-7 Planning Tab ............................................................................................................................................. 6-7 Planning Tab | Calculation Panel ...................................................................................................... 6-8 Planning Tab | Fluence Panel for IMRT Plans ................................................................................ 6-9

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Table of Contents Section 6. IMRT Tools (cont.)

Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans........................ 6-11 Fluence Analysis and Visualization Tools ..................................................................................... 6-13 Planning Tab | Grid Volume Panel................................................................................................. 6-14 Volume Cursor ........................................................................................................................... 6-14 Studyset and Grid Slider Bar..................................................................................................... 6-15 Plan Options Tab .................................................................................................................................... 6-16 Optional Panel ................................................................................................................................... 6-16 Fluence Statistics ........................................................................................................................ 6-16 Show Dose Extents ..................................................................................................................... 6-17 DVH Panel ......................................................................................................................................... 6-17 Dose Normalization Panel ............................................................................................................... 6-18 Tools Tab ................................................................................................................................................. 6-19 Interest Points and Markers............................................................................................................. 6-19 Editing Interest Points and Markers........................................................................................ 6-19 Additional Interest Point and Marker Functionality ............................................................ 6-20 Measure Tool ..................................................................................................................................... 6-20 Additional IMRT Tools ......................................................................................................................... 6-21 Progress Meter ................................................................................................................................... 6-21 Beam Visibility Control .................................................................................................................... 6-22

Section 7. Planning and Workflow: Calculation Parameters and IMRT Constraints

Calculation Properties.............................................................................................................................. 7-1 Calculation Parameters....................................................................................................................... 7-2 Algorithm ............................................................................................................................................. 7-2 Grid Spacing......................................................................................................................................... 7-2 Calculate Dose Deposition to: ........................................................................................................... 7-3 Statistical Uncertainty (%) ................................................................................................................. 7-3 Statistical Uncertainty Per Control Point (CP) ............................................................................... 7-4 Statistical Uncertainty Per Calculation............................................................................................. 7-5 IMRT Constraints: Structure .................................................................................................................. 7-7 Introduction ......................................................................................................................................... 7-7 Structure ............................................................................................................................................... 7-9 Structure Mismatch............................................................................................................................. 7-9 Structure Layering ............................................................................................................................... 7-9 Structure Optimization Properties and IMRT Prescription Parameters ................................... 7-11 Clear all Voxels below the Minimum CT number ................................................................ 7-13 Clear and Fill Example: ............................................................................................................. 7-13

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Table of Contents Section 7. Planning and Workflow: Calculation Parameters and IMRT Constraints (cont.)

Display Total Volume DVH ..................................................................................................... 7-15 Auto Flash ................................................................................................................................... 7-15 Do Not Store Dose ..................................................................................................................... 7-16 Avoidance.................................................................................................................................... 7-17 Surface Margin – IMRT Prescription Parameter ................................................................... 7-17 Beamlet Width – IMRT Prescription Parameter ................................................................... 7-17 Target Margin – IMRT Prescription Parameter .................................................................... 7-18 Avoidance Margin- IMRT Prescription Parameter............................................................... 7-18 IMRT Constraints: Cost Functions ...................................................................................................... 7-19 Cost Function Overview ................................................................................................................... 7-19 Objective ............................................................................................................................................. 7-19 Constraint........................................................................................................................................... 7-19 EUD (Equivalent Uniform Dose) ................................................................................................... 7-19 Application of Objectives and Constraints .................................................................................... 7-20 Required Cost Function Parameters ............................................................................................... 7-21 Target Penalty ............................................................................................................................. 7-21 Target EUD ................................................................................................................................. 7-22 Serial............................................................................................................................................. 7-24 Parallel ......................................................................................................................................... 7-28 Conformality............................................................................................................................... 7-34 Quadratic Overdose ................................................................................................................... 7-36 Calculating a Root Mean Square for Dose Excess ................................................................... 7-37 Quadratic Underdose ....................................................................................................................... 7-38 Maximum Dose .......................................................................................................................... 7-41 Overdose DVH ........................................................................................................................... 7-42 Underdose DVH ........................................................................................................................ 7-44 Optional Parameters ......................................................................................................................... 7-45 Shrink Margin............................................................................................................................. 7-45 Surface Margin ........................................................................................................................... 7-48 Optimize Over All Voxels in Volume ..................................................................................... 7-53 Multicriterial ...................................................................................................................................... 7-54 IMRT Constraints: Other ...................................................................................................................... 7-57 Rescale Dose ....................................................................................................................................... 7-57 Enabled ............................................................................................................................................... 7-58 Bias Dose (only shows for Bias Dose Plans) .................................................................................. 7-58 Status ................................................................................................................................................... 7-60 Manual Weighting ............................................................................................................................ 7-60 Isoeffect ............................................................................................................................................... 7-61 Isoconstraint ...................................................................................................................................... 7-61

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Table of Contents Section 7. Planning and Workflow: Calculation Parameters and IMRT Constraints (cont.)

Reference Dose .................................................................................................................................. 7-61 Multicriterial ...................................................................................................................................... 7-62 Relative Impact .................................................................................................................................. 7-63 Optimization Modes ......................................................................................................................... 7-63 Constrained Optimization Mode ............................................................................................. 7-63 Pareto Optimization Mode ....................................................................................................... 7-64 Exercises ................................................................................................................................................... 7-64

Section 8. Planning and Workflow: Optimization and Sequence Parameters

Optimization ............................................................................................................................................. 8-1 Step and Shoot IMRT Delivery Mode .............................................................................................. 8-2 Stage One – Fluence Optimization ............................................................................................ 8-2 Stage Two – Aperture Optimization and Dose Calculation ................................................... 8-3 Conformal RT Delivery Mode ........................................................................................................... 8-6 Stage One – Optimization ........................................................................................................... 8-6 dMLC Delivery Mode ......................................................................................................................... 8-8 Stage One – Fluence Optimization ............................................................................................ 8-8 Stage Two – Aperture Optimization and Dose Calculation ................................................. 8-10 VMAT Delivery Mode ...................................................................................................................... 8-12 Stage One – Fluence Optimization .......................................................................................... 8-12 Stage Two – Aperture Optimization and Dose Calculation ................................................. 8-13 Dynamic Conformal Arc Delivery Mode....................................................................................... 8-14 Aperture Optimization and Dose Calculation ....................................................................... 8-14 Editing the Sequencing Parameters...................................................................................................... 8-16 Segment Shape Optimization .......................................................................................................... 8-19 Min. Segment Area (cm) .................................................................................................................. 8-20 Max. # of Segments per Plan ............................................................................................................ 8-20 Max. Number of Arcs (Elekta and Varian machines) .................................................................. 8-20 Max. # Control Points/Beam ........................................................................................................... 8-20 Max. # Control Points/Arc ............................................................................................................... 8-20 VMAT Specific information: .................................................................................................... 8-20 Target Dose Rate ............................................................................................................................... 8-21 Recommended Ranges for Non-SSO VMAT: ........................................................................ 8-21 Min. Segment Width (cm) ............................................................................................................... 8-22 Fluence Smoothing ........................................................................................................................... 8-22 Min. MU/Segment ............................................................................................................................ 8-23

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Table of Contents Section 8. Planning and Workflow: Optimization and Sequence Parameters (cont.)

Park Closed Leaf Gaps Under Jaw .................................................................................................. 8-23 Max Sweep Efficiency ....................................................................................................................... 8-23 Allow Move Only Segments (dMLC Only): .................................................................................. 8-24 Constant Dose Rate ........................................................................................................................... 8-24 Min. MU per Dynamic CP ............................................................................................................... 8-24 Exercises ................................................................................................................................................... 8-25

Section 9. Planning and Workflow: Plan Analysis and Evaluation

Plan Analysis Tools .................................................................................................................................. 9-1 Showing the Console during Optimization ..................................................................................... 9-1 Console Messages after Stage Two............................................................................................. 9-3 Number of Segments/CP............................................................................................................. 9-3 Number of Monitor Units........................................................................................................... 9-3 Estimated Total Delivery Time .................................................................................................. 9-4 Minimum # of MU for ideal delivery ........................................................................................ 9-4 Estimated MU efficiency ............................................................................................................. 9-4 Evaluating Sensitivities ....................................................................................................................... 9-5 Point Sensitivity............................................................................................................................ 9-6 Using the Progress Meter ................................................................................................................... 9-7 Target EUD(s) .............................................................................................................................. 9-7 Constraint Violation .................................................................................................................... 9-8 Modulation Degree ...................................................................................................................... 9-8 Using the Volume Cursor .................................................................................................................. 9-9 Grid Volume Toolbar ....................................................................................................................... 9-10 Dose ............................................................................................................................................. 9-10 Dose Raw ..................................................................................................................................... 9-11 Electron Density ......................................................................................................................... 9-11 VOI Occupancy .......................................................................................................................... 9-11 CF (Cost Function) Occupancy ............................................................................................... 9-11 CF (Cost Function) Variation .................................................................................................. 9-12 CF (Cost Function) Relax Response ........................................................................................ 9-14 CF Sensitivities ........................................................................................................................... 9-14 Dose Uncertainty ....................................................................................................................... 9-15 Evaluating the Isodoses and Dose-Volume Histograms .............................................................. 9-15 Total Volume DVH ................................................................................................................... 9-15

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Table of Contents Section 9. Planning and Workflow: Plan Analysis and Evaluation (cont.)

Optimized DVH ......................................................................................................................... 9-16 Optimized Total DVH (Bias Dose Plans only) ...................................................................... 9-16 Evaluating Intensity Maps and Monitor Units ............................................................................. 9-17 Review Segments and Monitor Units per Segment ...................................................................... 9-17 Using the Fluence Statistics.............................................................................................................. 9-18

Section 10. Monaco Planning Suggestions

Workflow ................................................................................................................................................. 10-1 Cap Bolus............................................................................................................................................ 10-2 Templates................................................................................................................................................. 10-3 Machine Energy ...................................................................................................................................... 10-3 Standardize Planning ............................................................................................................................. 10-4 Status Messages ....................................................................................................................................... 10-4 DVH & Statistics Resolution ................................................................................................................. 10-4 Setup Beams for Portal Imaging ........................................................................................................... 10-4 Calculation Region Volume .................................................................................................................. 10-5 Applying Structure Optimization Properties to a Non-Optimized Structure................................ 10-5 Target Coverage ...................................................................................................................................... 10-5 IMRT Beam Arrangement..................................................................................................................... 10-6 Prescription ............................................................................................................................................. 10-6 General Suggestions .......................................................................................................................... 10-6 Tips When Creating Target Volume Prescriptions ...................................................................... 10-7 Tips When Creating Organ at Risk Prescriptions ........................................................................ 10-8 Avoid Hot Spots in Unspecified Tissue.......................................................................................... 10-9 Controlling Mean Dose in OARs .................................................................................................. 10-10 Controlling Maximum Dose.......................................................................................................... 10-10 Using Biological Cost Functions to Control Dose ...................................................................... 10-11 Bias Dose .......................................................................................................................................... 10-12 Optimization ......................................................................................................................................... 10-13 DVH Statistics.................................................................................................................................. 10-13 Sensitivity Analysis.......................................................................................................................... 10-13 Multicriterial .................................................................................................................................... 10-13 Troubleshooting an Optimization Failure ................................................................................... 10-14 Plan Analysis ......................................................................................................................................... 10-15 Fluence Statistics ............................................................................................................................. 10-15 Auto Flash ON ...................................................................................................................................... 10-15 Performance .......................................................................................................................................... 10-17 Grid Spacing..................................................................................................................................... 10-17 Statistical Uncertainty per Calculation vs. per Control Point ................................................... 10-17

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Table of Contents Section 10. Monaco Planning Suggestions (cont.)

Pilot Beamlets .................................................................................................................................. 10-17 QA Plan .................................................................................................................................................. 10-18 Multiple QA Plans ........................................................................................................................... 10-18 Show Coronal Slice at Measured Depth ....................................................................................... 10-18

Section 11. Prostate IMRT Case

Practice Exercise ..................................................................................................................................... 11-1 Task 1. Select Patient and Open Studyset ...................................................................................... 11-2 Task 2. Start an IMRT Plan .............................................................................................................. 11-3 Task 3. Add Beams in Planning Activity........................................................................................ 11-5 Task 4. Enter the Prescription ......................................................................................................... 11-5 Task 5. Enter the IMRT Constraints............................................................................................... 11-6 Task 6. Edit Calculation Properties............................................................................................... 11-10 Task 7. Edit IMRT Parameters ...................................................................................................... 11-11 Task 8. Edit Sequencing Parameters ............................................................................................. 11-12 Task 9. Save an IMRT Template.................................................................................................... 11-12 Task 10. Optimize Fluence (Stage 1)............................................................................................. 11-13 Task 11. Evaluate Optimized Fluence and Dose ......................................................................... 11-15 Task 12. Re-Optimize and Evaluate (Optional) .......................................................................... 11-16 Task 13. Optimize Segment Shapes/Calculate Dose (Stage 2) .................................................. 11-16 Task 14. Evaluate Final Plan .......................................................................................................... 11-17 Task 15. Save Plan ........................................................................................................................... 11-18 Task 16. Print the Plan.................................................................................................................... 11-19 Subtask 1. Print or Export IMRT Reports............................................................................. 11-19 Subtask 2. Print Single Plane View, 3D Image or DVH Graph ......................................... 11-20 Subtask 3. Print DRR/BEV...................................................................................................... 11-21 Task 17. Create/Calculate a QA Plan ............................................................................................ 11-22 Task 18. Edit QA Plan Beam Weights (Optional) ...................................................................... 11-23 Task 19. Save the QA Plan ............................................................................................................. 11-23 Task 20. Export the Dose Planes ................................................................................................... 11-23 Task 21. Print the QA plan............................................................................................................. 11-24 Subtask 1. Print QA Plan Reports .......................................................................................... 11-24 Subtask 2. Print QA Plan Images ........................................................................................... 11-24

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Table of Contents Section 12. Prostate VMAT Case

Practice Exercise ..................................................................................................................................... 12-1 Task 1. Select Patient and Open Studyset ...................................................................................... 12-2 Task 2. Start a VMAT Plan using a Template ............................................................................... 12-2 Task 3. Add VMAT Sequences in Planning Activity.................................................................... 12-3 Task 4. Enter the Prescription ......................................................................................................... 12-4 Task 5. Enter the IMRT Constraints............................................................................................... 12-4 Task 6. Edit Calculation Parameters ............................................................................................... 12-8 Task 7. Edit Sequencing Parameters ............................................................................................... 12-9 Task 8. Save a VMAT Template ...................................................................................................... 12-9 Task 9. Optimize Fluence (Stage 1)............................................................................................... 12-10 Task 10. Evaluate Optimized Fluence and Dose ......................................................................... 12-11 Task 11. Re-Optimize and Evaluate (Optional) .......................................................................... 12-12 Task 12. Optimize Segment Shapes/Calculate Dose (Stage 2) .................................................. 12-13 Task 13. Evaluate Final Plan .......................................................................................................... 12-13 Task 14. Save Plan ........................................................................................................................... 12-14 Task 15. Print the Plan.................................................................................................................... 12-14 Subtask 1. Print or Export IMRT Reports............................................................................. 12-14 Subtask 2. Print Single Plane View, 3D Image or DVH Graph ......................................... 12-15 Subtask 3. Print DRR/BEV...................................................................................................... 12-15 Task 16. Create/Calculate a QA Plan ............................................................................................ 12-16 Task 17. Edit QA Plan Beam Weights (Optional) ...................................................................... 12-17 Task 18. Save the QA Plan ............................................................................................................. 12-17 Task 19. Export the Dose Planes ................................................................................................... 12-18 Task 20. Print the QA Plan ............................................................................................................ 12-18 Subtask 1. Print QA Plan Reports .......................................................................................... 12-18 Subtask 2. Print QA Plan Images ........................................................................................... 12-18

Section 13. Head and Neck Case

Practice Exercise ..................................................................................................................................... 13-1 General Planning Instructions ........................................................................................................ 13-2 Example Prescription........................................................................................................................ 13-3

Section 14. Breast Case

Practice Exercise ..................................................................................................................................... 14-1 General Planning Instructions .............................................................................................................. 14-2 Breast Plan Scoring Criteria ............................................................................................................. 14-2 Left Breast Practice Exercise.................................................................................................................. 14-3 General Planning Instructions ........................................................................................................ 14-3 Prescription A .................................................................................................................................... 14-4

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Table of Contents Section 15. Brain Case – Two Partial Arcs

Practice Exercise ..................................................................................................................................... 15-1 Task 1. Select Patient and Open Studyset ...................................................................................... 15-2 Task 2. Start a Dynamic Conformal Arc or VMAT Plan ............................................................. 15-2 Task 3. Add Beams in Planning Activity........................................................................................ 15-3 Task 4. Enter/Update the Prescription ........................................................................................... 15-4 Task 5. Edit Calculation Properties................................................................................................. 15-5 Task 6. Edit IMRT Parameters ........................................................................................................ 15-5 Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) ................................................ 15-6 Task 8. Optimize Fluence and Calculate Dose .............................................................................. 15-6 Task 9. Evaluate Plan ........................................................................................................................ 15-7 Task 10. Re-Optimize and Evaluate (Optional) ............................................................................ 15-8 Task 11. Save Plan ............................................................................................................................. 15-9

Section 16. mARC Brain Case

Practice Exercise ..................................................................................................................................... 16-1 Task 1. Select Patient and Open Studyset ...................................................................................... 16-2 Task 2. Start an mARC Plan ............................................................................................................ 16-2 Task 3. Add Beams in Planning Activity........................................................................................ 16-3 Task 4. Enter/Update the Prescription ........................................................................................... 16-4 Task 5. Edit Calculation Properties................................................................................................. 16-5 Task 6. Edit IMRT Parameters ........................................................................................................ 16-5 Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) ................................................ 16-6 Task 8. Optimize Fluence and Calculate Dose .............................................................................. 16-7 Task 9. Evaluate Plan ........................................................................................................................ 16-8 Task 10. Re-Optimize and Evaluate (Optional) ............................................................................ 16-9 Task 11. Save Plan ........................................................................................................................... 16-10

Section 17. Multiple Prescription

Breast Planning Forward Planning ...................................................................................................... 17-1 Task 1. Open the Patient .................................................................................................................. 17-2 Task 2. Create Contours ................................................................................................................... 17-3 Task 3. Use Auto Margin to Expand the Target Volume ............................................................ 17-3 Task 4. New Plan from Template .................................................................................................... 17-4 Task 5. Edit Beam Isocenter ............................................................................................................. 17-6 Task 6. Edit Gantry Angle ................................................................................................................ 17-8 Task 7. Manage Structure Display .................................................................................................. 17-9 Task 8. Edit Field Size ..................................................................................................................... 17-10 Task 9. Create and Edit Port .......................................................................................................... 17-11

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Table of Contents Section 17. Multiple Prescription (cont.)

Task 10. Duplicate and Oppose Beam to Create Lateral Tangent ............................................ 17-13 Task 11. Edit Beam Descriptions in the Beam Control .............................................................. 17-13 Task 12. Line up Superior Edge of the Fields .............................................................................. 17-14 Task 13. Re-evaluate the Ports ....................................................................................................... 17-15 Task 14. Add an Interest Point ...................................................................................................... 17-16 Task 15. Enter Prescription ............................................................................................................ 17-18 Task 16. Calculate Dose .................................................................................................................. 17-19 Task 17. Evaluate Dose/Isodose Templates ................................................................................. 17-19 Task 18. Edit Beam Weighting ...................................................................................................... 17-21 Task 19. Display 3D Isodose for Forward Planning ................................................................... 17-21 Task 20. Manage MU/Fluence Display ........................................................................................ 17-22 Task 21. Create Second Medial Segment ..................................................................................... 17-23 Task 22. Calculate Dose and Adjust Beam Weighting for Second Medial Segment .............. 17-25 Task 23. Create Second Lateral Segment...................................................................................... 17-26 Task 24. Calculate Dose and Adjust Beam Weighting for Second Lateral Segments ............ 17-28 Task 25. Calculate Dose and Adjust Beam Weighting for Remaining Segments .................. 17-29 Task 26. Rescale a Plan ................................................................................................................... 17-29 Task 27. Add Setup Beams ............................................................................................................. 17-30 Breast Planning – Multiple Prescriptions – Electron Boost Plan ................................................... 17-31 Task 1. Add another Prescription ................................................................................................. 17-31 Task 2. Fill in the New Prescription Information ....................................................................... 17-33 Task 3. Edit Electron Beam ............................................................................................................ 17-34 Task 4. Edit Isocenter Location ..................................................................................................... 17-35 Task 5. Add Applicator................................................................................................................... 17-36 Task 6. Create Electron Aperture .................................................................................................. 17-37 Task 7. Calculate Dose .................................................................................................................... 17-39 Task 8. Evaluate Dose ..................................................................................................................... 17-39 Breast Planning – Breast Bolus ........................................................................................................... 17-40 Task 1. Generate and Assign Bolus to Beams .............................................................................. 17-40 Prostate with Nodes Exercise .............................................................................................................. 17-42 General Planning Instructions ...................................................................................................... 17-42 Prescription A .................................................................................................................................. 17-43 Prescription B .................................................................................................................................. 17-44 Prescription C .................................................................................................................................. 17-47 Bias Dose Plan ....................................................................................................................................... 17-50 General Planning Instructions ...................................................................................................... 17-50 Prescription A .................................................................................................................................. 17-51 Prescription B .................................................................................................................................. 17-52 Prescription C .................................................................................................................................. 17-58

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Table of Contents Section 18. Bias Dose – Head and Neck

Bias Dose – Head and Neck Exercise ................................................................................................... 18-1 Prescription Goals ............................................................................................................................. 18-1 Task 1. Fuse Base Plan CT with Bias Dose Plan CT ..................................................................... 18-2 Task 2. Review the Base Plan ........................................................................................................... 18-2 Task 3. Create a Bias Dose Plan from a Base Plan ........................................................................ 18-3 Task 4. Enter the Bias Dose Prescription ....................................................................................... 18-3 Task 5. Start the Optimization and Dose Calculation .................................................................. 18-4

Section 19. MR Planning

Oblique MR Planning ............................................................................................................................ 19-1 Import the New Patient .................................................................................................................... 19-2 General Planning Instructions ........................................................................................................ 19-5 RTOG 1115 – Plan Scoring Criteria ........................................................................................ 19-5

Section 20. Additional Cases

Esophageal Case ...................................................................................................................................... 20-2 General Planning Instructions ........................................................................................................ 20-2 Rectal Case ............................................................................................................................................... 20-3 General Planning Instructions ........................................................................................................ 20-3 RTOG 0822 – Plan Scoring Criteria ........................................................................................ 20-3 Head and Neck Case II........................................................................................................................... 20-4 General Planning Instructions ........................................................................................................ 20-4 Practice Exercise 1. IMRT and QA....................................................................................................... 20-5 Create an IMRT Plan ........................................................................................................................ 20-5 Create a QA Plan ............................................................................................................................... 20-6 Practice Exercise 2. Plan Review ........................................................................................................... 20-7 Practice Exercise 3. Editing IMRT Prescription Elements ................................................................ 20-8 Practice Exercise 4. Optimization and Plan Evaluation .................................................................... 20-9 Practice Exercise 5. Serial Power Law (k) .......................................................................................... 20-10 Task 1. Select Patient and Open Studyset .................................................................................... 20-10 Task 2. Enter/Adjust Power Law and Optimize IMRT Plans.................................................... 20-10 Task 3. Plan Review......................................................................................................................... 20-13 Practice Exercise 6: Parallel Power Law (k)....................................................................................... 20-14 Task 1. Select Patient and Open Studyset .................................................................................... 20-14 Task 2. Load IMRT Template ........................................................................................................ 20-14 Task 3. Enter the Prescription ....................................................................................................... 20-16 Task 4. Enter the IMRT Constraints............................................................................................. 20-16 Task 5. Enter Calculation Properties ............................................................................................ 20-18 Task 6. Enter IMRT Parameters .................................................................................................... 20-18 Task 7. Adjust Power Law (k) and Optimize IMRT Plans ........................................................ 20-19 Task 8. Plan Review......................................................................................................................... 20-20

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Table of Contents Section 21. QA Tools

Overview .................................................................................................................................................. 21-1 Dose Calculation Tools .......................................................................................................................... 21-1 Beam Tools ......................................................................................................................................... 21-2 Fluence Toolbar ...................................................................................................................................... 21-3 Beam and Dose Visibility Control .................................................................................................. 21-4 Dose Plane Output ................................................................................................................................. 21-5 Show Dose Extents ............................................................................................................................ 21-6 Measure and Interest Point Tools ........................................................................................................ 21-6 Dose Reference Points............................................................................................................................ 21-6 Create a QA Plan .................................................................................................................................... 21-7 Edit Dose Calculation Properties ....................................................................................................... 21-10 Edit Assigned Electron Densities........................................................................................................ 21-11 Save the QA Plan .................................................................................................................................. 21-11 Export the QA Plan .............................................................................................................................. 21-12 Tips When Creating a QA Phantom .................................................................................................. 21-13 Exercise .................................................................................................................................................. 21-13

Section 22. QA Exercise

Creating an IMRT QA Phantom .......................................................................................................... 22-1 Add a Couchtop to an Existing Studyset........................................................................................ 22-3 Create an IMRT QA Plan ...................................................................................................................... 22-5 Create QA Verification Beams.............................................................................................................. 22-8

Section 23. Stereotactic Planning with Monaco Outline for Stereotactic Planning with Monaco Section ................................................................... 23-1 Learning Objectives ................................................................................................................................ 23-2 Introduction: Stereotactic Planning ..................................................................................................... 23-2 Workflow Diagrams ............................................................................................................................... 23-3 Stereotactic Cone Configuration .......................................................................................................... 23-4 Visualization Increment in Graphical Preferences ............................................................................ 23-5 Monaco Planning with Stereotactic Cones ......................................................................................... 23-7 Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones ................................................. 23-17 References......................................................................................................................................... 23-17 Task 1. Pre-Exercise Work and Select Patient ............................................................................. 23-18 Task 2. Add Planning Margin........................................................................................................ 23-19 Task 3. Start a New Monaco Plan & Import Template .............................................................. 23-20 Task 4. Enter Dose Prescription .................................................................................................... 23-21 Task 5. Determine Stereotactic Cone Size.................................................................................... 23-22

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Table of Contents Section 23. Stereotactic Planning with Monaco (cont.)

Task 6. Determine Beam Geometry, Information, and Number of Beams............................. 23-23 Task 7. Set Calculation Properties and Calculation .................................................................... 23-24 Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics ........................................... 23-26 MLC Stereotactic Planning: Training Guide Exercises ................................................................... 23-30 Practice Exercise 2. SBRT Lung with VMAT.................................................................................... 23-30 References......................................................................................................................................... 23-30 Task 1. Pre-Exercise Work and Select Patient ............................................................................. 23-31 Task 2. Add Planning Structures ................................................................................................... 23-32 Task 3. Start a New Monaco Plan, Import Template, Set Isocenter ......................................... 23-32 Task 4. Enter Dose Prescription .................................................................................................... 23-34 Task 5. Set Beam Geometry ........................................................................................................... 23-35 Task 6. Set Structure Optimization Properties ............................................................................ 23-36 Task 7. Set Calculation Properties, IMRT Parameters and Sequencing Parameters.............. 23-36 Task 8. Set Initial Cost Function Constraints .............................................................................. 23-38 Task 9. Calculate Fluence – Optimization Phase 1 ..................................................................... 23-40 Task 10. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate.............. 23-40 Task 11. Calculate Segments – Optimization Phase 2 ................................................................ 23-42 Task 12. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize ........ 23-42 Practice Exercise 3. SBRT Lung with DCA ....................................................................................... 23-43 References......................................................................................................................................... 23-43 Tasks 1 and 2. Pre-Exercise Work, Select Patient, Add Planning Structures .......................... 23-43 Task 3. Start a New Monaco Plan, Import Template, Set Isocenter ......................................... 23-44 Task 4. Enter Dose Prescription .................................................................................................... 23-46 Task 5. Determine Arc Beam Number and Geometry ............................................................... 23-47 Task 6. Set Structure Optimization Properties ............................................................................ 23-47 Task 7. Set Calculation Properties and Sequencing Parameters ............................................... 23-47 Task 8. Set Initial Cost Function Constraints .............................................................................. 23-50 Task 9. Calculate Full Fluence Modulation – Optimization...................................................... 23-51 Task 10. Evaluate Plan, Adjust Cost Functions, Re-evaluate .................................................... 23-51 Task 11. Final Calculation .............................................................................................................. 23-53 Task 12. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize ........ 23-53 Practice Exercise 4. SBRT Spine with VMAT ................................................................................... 23-54 References......................................................................................................................................... 23-54 Task 1. Pre-Exercise Work and Select Patient ............................................................................. 23-54 Task 2. Add Planning Structures ................................................................................................... 23-55 Task 3. Start a New Monaco Plan, Import Template, Set Isocenter ......................................... 23-55 Task 4. Enter Target Dose Prescription........................................................................................ 23-56 Task 5. Set Beam Geometry ........................................................................................................... 23-57

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Table of Contents Section 23. Stereotactic Planning with Monaco (cont.)

Task 6. Set Calculation Properties, IMRT Parameters and Sequencing Parameters.............. 23-57 Task 7. Set Initial Cost Function Constraints .............................................................................. 23-60 Task 8. Calculate Fluence – Optimization Phase 1 ..................................................................... 23-61 Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate ................. 23-61 Task 10. Calculate Segments – Optimization Phase 2 ................................................................ 23-63 Task 11. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize ......... 23-63 References......................................................................................................................................... 23-64

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Table of Contents Volume III of IV – Physics Section 1. Monaco Patient Model (Presentation) Section 2. Dose to Medium / Dose to Water Considerations (Presentation) Section 3. MU Workflow in Monaco (Presentation) Section 4. Monaco Optimization Dose Calculation Algorithms (Presentation) Section 5. Electron Monte Carlo Algorithm (Presentation) Section 6. Head Model and Collapsed Cone Photon Algorithm for 3D Calculations (Presentation) Section 7. Monaco Optimization Processes (Presentation) Section 8. Setting the Couch Densities

Open the Full Beams Package ................................................................................................................. 8-1 Save the Plan as a Template..................................................................................................................... 8-3 Create the Dummy Plan .......................................................................................................................... 8-4 Remove All Unnecessary Beams............................................................................................................. 8-9 Edit the Couch Densities ....................................................................................................................... 8-11

Section 9. Post Modeling Adjust of MLC Parameters

Open the Test Beams Package ................................................................................................................ 9-3 Save the Plan as a Template..................................................................................................................... 9-5 Evaluate the First Beam ......................................................................................................................... 9-10 Tune the MLC Offset ............................................................................................................................. 9-12 Step 1. Check MLC Calibration ....................................................................................................... 9-12 Editing the MLC Offset in Monaco ......................................................................................... 9-13

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Table of Contents Section 9. Post Modeling Adjust of MLC Parameters (cont.)

Evaluate the 20x20, 10x10 and DMCL1 beams from the Express QA Package ............................. 9-16 Evaluate Plans 7SegA and FOURL for MLC Offset and Leaf Transmission .................................. 9-22 Evaluate the FOURL Field................................................................................................................ 9-24 Evaluate the field of “7SegA” ........................................................................................................... 9-28 Evaluate the field of “7SegA” ........................................................................................................... 9-29 Editing the Leaf Transmission and Leaf Groove Width (mm) in Monaco ........................ 9-29 The Effect of MLC Leaf Offset on Test Beams Dose .......................................................................... 9-32 Evaluate the fields of “HIMRT” and “HDMLC” ................................................................................ 9-35 Interest Points at Different Dose Levels in a Typical HN Case ........................................................ 9-38

Section 10. Folder Structure (Presentation) Section 11. Monaco Beam Modeling (Presentation)

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Table of Contents Volume IV of IV – Appendices Appendix A. User Authorization Setup for Plan Approval

User Authorization.................................................................................................................................. A-1 Create Users and Permissions in User Authorization................................................................... A-1 Create a New User .............................................................................................................................. A-2 Create a New Group .......................................................................................................................... A-4 Edit Group’s Permissions and Users ............................................................................................... A-5

Appendix B. Machine Configuration and Jaw Labeling (Standalone Users)

Edit Machine Configuration .................................................................................................................. B-1 Copy to Create a New Machine ............................................................................................................. B-2 Customize the Jaw Labels ....................................................................................................................... B-3

Appendix C. Settings

General Information ............................................................................................................................... C-2 Graphical Preferences ............................................................................................................................. C-4 Tolerance Tables ...................................................................................................................................... C-5 Rx Sites ...................................................................................................................................................... C-6 Ports and Materials.................................................................................................................................. C-7 DICOM Machine Mapping .................................................................................................................... C-8 Parameters ................................................................................................................................................ C-9 MLC Dynamic Parameters................................................................................................................ C-9 MLC Geometric Parameters ........................................................................................................... C-11 MLC Leakage ............................................................................................................................. C-16 Wedge Parameters ........................................................................................................................... C-18 Stereotactic Cone Parameters .............................................................................................................. C-21 Treatment Units..................................................................................................................................... C-23 Treatment Unit Storing ................................................................................................................... C-23 Adding Treatment Units ................................................................................................................. C-23 Treatment Unit Mapping ................................................................................................................ C-25

Appendix D. MLC Geometry Definitions

General Information ............................................................................................................................... D-1

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Table of Contents Appendix E. DICOM

Import Utility Scenarios ......................................................................................................................... E-1 Import One or Multiple Series for the Selected DICOM Patient ................................................ E-1 Import Utility Scenarios ......................................................................................................................... E-2 Selecting Image Sets that have Different Patient IDs for Fusion ................................................. E-2 Merge and Import Multiple Image Series for the Selected DICOM Patient .............................. E-2 Enter or Edit DICOM Settings ......................................................................................................... E-2 Export Utility............................................................................................................................................ E-3 Setup your DICOM File Export Data Location ...................................................................... E-3 Setup Storage of Incoming Images for Future Export............................................................ E-4 Setup DICOM Export Locations ............................................................................................... E-4 Exporting via DICOM ....................................................................................................................... E-5

Appendix F. Patient Information Management

General Functionality............................................................................................................................... F-1 Configuration of the Monaco and XiO Interface............................................................................ F-1 Send and Unget Overview ....................................................................................................................... F-1 Send a Patient to XiO ............................................................................................................................... F-2 Unget a Patient to XiO ............................................................................................................................. F-3 Handling XiO Patients ............................................................................................................................. F-4 Opening a Remote XiO Patient in Monaco ..................................................................................... F-4 Open Pushed data from XiO ...................................................................................................... F-4 Select a Batch of Patients to Import from XiO ................................................................................ F-4 Anatomical Groups .................................................................................................................................. F-5 Structures List ...................................................................................................................................... F-5 Plan Review ............................................................................................................................................... F-6 View Images from XiO ....................................................................................................................... F-6

Appendix G. Workflow Scenario for Margin Recipe Usage

Creating and Customizing the Advanced Margin Template ............................................................. G-1 Introduction and Background .......................................................................................................... G-1 Example: Lung SBRT .............................................................................................................................. G-3 How to Establish Margin Recipe Input Data for Your Clinic ........................................................... G-6 References ................................................................................................................................................. G-7

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Overview Volume I of IV Monaco Training Guide

Overview Monaco Products Congratulations on your purchase of Monaco. The Monaco products run on a PC workstation and may be used in conjunction with XiO or other Treatment Planning System (TPS). Before you begin, it may be useful to understand the functionality available with the licenses you purchased. Consult with your internal purchasing agent, Sales Representative, or Customer Support Representative if you are not sure which features are available to you. The following is a list of possible features: Simulation includes 4D support, Contouring Tools, Fusion, beam placement, block/port definitions, and real-time DRRs. Multiple customizable views ensure efficient access to all required images and planning perspectives. Plans may be sent to XiO or another treatment planning system for dose calculation and optimization. DICOM Import/Export is a purchasable option for Monaco and is required if you plan to use this product with any other TPS besides XiO. 3D Planning utilizes a Collapsed Cone algorithm which lets you add treatment aids and calculate isodose distributions. You calculate isodose distributions for an electron plan using the Electron Monte Carlo algorithm. You can use a Photon Monte Carlo dose calculation engine for plans which contain MLCs. IMRT/VMAT Planning uses segment shape optimization and a Photon Monte Carlo dose calculation engine for accurate results. A biological optimization ensures superior treatment plans. Stereotactic Planning is full MLC-based planning that includes Apex micro-MLC support. It also includes Contouring, CT Simulation, Plan Review, and DICOM import/export capabilities. You calculate the isodose distribution using the Photon Monte Carlo algorithm. Plan Review is an application that offers an array of review tools and rapid off-line access for plan analysis and approval.

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Overview Volume I of IV Monaco Training Guide

Overview Monaco Products (cont.) You can view the Intended Use Statement for this product in the Monaco User’s Guide. The Monaco guide is divided into two sections. The first section covers the Settings, General Operation and Navigation and Sim Planning. The second section covers treatment planning, calculation algorithms and QA tools. There are planning exercises you can use throughout the training, an appendix, and useful IMRT references. Detailed discussions of the planning process and cost functions are in the Monaco guide. Refer to the table of contents for a more detailed outline.

Disclaimer The examples and exercises used throughout this training guide are for illustrative purposes only, and are in no way to be construed as Elekta acting in any way to provide medical direction or advice. The information included in this training guide is not intended to replace or to be a substitute for the knowledge, expertise, skill, and judgment of a qualified healthcare professional. The professional duty to the patient in providing healthcare services lies solely with the healthcare professional providing patient care services. Full responsibility for the use of information provided in this training guide resides with the healthcare professional providing patient care services.

System Activities

Figure 1-1: Patient Workspace Control - System Activities The major sets of features are separated into activities you can access from the Patient Workspace Control. Click on the activity button on the Patient Workspace Control. Monaco activities include:

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•

Fusion Activity - Manual and Auto Registration of CT, MRI and/or Pet Images

•

Planning Activity - Contouring, Plan Creation, Beam Manipulation

•

Plan Review Activity - Plan Evaluation and Comparison

Overview Volume I of IV Monaco Training Guide

Overview Planning Activity The Planning activity is available to all users. However, if you purchased Monaco Sim, the features are limited. The system has a dedicated set of CT Simulation tools tailored to these tasks: •

Image import

•

Target and organ contouring

•

Beam placement

•

Port designing

•

DRR generation

You can import images straight into Monaco, fuse images from CT, MR, or PET (that is, if you purchased Fusion), and prepare new patients for dose calculation later on XiO. You can use the Planning Activity tools to contour, edit and create XiO plans, or it can be used by any 3rd party vendor strictly as a CT Simulation tool. This training guide does not teach CT simulation. It teaches you how to use this software. You can send CT simulation shift information to Gammex or LAP laser marking systems. For information on Gammex and LAP Laser Marking Systems, see the Monaco Installation Instructions guide.

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Overview Volume I of IV Monaco Training Guide

Overview Fusion Activity The Fusion activity is only available to those who purchased this feature. Fusion is a process that lets you to register datasets for the purpose of contouring from either dataset or both datasets. Fusion lets you to combine patient data collected from multiple diagnostic imaging methods for a single patient's anatomy. The fusion of a primary studyset with a secondary studyset lets you combine important anatomical data garnered from each method. The system offers two methods for aligning the studysets: (1) Use the first method, Auto Registration, to automate the alignment process. The software computes the geometric transformation that best registers corresponding anatomic details in two 3D studysets of the same patient's anatomy. The alignment criterion is mutual information that is a measure of the statistical similarity of the overlapping data. (2) Use the second method (Interactive Registration) to manually align the studysets. However, you must first adjust the display of the images to better see the individual structures, then manually translate and rotate the secondary studyset until you achieve the desired alignment. The image sets are considered fused when the resulting registration is accepted. You can now show the primary and secondary studysets together in the Planning and Plan Review activity. The system lets you use studysets comprised of CT, MRI, and PET images.

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Overview Volume I of IV Monaco Training Guide

Overview Plan Review Activity This activity is available to all system users. Plan Review lets a physician, physicist, or dosimetrist review and compare treatment plans in real time. Plan Review gives a visual display of the following: • • • • •

Dose distributions superimposed on volumetric CT data in colorwash or isodose line Dose distribution on a 3D image Dose distribution on secondary studyset Dose volume histograms (DVHs) Beam arrangements

Plan Review lets you to do these functions: •

Review multiple plans for the same patient

•

Manipulate the images with basic tools like window/level, dose transparency, zoom, and pan

•

Adjust the isodose levels for display

•

Review the beam arrangements for a given plan

•

Review the dose volume histogram

•

Provide organ-based DVH summaries

•

Review a dose comparison display to determine the differences between two plans

•

Review Plan Summation results and Plan Summation DVH.

•

Make NOTEs about individual patient plans and store these NOTEs for the dosimetrist or planner

•

Select and mark a plan for approval

Conditions that Prevent Opening Studysets

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•

The studyset contains fewer than five cross-sections (2D plans).

•

The studyset contains no CT, MRI, or PET images (non-image based plans).

•

The studyset is a CT or PET studyset defined with a roll angle other than 0 or 180 (prone or supine).

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Overview Volume I of IV Monaco Training Guide

Overview Conditions that Prevent Plans from Being Available The plan types below sent proprietarily from XiO are not supported. 

Brachytherapy plans



Plans with rotational beams



Stereotactic plans



Relative dose plans without a valid prescription

NOTE:

Plan Review supports plans with rotational beams and stereotactic plans imported through DICOM. Plan Review also supports rotational plans from Monaco.

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Overview Volume I of IV Monaco Training Guide

Overview Entering and Editing the Monaco License Once Monaco is loaded, it must be licensed for the features you purchased. If your system was set up by support personnel, the system may already be licensed. However, if you need to verify features or make edits, you can do so on the Edit License dialog box. If you think that an edit is needed, please contact customer support to verify your features and get a new activation code, if necessary. 1.

Click Start | All Programs | Elekta | Edit License to show the Edit License dialog box Figure 1-2.

Figure 1-2: Edit License dialog box

Monaco®

2.

Your System ID and the software Version fields automatically populate.

3.

The Site ID is listed on the activation code generated by applications support.

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Overview Volume I of IV Monaco Training Guide

Overview Entering and Editing the Monaco License (cont.) 4.

All features on your activation code must have a checkmark beside them on the Edit License dialog box for the activation code to be correct.

5.

Click Check License to verify that the activation code and feature combinations are correct.

6.

You can print the information on this dialog box by clicking the Print button.

7.

Click the Save and Exit button when you are finished or the Cancel button if you do not want to accept any edits you made.

Online Help The online help includes an Index function where you can search for a topic when you use the Index tab and type a key word. The Find function lets you to search for a topic when you use the Find tab and type a single character or an entire word. The system does the search for you.

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Overview Volume I of IV Monaco Training Guide

Overview Online Help (cont.) Keep the Online Help Window in an Open Status while Performing Functions To keep the online help procedures for a task in view while you complete a task, follow these steps: 1.

Click Monaco Application button followed by the Help menu item. The Help window remains open until you either minimize the window or close it.

2.

box in the upper To minimize the help window while you do a task, click the right corner of the help window. (This feature works identically to other Windows applications.)

3.

To bring the help window back into view, right-click the Online Help session identifier computer screen.

4.

on the Start taskbar at the bottom of your

box in the upper right-hand corner of the To close the help window, click the help window. (This feature works identically to other Windows applications.)

User Authorization Database Before you set up your clinic, it is important for the administrator to create users and assign the users to the appropriate group based on the group’s permissions in the User Authorization database. This is done so that they can do certain functions, such as, Plan Approval. We give the user a username and password so they can login with the specific rights and information assigned to them.

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Overview Volume I of IV Monaco Training Guide

Overview Other Training Resources If you have additional questions about the functions that are not described in the online help or in the training practice exercises, refer to any of these resources:

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•

Monaco User Guide

•

Monaco Upgrade Instructions

•

Customer Support (supply phone and technical resources around the world)

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Overview This section provides information related to the general operation and navigation tools available. When applicable, tools that are activity-specific will be labeled as such. TERMINOLOGY NOTE:

Monaco uses the term Studyset to represent the set of images that make up one complete patient scan. You can also refer to a studyset as an image set. The term Study refers to a set of studysets or image sets relating to one patient.

Open the Monaco Application and Log In Once you configure the Monaco application for clinical use, follow these instructions. If configuration is not complete, refer to the Monaco Installation Instructions for more detailed information. 1.

Double-click on the Monaco desktop icon. OR Click Start | All Programs | Elekta | Monaco to open and show the application.

2.

Monaco®

Type a valid username and password.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Open the Patient As soon as you open the application and log in, Monaco shows the Patient Selection dialog box (Figure 2-1). From here, you can access all local or remote Monaco patients.

Figure 2-1: Patient Selection dialog box

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Open the Patient (cont.) Local Patient Tab Click this tab to show a list of patients that currently reside on the Monaco PC. Remote XiO Patient Tab (not available for standalone Monaco users) Click this tab to show a list of patients that currently reside on XiO. When you select a patient from this list and open in Monaco, the patient becomes inaccessible in XiO. Remote Focal Patient Tab Click this tab to show a list of patients that currently reside on other Monaco computers. When you select a patient from this list and open in a Monaco application, the system moves the patient completely from one system to the other. Selecting, Filtering and Loading a Patient 1.

Left-click on a Clinic or Installation to show the patient listing. NOTE:

Monaco®

Patients that are grayed out indicate that they are in use or locked in the current or remote application.

2.

Filter the patients by typing the first few characters of the Patient Name or Patient ID in the filter dialog. The filter works on both the Patient Name and Patient ID text simultaneously.

3.

Click the patients.

4.

Click the Patient Name title bar to reverse the order of the patient names.

5.

Click the Patient ID title bar to reverse the order of the patient IDs.

button next to the filter to remove the filter entry and show all the

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Open the Patient Selecting, Filtering and Loading a Patient (cont.)

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6.

Click the Creation Date title bar to reverse the order of the patients by date of creation.

7.

Double click on a Patient Name to load, or click on a Patient Name and click OK. This action loads the patient/plans into the Patient Workspace Control. The patient, studyset, plan, and server name appear in the title bar.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Treatment Couch Library This button opens a library of treatment couches or accessories that you can apply to your plans. Eight sample couches are available for you. But, you can DICOM import, contour and save your clinic-specific couches and accessories into this library for future use. Refer to the exercise on Importing a Treatment Couch in this guide for more information. Sample Couches: •

sampleElekta

•

sampleVarian

•

Fraxion

•

SampleConnexionHN

•

SampleConnextionImaging

•

SampleConnexionLatOpen

•

SampleConnexionNoInlay

•

SampleConnexionSolidInlay

NOTE:

Monaco®

Before you use a sample treatment couch, you must complete these tasks: a) Review sample couches for accuracy. b) Force electron density values (default value is 1.0).

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Treatment Couch Library (cont.) Open Treatment Couch Library 1.

Click Treatment Couch Library on the Patient Selection dialog box. The system loads the couches into the Workspace Control.

2.

Double-click on a couchtop or accessory in the workspace to load.

3.

Edit couchtop structures just like any other structure in the system.

See the Contouring Tools section of this guide for more information on editing contours. Remove Couches from Treatment Couch Library 1.

Click on the Monaco Application button followed by Treatment Couch| Remove Couches from Library (Figure 2-2).

Figure 2-2: Remove Couches from Library

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2.

Under the Delete heading, place a check in the box next to the couches you want to delete.

3.

Click OK.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Import New Data Use the Import New Data utility to manage the selection of DICOM series for import. From this interface, you can import DICOM images from CT, PET, and MRI. You can also import RT Structure Sets, RT Plans, RT Dose, and couchtop images. No user intervention is necessary to determine patient orientation, image view orientation, or image labeling. Monaco extracts all of this data automatically upon import based on the DICOM header. 1.

To access the DICOM import utility, click the Import New Data button on the Patient Selection dialog box. This action opens the DICOM Import dialog box.

Figure 2-3: DICOM Import dialog box 2.

Monaco®

Click the Browse button to search your network for the DICOM patient you want to import. This opens a standard Windows browser. You can import DICOM patients from a local folder, a CD, a removable drive, or any networked location.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Import New Data (cont.) NOTE:

You can right-click in multiple locations on this dialog box to show a menu of available options.

3.

Select the loaded patient from the DICOM Patient drop-down list. Monaco shows the study, studysets (image sets) and/or plans for this patient in the window at the top left.

4.

Left-click on the studyset, plan, or dose to select the data you would like to import. If you would like to select multiple sets of information, hold down the Ctrl key on the keyboard and left-click to select the data. DICOM Header information is automatically shown in the top-right window. NOTE:

Monaco does not handle RT DOSE import of BEAM level or CONTROL POINT level doses or dose of type MULTI PLAN. If you compare doses in Monaco, you must import the total plan dose. The import of large DVH files may fail. Contact Customer Support if the import fails.

5.

Select a local installation and clinic where you want this imported data to reside.

6.

Monaco automatically shows a patient ID and Patient Name based on the DICOM Header information, or you can enter a new patient ID and Name.

7.

Click the Add button to add the selected data to the import. Monaco automatically shows images in the image window on the right side of the dialog box and populates the window below the Add button with the data you want to import. OR Click the Clear button if you would like to clear your selections and start again. OR

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Import New Data (cont.) Click the Merge button to merge multiple image series from the same studyset into one studyset for import. NOTE:

8.

If you do not import plans or dose, you can right-click on the studyset name and select Rename from the menu to rename the studyset. The studyset name is now editable. Type a new studyset name.

9.

You can move the slider bars that appear just beneath the image to adjust the window and level.

10.

Right-click on the image to maximize a shown image.

11.

Left-click on a new one on the list shown below the image to change the shown cross section. The Left/Right, Anterior/Posterior, and Foot/Head rotational information around the base image (transverse, sagittal, coronal) for the displayed image shows to the right of the image list. These values are zero for coronal, sagittal, and transverse images. These values are non-zero for oblique MR images. If an image has less than one degree of rotation, it is transverse, sagittal, or coronal. If an image has more than one degree of rotation, it is oblique.

12.

You can click on a cross section and click on the Remove button in order to remove a cross section. The cross section appears grayed out. You can hold down the Ctrl or Shift key on the keyboard and left-click to select cross sections with your left mouse to remove multiple cross sections. NOTE:

Monaco®

See Appendix E of this training guide for detailed scenarios about the selection of images for DICOM Import.

If you import dose, Monaco does not show the Remove cross section buttons.

13.

Select the grayed out cross section and click on the Restore button to restore a cross section. (Monaco only shows Restore if a selected cross section is grayed out.)

14.

Click on the Remove Even or Remove Odd button to remove all even or odd cross sections.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Import New Data (cont.) 15.

Click the Restore Even or Restore Odd button to restore all even or odd cross sections. (Monaco only shows Restore Even or Restore Odd if the selected cross sections are grayed out.)

16.

Select a CT-to-ED file from the CT-to-ED Assignment drop-down list.

17.

(Optional) If you have any anatomical sites in the Installation/Clinic that you selected and you want to assign one to this patient, select the anatomical site from the Anatomical Group drop-down list. NOTES:

Anatomical groups are assigned to studysets instead of structure sets to avoid overwriting anatomical groups that may exist on a structure set. Anatomical groups are not available to standalone users at this time.

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18.

Place a checkmark next to Delete After Transfer if you would like to delete the patient from the location where you retrieved it. This is an easy way to clean up the DICOM Import folder if you have one locally.

19.

Click the Import button to complete the Import of the selected data.

20.

Click the Show Log button to see the error log. Customer Support may ask for this information if you call them because you cannot import your images.

21.

When the DICOM Import dialog box clears, the import is complete. Click Close to close the dialog box.

22.

Click the Open Patient

23.

Select the imported patient from the Installation/Clinic where you imported.

button to show the Patient Selection dialog box.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Recalculate DICOM Plan You can use the Recalculation of DICOM imported plans to create and calculate a Monaco plan from an imported DICOM treatment plan. The imported DICOM plans can come from any manufacturer’s treatment planning system. During the import, Monaco converts the control point data in the DICOM file into a Monaco treatment plan. Once the plan is recalculated, you can compare the imported DICOM dose with the Monaco calculated dose. This comparison is done for various reasons but not limited to the following: independent QA check, dose comparison for research purposes, dose recalculation to transfer patient to a different machine. When you assign a machine to an imported plan, verify that the machine geometry (leaves, jaws, collimator/gantry angles, etc.) of Monaco’s TU match the machine geometry on the original treatment planning system. 1. Right-click on a plan and select Recalculate DICOM Plan in the right-click menu. The Map DICOM Machine to Monaco Treatment Unit opens.

Figure 2-4: Map DICOM Machine to Monaco Treatment Unit 2. Select a treatment unit in the Suggested Monaco TU drop-down menu on the Map DICOM Machine to Monaco Treatment Unit dialog box. You only see Treatment Units with a status of ‘Clinical’. You see an error message if none of your Treatment Units match the imported machine. 3. (Optional) If you want to save the TU, place a checkmark next to Save Mapping to save the settings selected. Future plans which use this same machine will use this same TU mapping. 4. Click on the Reset to defaults button if you want to reset to the default setting.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Recalculate DICOM Plan (cont.) 5. Dose will not calculate until all the parameters of the plan are correct. Look in the status bar at the bottom of the screen. Correct any error messages related to the Prescription Dose or Patient Contours you see (shown in red).

Figure 2-5: Error message before calculating an imported DICOM RT Plan 6. If the imported MLC or Jaw positions violate constraints in Monaco, you will see a warning message that the plan may not be deliverable. Click OK to close the message. Monaco will usually continue with the dose calculation using the imported MLC configuration.

Figure 2-6: Segmentation Validation error message 7. Monaco uses a relative electron density for its dose calculation. Some treatment planning systems use a mass density. Monaco imports density overrides for a structure when reported as relative electron density (for example, if there is contrast in the bladder), you should check that structure densities are set correctly. You can manually set a structure’s density. Use the Force ED and option on the Structures tab of the Planning Control to define a structure’s density. Check that you are using the correct cttoed file and that your structure densities are set correctly. Differences in these parameters could cause differences in the dose calculated in the 3rd party TPS and Monaco. For information on converting from Mass Density to Relative Electron Density, see the Dose to Medium/Dose to Water presentation in Volume III of this guide for more information.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Recalculate DICOM Plan (cont.) 8. Once you select a TU and address any errors, click Calculate to calculate dose. 9. You cannot select the Calculate button if the plan: a. Is from Tomotherapy b. Contains beam modifiers such as blocks, wedges, compensators, applicators, cones or an add-on MLC c. Contains electron or proton beams d. Does not contain an MLC e. Was imported prior to Monaco 5.1 NOTE:

Monaco®

There is no treatment machine data contained within the DICOM treatment plan file. Also, most of the calculation settings are not contained in the DICOM treatment plan file. You must select and verify the appropriate machine model for recalculation in Monaco. Differences in these settings/data between the original calculation and any Monaco calculation can result in calculated dose differences. These differences can include: CT to ED File, Dose Grid, Dose to Water vs. Dose to Medium, Heterogeneity Correction, and Structure Set density overrides may not be read by Monaco.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Enter or Edit DICOM Export Settings These settings apply to data that you want to export to any application that receives DICOM Imports. They do not apply to sending data to XiO. The actual DICOM export is done from the Output tab | DICOM Export. The export process is explained in detail after this section.

Setup your DICOM File Export Data Location Type in the location where you would like to store DICOM Export data when you choose to export to a file. 1.

To type in or edit the DICOM Export Settings, click Monaco Application button| Setup | DICOM Settings to show the DICOM Settings dialog box.

Figure 2-7: DICOM Settings dialog box

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2.

The default location for the DICOM File Export data automatically appears. You can click the Browse button to set a new data location, if desired.

3.

The SCU Name is the AE_Title of the Monaco PC where you are entering these settings. Monaco provides a default name. You can edit the default name. The receiving application must have this AE_Title assigned in its DICOM Import program in order to receive the exported data.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Enter or Edit DICOM Export Settings Setup your DICOM File Export Data Location (cont.) Setup Storage of Incoming Images for Future Export If you plan to export image data that was previously transferred in to Monaco, you must have the Store Incoming DICOM Images box checked before you import the images. This creates a copy of the image data that is used during export. If you do not plan to export image data, we recommend that you do not place a checkmark  in this box to avoid the population of unnecessary sets of image data on your hard drive. Setup DICOM Export Locations Type in the location(s) where you would like to send DICOM Export data when you choose to export to an SCP location.

Monaco®

1.

Click Add or .

2.

Type the Label for the location. This is the location label you select from the DICOM Export dialog box when you export to an SCP location.

3.

Type the AE Title for the receiving system.

4.

Type the resolvable hostname or a valid IP address for the receiving system.

5.

Type the Port Number that will be used for this DICOM transfer.

6.

Once you type in all the information for an export location, highlight the export location you want to test. Click the Test button to verify communication between the two systems.

7.

Assuming the test was successful, click OK when you finish entering or editing these settings.

8.

Add or Delete Export locations. Highlight the location you want to remove and click the Add or Delete button.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Export Patient via DICOM You can export these objects through DICOM to a record and verify system or another treatment planning computer: • • • • • • • •

Images Specialty Images Structure Sets RT Plans RT Images (DRR’s) Monaco dose - total and/or individual beam doses for single prescription, multiple prescription, and MR plans Monaco QA dose- total and/or individual beam doses DVH

In Planning or Plan Review, click Output tab | DICOM Export. NOTE:

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If the Export option is not available, verify the information below: (1) You have a patient loaded. (2) You have turned on the proper DICOM license features.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Exporting via DICOM Use these steps to export data via DICOM: 1.

Click Output tab | DICOM Export to show the DICOM Export dialog box.

Figure 2-8: DICOM Export dialog box 2.

Monaco®

Select the modalities you want to export. Monaco limits what you can export based on the plan properties:

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General Operation and Navigation Patient Management Exporting via DICOM (cont.) Table 2-1 DICOM Export Options

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RT Plan Option

This option is only available if you have a plan loaded.

RT Ion Plans

Are exported as RT Plans. In the export file, the machines are changed to generic IEC photon machines.

Dose Option

Only available if you have RT Plan selected and dose was calculated in Monaco.

Composite Plans

You cannot export composite plans.

Multiple Prescriptions

You can export all prescriptions, or select which one(s) to export.

Frozen Dose

You can export Frozen Dose Plans.

QA Plans

You can DICOM export images, structure sets, plans, and dose from within a QA Plan. Monaco updates the DICOM fields for exported QA plan images. The Study and Demographic modules are updated.

DVH

You can DICOM export the DVH if the Total Dose box is checked.

Specialty Images

MIN, MINiP, AVG can be exported.

MR Images and Structure Sets

You can export T/S/C structure sets for MR images. However, you cannot export oblique structure sets. You can export oblique MR Images.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Exporting via DICOM (cont.) 3.

(For Elekta non-micro MLC: Step and Shoot IMRT, VMAT, Conformal RT, and dMLC plans. Siemens: Step and Shoot IMRTand Conformal RT Plans only) When you check the RT Plan option, you can also check Composite Field Sequencing to group beams with a common couch angle into a single control point sequence. Composite Field Sequencing is not available if your plan contains more than one Rx or multiple machines. (For detailed information about composite field sequencing, refer to the Online Help.)

4.

When you check the Include Setup Beams option, the system exports the setup beams created in the beam spreadsheet. The Setup Beams/Sequences are DICOM exported as SETUP with the RT plan.

5.

When you click on the Addt’l Options button, the Additional Plan Export Options dialog box shows a table of options you can DICOM export. You use these options to match the information defined in your record & verify system.

Figure 2-9: Addition Plan Export Options dialog box

Monaco®

6.

If you have RT images associated with your plan, you can select to export all the images or select individual beam images. Below RT Image Options, you can check the respective boxes to Add Overlays, Add Anatomy, and Add Annotation.

7.

When you check Total Dose, the system exports the total composite dose for all the beams.

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General Operation and Navigation Patient Management Exporting via DICOM (cont.)

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8.

When you check individual beams below total dose, the system exports individual beam doses.

9.

When you select RT Plan as a modality to export, the system activates the Map Machine feature. Click Map Machine to show the modeled machine names.

10.

Next to each modeled machine name, type a name that the receiving system recognizes.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Delete a Patient (Standalone Users Only) If you are a standalone Monaco user and would like to delete a patient, use these steps: 1.

Click the Monaco Application button | Delete Patients to show the Remove Patient dialog box.

Figure 2-10: Remove Patient dialog box 2.

Check the box next to the patient you want to Remove.

3.

Click the Remove button. Monaco shows the Delete Patient Confirmation dialog box.

Figure 2-11: Delete Patient Confirmation dialog box 4. You can select to Recycle, Delete, or Cancel the deletion.

Monaco®

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General Operation and Navigation Patient Management (cont.) Patient Workspace Control The Patient Workspace control is available for all activities. Once you open a patient, you must select the studysets or plan(s) you want to load and activate. The Workspace Control is where you can: • • •

Load primary and secondary studysets Start new Sim or Monaco plans View DICOM information about a studyset.

Here is a list of patient workspace control icons you might observe: Study ID Studyset (orientation is shown if nontranverse) Structure Set (orientation is shown if non-tranverse) Conventional Plan Conventional Plan with Dose XiO IMRT Plan XiO IMRT Plan with dose Monaco Plan Monaco Plan with Dose Monaco QA Plan Summation Plan (Plan Review) Subtraction Plan (Plan Review) Base Plan (used to create Composite Plan) Composite Plan (Bias Dose) Composite Plan (With Dose) Frozen Dose Plan Approved Figure 2-12: Workspace Icons

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Multiple Prescription Plan Multiple Prescription Plan (With Dose)

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management Patient Workspace Control (cont.) Load a Patient/Plan from Patient Workspace Control Follow these instructions to load a patient that has recently been imported to Monaco via DICOM, or a patient that already resides locally on the Monaco PC and was opened from the Patient Selection dialog box. You can load multiple plans and studysets at one time. The active studyset and/or plan appear in Blue Underlined Italics in the workspace and also are listed on the title bar. A studyset and/or plan that is loaded, but not active is shown in Black Bold in the workspace. A secondary studyset is shown in Green Italics in the workspace. Studysets and plans that are not loaded appear as Black in the workspace. Load a Studyset To load a studyset, double-click the studyset name. OR Click the studyset name then, click Load to load the selected studyset. OR Right-click on the name and select Load/Activate from the right mouse menu options.

Monaco®

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General Operation and Navigation Patient Management Load a Patient/Plan from Patient Workspace Control (cont.) Load a Primary and Secondary Studyset The instructions below demonstrate how to load a primary and secondary studyset so you can fuse them or use them both in contouring. It is assumed that both studysets have been transferred into the system directly and both reside in the local directory. Or they have both been transferred into XiO and you have selected the patient from the Remote XiO Directory to be opened in Monaco. 1.

Select the patient from the Patient Selection dialog box to open it and to show both studysets in the Patient Workspace Control.

2.

Click and Load the studyset that you want to be the primary studyset. (This is the planning CT.)

3.

Right-click on the studyset that you want to be the secondary studyset and select Load/Set as Secondary. Studysets open directly in the Fusion activity if they have not been fused, or open in the Planning or Plan Review activity, if they have. OR Load the primary study set. Then, select one or multiple secondary studysets. Right-click and select Load/Set as Secondary. OR Load all the studysets into the workspace as primary studysets using Ctrl or Shift + selecting multiple studysets. Then, load one of them as a secondary studyset. Use the right mouse menu option on the Workspace Control to Load/Set as Secondary.

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General Operation and Navigation Patient Management Load a Patient/Plan from Patient Workspace Control (cont.) Load an Existing Plan To load an existing plan, double-click one of the plan names. OR Click one of the plan names, then click Load to load the selected plan. OR Right-click the plan on the Workspace Control and choose the option Load/Activate. NOTE:

Monaco shows an Electron Densities Warning message if the Studyset timestamp is later than the Plan timestamp. It also shows the warning message if the plan electron densities are different than the studyset electron densities.

Figure 2-13: Electron Densities warning message Unload an Existing Studyset and/or Plan To unload a studyset and/or a plan, right-click on the studyset or plan name and select Unload. OR Click a studyset or plan to highlight it. Then, click the Unload button at the bottom of the Workspace Control. If you unload a studyset where a plan is also loaded, both the plan and studyset are unloaded.

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General Operation and Navigation Patient Management Load a Patient/Plan from Patient Workspace Control (cont.) Activate a Loaded Studyset and/or Plan To activate a loaded studyset and/or plan that is not currently active, right-click on the studyset or plan that you want to make active and select Load/Activate. Notice that the plan updates and the active plan name updates on the title bar. Load Existing Plan(s) Into a Specific Activity You can load plans in Planning or Plan Review Activity through the Workspace Control. Options are available based on whether or not the plan has calculated dose. You can only review imported RT Ion Plans in Plan Review. Right-click on a plan in the workspace control and select Load Into, then Planning or Plan Review. To load multiple plans at one time, hold down the Ctrl key while clicking on each plan you want to load. Then, right-click and select Load Into, then Planning or Plan Review. Delete a Plan Right-click on a plan in the Workspace Control and select Delete Plan. OR Click on the Planning tab. Then, select Delete Plan

button.

Studyset Info You can show DICOM header information about a studyset. To do this, right-click on icon in the Patient Workspace Control and select Properties. This the Studyset action shows the Studyset Info dialog box with information such as: • Number of Images • Patient Name • Patient ID • Study ID • Study Date • Study Description • Series Date • Series Description NOTE:

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You cannot edit the Studyset Info. It is read only. If the studyset information is incorrect from the scanner, it cannot be changed in Monaco.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Patient Management (cont.) Frozen Dose Frozen dose is saved dose that is no longer current. Monaco shows frozen dose with a next to the plan in the Patient Workspace Control. When you snowflake icon hover over the snowflake, Monaco shows you the reason the plan has frozen dose. When you delete, edit a shape, or change the structure type from bolus or couch that is assigned or assign a new couch, the system removes the dose of the current active plan and freezes the dose for the saved plans with the same assigned bolus or couch. When you load a frozen dose plan, the DVH shows the frozen dose with the current structure set volumes, not those that were present at the time the dose was frozen. When you load a plan with frozen dose, you have the option to keep the frozen dose or recalculate (Figure 2-14)

Figure 2-14: Frozen Dose-Load Plan A Monaco plan’s dose freezes if you:

Monaco®

•

Change an internal structure with an assigned electron density.

•

Change the CT to ED assignment.

•

Modify the external structure.

•

Edit or delete a bolus or couch structure assigned in a Monaco plan.

•

Edit MLC Dynamics parameters.

•

Edit MLC Geometry parameters.

•

Edit MLC Leakage parameters.

•

Edit a cone model.

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General Operation and Navigation Patient Management Frozen Dose (cont.) QA Plans You can make a QA plan from a Monaco plan with frozen dose. For existing QA plans, if the QA plan is based on the same modified studyset as the Monaco plan, the QA plan dose becomes frozen too. Multiple Prescription Plans For Multiple Prescription plans, if any calculated prescription has frozen dose, the snowflake icon is shown by the plan. This plan does not have to be fully calculated. If a frozen prescription is modified then dose for all prescriptions is removed. Also, if a prescription of a frozen dose plan is added or deleted, the dose is removed.

Patient Workspace Control Tooltip When you place your mouse over an existing studyset or plan, Monaco shows a tooltip that describes these items: Studyset •

Studyset Name

•

Image Type

•

Number of Images

Plan

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•

Plan Name

•

Description

•

Delivery Mode (Monaco Plans Only)

•

Modality

•

Number of Beams

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Navigating Monaco Ribbons Each ribbon contains several different groups (Figure 2-15). These groups keep similar buttons in the specific group. You can double-click on any tab in the ribbon to collapse the entire ribbons panel. You can also add buttons that you frequently use to the Quick Access toolbar so you do not have switch between ribbons during treatment planning. For detailed information about the various groups on each tab, refer to Online Help.

Figure 2-15: Ribbons display In addition to the ribbons, you can click on the Monaco Application do these tasks:

Monaco®

•

Open, close, or delete patients

•

Save plans

•

Save templates

•

Manage Templates

•

Change settings

•

Add/remove treatment couches

•

Change setup options

•

View log files

•

View Online Help

button to

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General Operation and Navigation Navigating Monaco (cont.) Styles You can pick a color style for the Monaco interface. Click on the drop-down arrow to the right of the Style choose one of these styles: •

Black

•

Blue

•

Aqua

•

Silver

button in the top-right corner of the ribbons. You can

Planning Control The Planning Control (Figure 2-16) contains several dialog boxes. You can click on the associated tab to see the dialog box. The tabs below are available on the Planning Control:

Figure 2-16: Planning Control

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•

Structures

•

Prescription

•

Beams

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Navigating Monaco Planning Control (cont.) •

IMRT Constraints

•

Dose Reference Points

Planning Control-Tabs Always Available:

Limited Availability:

Structures

Prescription (Only shown with 3D or IMRT Plans in Planning Activity)

Beams

IMRT Constraints (Only shown with IMRT Plans in Planning Activity)

Dose Reference Points

Save a Plan You can click on the Save button, or click on the Monaco Application button then the Save or Save Plan As option to save your plan. The Save option saves the active patient or plan with changes. The Save Plan As option lets you save the active plan as a new plan. 1.

Click Monaco Application button | Save or Save Plan As to show the Save As Plan dialog box.

Figure 2-17: Save As Plan dialog box

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General Operation and Navigation Navigating Monaco Save a Plan (cont.) 2.

In the Plan Name field, type the plan name. OR Select a plan name you previously used in the drop-down menu.

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3.

In the Plan Description field, you can type a plan description up to 24 characters long. The plan description appears in the plan’s tooltip on the workspace control.

4.

When you save a bias dose plan, you have the option to save the composite plan or the current plan when you check or uncheck the option Include Base Doses.

5.

Click the Save button to save the plan.

6.

If a plan name already exists, the system prompts you to overwrite it.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Navigating Monaco (cont.) Save a Template To save your own plan templates, you must first add an existing plan template to your patient. Make changes to the beams until your plan is set up the way you want it. Select Save Template or Save Template as. The Save Template options saves the active template with the changes you made. The Save Template as option lets you save active template as a new template for future use. Complete these steps to save the beam arrangement as a new template. 1.

Click on the Monaco Application button then Save Template As to show the Save Template As dialog box.

Figure 2-18: Save Template dialog box 2.

Type the Template Name and Description. OR To overwrite an existing template, select a template from the Template Name drop-down.

3.

Select an Anatomical Site from the drop-down. This lets you filter your templates by site when you start a new plan.

4.

Select Save to save the template. NOTE:

Monaco®

Only users with Physics rights can overwrite an existing SIM or Monaco template. All other users can save the template with a new name.

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General Operation and Navigation Navigating Monaco (cont.) Autosave Contours Autosave is a function in Planning activity that, when activated, automatically saves contours as you define them. The appropriate time to use this tool is when you start a new patient and have not yet created any plans. This tool ensures that you do not lose all of your contouring in the event of a catastrophic event, such as a power failure. Place a checkmark next to Contour Autosave (Figure 2-16) on the Tools tab. Each time you add, edit, or delete a contour, Monaco automatically saves all contours.

Figure 2-19: Contour Autosave

Close a Patient To close a patient, click the Close Patient

button.

OR Click on the Monaco Application button then Close Patient. OR Open another patient. Monaco prompts you to save the currently shown patient’s plan before you open the new one.

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General Operation and Navigation Navigating Monaco (cont.) Image Navigation and View Types Before you begin contouring and planning, it would be useful to understand how to navigate through your images and show different views. Throughout Monaco, you can choose to show different image views in selected windows. These types of views include: • • • • • • •

Transverse Sagittal Coronal Oblique beams-eye view (DRR) Side by side primary and secondary images 3D view

Not all views are available in all activities. This section defines each view type and any related tools available to manipulate those images.

Transverse, Sagittal, Coronal, and Oblique Views All activities support transverse, sagittal, and coronal views. There are a multitude of tools you can access when you right-click in any T/S/C/O window. In the Planning activity, the T/S/C/O view that defaults is considered the Standard layout. Refer to Online Help for detailed information about T/S/C/O Views warning messages.

Oblique Views Only the Planning activity supports oblique views. Panning in a T/S/C view does not pan an oblique view. Quick Locate will update an oblique view. Refer to Online Help for detailed information about what functionality is available in oblique views. Navigate Through T/S/C/O Images There are several methods you can use to navigate through your transverse, sagittal, coronal, and oblique images.

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General Operation and Navigation Navigating Monaco Transverse, Sagittal, Coronal, and Oblique Views Navigate Through T/S/C/O Images (cont.) • • • • • •

Use the color coded T-bars (non-oblique images) Use the Scroll Wheel on the Mouse Use the Quick Locator Method Use the Navigation Toolbar Use the Page Up/Page Down keys (transverse images only) Use the Active Slice Tracker (transverse and oblique images only)

Use the Color-coded T-bars Each of the three graphics windows has a color frame. The transverse image window frame is green, the coronal image window frame is cyan (light blue), the oblique image frame is white, and the sagittal image window frame is yellow. In each window, Monaco shows colored T-bars representing the slice location of the currently viewed slice for all three views. The T-bars are called partial slice trackers. If you would like to show solid lines, instead of T-bars, click the Workspace tab and remove the checkmark next to the Partial Slice Tracker option.

T-Bars

Solid Lines

Figure 2-20: Partial Slice Tracker selected and unselected

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General Operation and Navigation Navigating Monaco Transverse, Sagittal, Coronal, and Oblique Views (cont.) Navigate Through T/S/C/O Images Use the Color-coded T-bars (cont.) To navigate through the transverse images, hold down your left mouse button and drag the green T-bar/line in the sagittal or coronal window. Monaco automatically updates the transverse images as the T-bar/line moves. To navigate through the coronal images, hold down your left mouse button and drag the cyan T-bar/line in the sagittal or transverse window. Monaco automatically updates the coronal images as the T-bar/line moves. To navigate through the sagittal images, hold down your left mouse button and drag the yellow T-bar/line in the coronal or transverse window. Monaco automatically updates the sagittal images as the T-bar/line moves. Use the Scroll Wheel on the Mouse If you have a mouse with a scroll wheel, you can left-click in any transverse, sagittal, coronal or oblique window to activate it. Use the scroll wheel to navigate through the images. Use the Quick Locator Method You can quickly update the images to display a specific 3D location in all views by double-clicking your left mouse in any T/S/C/O view as long as no other menu option is selected. OR At any time, you can press the L key on your computer keyboard when your mouse points to the specific location. A cross hair temporarily appears in the window you click just before all the images update to that location. Pressing the L key is the only quick locator option within the Fusion Activity and in any activity when the mouse is occupied with other menu options.

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Navigate Through T/S/C/O Images (cont.) Use the Slice Navigator Toolbar The Slice Navigator toolbar (Figure 2-21) at the bottom of Monaco indicates the slice positions of the transverse, sagittal, and coronal planes that are currently shown.

Figure 2-21: Navigation Toolbar Use the Reference Plane Values Click the up and down arrow buttons next to any field to change the slice shown for that plane. OR Click the arrow buttons next to any field to highlight the field. Use the up/down arrow keys on your computer keyboard, or the scroll wheel on the mouse to change the slice shown for that plane. OR Type a distance value for each field to change the slice shown for that plane. OR Type in or use the arrow buttons to change the Active Slice. This field is available for native (non-reconstructed) slices when you have Slice Mode turned on. NOTE:

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If you click on Slice Mode, Monaco only lets you show real transverse slices. If you do not select Slice Mode, you can show any real or reconstructed transverse slice.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Navigate Through T/S/C/O Images (cont.) Use the Display Image Plane Option In any T/S/C/O view, click the Display Image Plane button view an outline of the Active slice in the 3D view.

to

Use the Jump to Point Option On the Tools tab, you can click the drop-down arrow next to the Jump to Point field to quickly update the display of the transverse, sagittal, and coronal images. Options for Jump to Point are: • • • • • •

A setup reference point Center of any structure Any defined interest point or marker Volume isocenter Plan isocenter Max dose (where available)

Use the Page Up/Page Down keys (Transverse Images Only) Click the Page Up and Page Down keys on the keyboard to navigate through transverse images. When you select Slice Mode, you can navigate through real transverse slices and in 0.1 cm increments through Coronal and Sagittal slices. When Slice Mode is not checked, you can navigate in increments of 0.1 cm. NOTE:

If the real transverse slices have a resolution smaller than 0.1 cm, then the coronal and sagittal slices will be reconstructed with whatever is the smallest transverse slice resolution.

Adjust Window and Level The window and level settings let you control the overall brightness and contrast of an image. You can adjust the window and level settings for each studyset independently when you have more than one studyset loaded. There are three methods available for adjusting window and level settings: • • •

Monaco®

Using the mouse Using the window/level toolbar Selecting user-definable window and level presets

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Adjust Window and Level (cont.) Adjust Window and Level Using the Mouse 1.

Right-click in any transverse, sagittal, coronal, or oblique window and select the Window/Level Tool option. OR From the Tools tab, click the Window/Level cursor to a black and white sun icon.

2.

button to change the mouse

Hold down your left mouse button and drag up or down to change the level, or left and right to change the window. NOTE:

If the studyset you want to adjust W/L for is not shown in the W/L Affects box, you can toggle this when you hold down the shift key on your keyboard, or when you move the P/S slider bar to 100% Primary or 100% Secondary position.

Adjust Window and Level from the Window and Level on Tools tab Type new values for the window and level in the Window and Level section on the Tools tab as shown below:

Figure 2-22: Window Level Section of the Tools tab OR Left-click on the up and down arrows next to the window and level fields to adjust the window and level in small increments.

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Adjust Window and Level (cont.) Select an Image Set/View in the Window/Level Affects Drop-Down Menu In the W/L Affects drop-down menu (Figure 2-23), you can select one of the image sets shown on the screen.

Figure 2-23: W/L Affects Drop-Down Menu The BEV, AP, and LAT view options do not appear in the W/L Affects drop-down menu unless they appear on the screen. Link W/L Affect to Image Sets You have the ability to change the window/level affect for all common image sets. Place a checkmark next to Apply to same type on the Tools tab, and then select the desired Window and Level for all of the common image sets.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Adjust Window and Level (cont.) Adjust Window and Level Using User-Definable Window Level Presets You can click on the Save As Preset button on the Tools tab to save, edit, and delete preset window and level settings from this list.

Figure 2-24: Save Window/Level Preset Values To apply presets to the shown images, click the arrow button next to the Window/Level Preset field and select a preset option from the list. Monaco applies the preset to all transverse, sagittal, and coronal images. To apply a preset to a secondary studyset (fused studyset), change the option in the W/L Affects field to Secondary Studyset. Select a window and level preset from the list. Monaco applies the selected preset to the secondary studyset. Non-Editable Window/Level Presets The PET Default and PET DICOM Window/Level Preset Values are non-editable values. The PET Default values are specific to the maximum pixel value in the studyset window/level. Monaco stores The PET DICOM values: window width and window level in the PET DICOM files. The system reads the values from the first image in the image series.

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views (cont.) Zoom and Pan T/S/C/O and 3D Images There are two locations where you can find zoom and pan tools for your transverse, sagittal, coronal, and oblique images: • •

The Tools tab Right-click in any T/S/C/O or 3D window

Zoom These procedures demonstrate the tools available to zoom and reset images. Zoom Continuously 1.

Click the Zoom icon.

button to change the mouse icon to a magnifying glass

OR Right-click in any T/S/C/O or 3D view and select Zoom. 2.

Hold down your left mouse button and drag left or right in any image window to smoothly zoom the selected image.

Reset Zoom and Pan 1.

Choose one of these two options: •

Click the Reset All Views T/S/C/O and 3D views.

•

Click the drop-down arrow next to the Reset All Views option to reset an individual tool in the Navigate panel.

button to reset zoom and pan in the

Figure 2-25: Reset Drop-Down Menu

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Zoom and Pan T/S/C/O and 3D Images Zoom (cont.) Magnifying Glass

1.

Click the Magnifying Glass magnifying glass.

tool to change the mouse into a moving

OR Right-click in any T/S/C/O or 3D window and select the Magnifying Glass option.

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2.

Hold down your left mouse button and drag over any image to magnify selected areas.

3.

Change the tool from a circle to a square by pressing the S key on the keyboard.

4.

To change the magnification from 1.2x to 5x magnified, hold down your left mouse to show the magnifying glass, then roll the scroll wheel to adjust the magnification.

5.

To change the size of the magnifying glass, hold down your left mouse to the show the magnifying glass, hold down the shift key on the keyboard, then roll the scroll wheel to adjust the size.

6.

To add a border to the magnifying glass, hold down your left mouse to show the magnifying glass, and then press the spacebar to turn on the border.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Zoom and Pan T/S/C/O and 3D Images Zoom (cont.) Zoom Area of Interest 1.

Click the Zoom Area

button to zoom in on an area of interest.

OR Right-click in any T/S/C/O or 3D window and select the AOI Zoom option.

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2.

Hold down your left mouse button and drag to create a box around the area of interest to zoom the area of interest on an single view.

3.

You can click middle-click to reset the AOI zoom on a single view.

4.

Hold down your left mouse button + the Shift key and drag to create a box around the area of interest to zoom an area of interest in all views (T/S/C/O) simultaneously.

5.

Hold down the Shift key + the middle mouse button to reset. You can reset the AOI zoom on all views.

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General Operation and Navigation Image Navigation and View Types Transverse, Sagittal, Coronal, and Oblique Views Zoom and Pan T/S/C/O and 3D Images (cont.) Pan These procedures demonstrate the various tools available to pan and reset images.

1.

Click the Pan

button to change the mouse icon to a hand icon.

OR Right-click in a T/S/C/O window and select the Pan option. 2.

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Hold down your left mouse button and drag in a T/S/C/O window to pan the selected image.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Screen Layout Layouts A layout is a predefined set of view settings. The layouts are saved per Microsoft Windows™ user and contain user-defined layouts and default layouts. All of the layouts are not available at all times. The available layout menu options are determined by the view types they contain. (Refer to Layouts in Online Help for detailed information about the default layouts and their associated workflow(s) and activities). You can do the tasks below with the layouts: •

Save Layouts

•

Manage Layouts

Save Layout as Preset Option You can save the layout configuration shown on your screen. You can save the layout with an existing layout name or type in a new name.

Figure 2-26: Save Layout As dialog box 1.

Click on the Workspace tab then the Save Layout as Preset button. OR Right-click in any T/S/C/O or 3D view and select Layouts | Save Layout As.

2.

In the Layout Name: field, type in a name. OR Click on the Layout Name: drop-down menu to select an existing layout name to save your layout as.

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General Operation and Navigation Screen Layout Layouts Save Layout as Preset Option (cont.) 3.

Click Cancel to discard your changes.

4.

Click Save to save your changes.

Manage Layouts You can set default layouts, view, rename, and delete Global and User layouts in the Manage Layouts dialog box. There are three tabs in the Manage Layouts dialog box: • • • 1.

User Defaults User Layouts Global Layouts Click on the Workspace tab then the Manage Layouts button. OR Right-click in any T/S/C/O or 3D view and select Layouts | Manage Layouts.

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General Operation and Navigation Image Navigation and View Types Layouts Manage Layouts (cont.) User Defaults On the User Defaults tab, you can select a default layout per a specified workflow.

Figure 2-27: Manage Layouts (User Defaults) dialog box 1.

Click on the drop-down arrow in the Layout column in the appropriate workflow.

2.

Select the user or global layout you want as the default layout for the appropriate workflow.

3.

Click Apply to accept your changes. OR Click Cancel to discard your changes.

4.

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Click OK to save your changes and close the dialog box.

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General Operation and Navigation Image Navigation and View Types Layouts Manage Layouts (cont.) User Layouts In the User Layouts tab, you can view, rename, and delete user layouts.

Figure 2-28: Manage Layouts (User Layouts) dialog box 1.

Click on the user layout you want to rename and type in a new name.

2.

Check the box next to the user layout(s) you want to delete.

3.

Click the Delete button to delete the selected user layouts.

4.

Click Yes to accept the changes and continue. If you click Yes, the changes are permanent. OR Click No to reject the changes and go back the User Layouts dialog box.

5.

Click Apply to accept your changes. OR Click Cancel to discard your changes.

6.

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Click OK to save your changes and close the dialog box.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Layouts Manage Layouts (cont.) Global Layouts In the Global Layouts tab, you can view, rename, and delete global layouts. Global Layouts are default layouts available to all users.

Figure 2-29: Manage Layouts (Global Layouts) dialog box 1.

Click on the user layout you want to rename and type a new name.

2.

Check the box next to the user layout(s) you want to delete.

3.

Click the Delete button to delete the selected user layouts.

4.

Click Yes to accept the changes and continue. If you click Yes, the changes are permanent. OR Click No to reject the changes and go back the User Layouts dialog box.

5.

Click Apply to accept your changes. OR Click Cancel to discard your changes.

6.

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Click OK to save your changes and close the dialog box.

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General Operation and Navigation Image Navigation and View Types (cont.) Side-by-Side Layout You can select the Side-by-Side Layout option in Planning or Plan Review Activity. You can see the selected studysets’ transverse, sagittal, and coronal images with contours side by side for comparison. In Plan Review Activity, you can show multiple plans side-by-side for comparison. You can compare up to twelve registered studysets in Planning Activity, and up to twelve plans in Plan Review Activity. 1. Click on the Workspace tab then the drop-down arrow to the right of the Side-bySide button to select the number or configuration of the studysets/plans. Click on the Side-by-Side button and then click on the drop-down arrow to the right of Layouts to select from the default list of side-by-side options. Side-by-Side Layout Options MPR 3x3

P-S Side-by-Side

P-S Side-over-Side

Side-by-Side Side-over-Side

Custom

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Multiple Plan Review 3x3 view: You can see T/S/C views for up to three (3) studysets/plans at the same time Registered Primary and Secondary studysets/plans in a side-by-side view Registered Primary and Secondary studysets/plans, one view over the other view Registered studysets/plans in a side-by-side view Registered studysets/plans, one view over the other view Option to select the number of panes you want to show

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Side-by-Side Layout (cont.) 2. Select the number of panes you want to show, or select one of the global side-byside layouts in the list. 3. Click on the Swap Views button to swap the location of the studysets/plans in the side-by-side panes. Drag and drop the image to the location you want to swap. 4. (Optional): Drag the borders inward/outward to adjust the size of the image. NOTES:

The message “Structures did not originate on displayed images” appears when a structure set overlaps a studyset that the structures were not done on. The message “Structures/Plans did not originate on displayed images” appears when both a structure set and plan overlap with a studyset that the structures or plan was not done on.

Side-by-Side: Planning Activity •

You can click on the Window/Level button on the Tools tab to adjust the window/level for individual studyset(s).

•

You can click on the Copy Structures button on the Contouring tab to copy structures from the active studyset to a selected or all registered studysets. (For detailed information regarding copy structures, refer to the Contouring Tools section of the guide.)

Side-by-Side: Plan Review Activity

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•

You can adjust the isodose display for individual plan(s).

•

You can show all loaded plans in the DVH.

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General Operation and Navigation Image Navigation and View Types (cont.) 3D View The 3D view option is available in the Planning and Plan Review activities. This view shows the contours in a three-dimensional rendering. You can view the 3D contours in wireframe, transparent, or solid rendering. When isolines are turned on for 3D, they also appear in the BEV. In Plan Review, you can show isodoses in the 3D view. Refer to Online Help for detailed information about 3D View warning messages. You also have the opportunity to view the field projection of beams on the skin surface in a 3D view. When beam projections overlap on the surface, Monaco shows that overlap with twice the intensity of the single field. Monaco shows up to three levels of intensity, so the intensity will not increase if more than three beams overlap. To show field projection, you must show the patient contour rendering as solid (0% transparency). The 3D view has its own section (Figure 2-30) that includes tools to rotate and translate the 3D image. The other tools in the Navigate panel are available for both 3D and T/S/C images. You can right-click in the 3D window and select these same options.

Figure 2-30: 3D Navigate Tools

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General Operation and Navigation Image Navigation and View Types 3D View (cont.) 3D Rotate 1.

Right-click in the 3D window and select the Rotate option. OR

Click the 3D Rotate a 3D rotation icon. 2.

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button on the 3D toolbar to change the mouse icon to

Hold down your left mouse button and drag around the 3D window to rotate the image.

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General Operation and Navigation Image Navigation and View Types 3D View (cont.) 3D Translate Translate differs from Pan in that translate shifts the patient off the axis of rotation. If you translate, then rotate, you will rotate around an axis that is no longer the center of the patient. You can also translate in and out of the screen to "cut away" contours so you can see inside the contours. 1.

Right-click in the 3D window and select the Translate in X and Y or Translate in X and Z option. OR Click the 3DTranslate X/Y

button or the 3D Translate X/Z

button on the Tools tab to change the mouse icon to a 3D translation icon. 2.

Hold down your left mouse button and drag in any direction to translate the image off the axis of rotation. OR Hold down your left mouse button while pressing the Shift key on your computer keyboard and drag up to translate into the screen, or down, to translate out of the screen towards you and "cut away" the contours.

Reset 3D Image Navigation Functions Reset 3D Functions Choose one of these two options:

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•

Click the Reset All Views T/S/C/O and 3D views.

•

Click the drop-down arrow next to the Reset All Views button to reset an individual function.

button to reset all the functions for the

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation 4D Imaging Overview 4D Imaging 4D imaging allows evaluation of multiple images sets that provide information about how a patient’s anatomy moves over time. Monaco gives you a variety of 4D Tools to use (Figure 2-31).

Figure 2-31: 4D Tools Import 4D Data You can import 4D data from Elekta XVI, GE, Philips, Siemens, and Toshiba. When you import images that share the same DICOM Study ID and frame of reference (FOR), they are put into a Study when imported. In a 4D data set, the image sets are named by the patient’s breathing phase (Figure 2-32). The Series Description information lists the phase name in the Studyset Info dialog box. For more detailed information about DICOM Import, refer to Appendix E.

Figure 2-32: Image Set Names

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General Operation and Navigation 4D Imaging Overview 4D Imaging (cont.) Multiple Structure Sets You can view multiple image sets and their structure sets for 4D image comparison. You can also view structure sets from other image sets on the active image set. 1.

To select multiple image sets, hold down the Ctrl key on the keyboard and leftclick on the image sets that you want to load.

2.

Click Load to open the image sets.

3.

Place a checkmark next to the structure sets you want to see. The active contour(s) appear in the contour color and the inactive contours appear in gray (Figure 2-33). Only like named structures among the structure sets appear.

Figure 2-33: 4D Structure Sets Create a Specialty Image You can create a specialty image when you select two or more image sets in the same study.

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1.

To select multiple images, hold down the Ctrl key on the keyboard and left-click on the image sets that you want to use to create.

2.

Right-click in the Patient Workspace Control.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation 4D Imaging Overview 4D Imaging Create a Specialty Image (cont.) 3.

Select Create Specialty Image Set in the right-click menu. This opens the Create Specialty Image Set dialog box (Figure 2-34).

Figure 2-34: Create Specialty Image Set dialog box

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4.

You can select a studyset in the Study drop-down menu.

5.

Left-click the images in the Image Sets list that you want to use to create the specialty image.

6.

Click the radio button next to the image set you want to create: MIP (Maximum Intensity Projection), MinIP (Minimum Intensity Projection), or Average.

7.

Type a name for the specialty image set in the box. A default name is generated; you can accept the default name or type in a new name.

8.

To close this dialog box, you have two options: •

Click OK to accept your changes. The new specialty image set is added in the Patient Workspace Control.

•

Click Cancel to discard your changes.

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General Operation and Navigation 4D Imaging Overview 4D Imaging (cont.) Measurement Grid The measurement grid appears in the T/S/C/O images. You can use it to measure the total movement of the tumor volume. The grid is sizeable has many display options from which you can make a selection. You usually use the grid in conjunction with Cine to see how much the tumor moves in all directions. Use Grid to Measure Movement 1.

To show the grid, click the Grid

button (Figure 2-35).

Figure 2-35: Grid Display 2.

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Click the drop-down arrow next to the Grid Grid Options dialog box (Figure 2-36).

button to show the

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation 4D Imaging Overview 4D Imaging Measurement Grid (cont.) Use Grid to Measure Movement (cont.)

Figure 2-36: Grid Options 3.

You can define the area of the displayed grid manually when you remove the checkmark next to Full Grid and type in a length and width. OR You can click on the Grid Editing with your mouse.

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icon to draw and/or rotate the grid

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General Operation and Navigation 4D Imaging Overview 4D Imaging Measurement Grid (cont.) Use Grid to Measure Movement (cont.)

Figure 2-37: Full Grid 4.

You can type a different value in the Spacing field to change the grid line spacing (Figure 2-39).

1 cm spacing Figure 2-39: 1 cm Spacing field

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Figure 2-38: Defined Grid

2 cm spacing Figure 2-40: 2 cm Spacing field

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation 4D Imaging Overview 4D Imaging Measurement Grid (cont.) Use Grid to Measure Movement (cont.) 5.

Click the drop-down arrow in the Grid Style field and make a selection, that is, Solid lines, Dashed lines, or Dotted lines.

6.

Click on the Color field to select a different grid color.

7.

Type a value in the Rotation (deg) field to change the angle of the grid.

8.

Click Reset to undo your changes. OR Click Close to save your changes and close the dialog box.

4D Margin You can use multiple structures from multiple structure sets to specify a 4D margin. Use the Auto Margin tool to make the new contour that encompasses the target volume across all of the phases. This is typically used in conjunction with the cine view. To create a 4D margin, you must have more than one studyset loaded with contoured structures.

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icon on the Contouring tab.

1.

Click the Auto Margin

2.

Select the image set to apply the new structure to in the Image Set drop-down menu.

3.

Select the corresponding structure set that you want to use in the Structure Set drop-down menu.

4.

Select or type the structure name in the Structure drop-down menu. This is the name of the new structure.

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General Operation and Navigation 4D Imaging Overview 4D Imaging 4D Margin (cont.) 5.

Select the image sets under the structure that you want to create an auto margin for in the Structure Selection List. You can select one instance of the structure at a time, or hold down the Shift key to select them all, or hold down the Ctrl key to select multiple instances of the structure.

6.

Click the Add button. This adds the data to the Selected Structures dialog box.

7.

Type a Uniform, Variable, or Advanced margin, as desired.

8.

Click the Apply to All button if you want the margin to apply to all instances of the structure. Otherwise, the margin only applies to the instance of the structure that was highlighted when the margin was made.

9.

Click the Create button at the bottom of the dialog box.

10.

Click the Close button when finished.

Print 4D Auto Margin Report You can print an auto margin report from the Auto Margin dialog box for the last created structure. OR You can print an auto margin report of all auto margin structures on the Output tab.

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General Operation and Navigation 4D Imaging Overview 4D Imaging (cont.) Cine View You can use the cine view to create a movie that demonstrates the motion of the structures during the breathing cycles (Figure 2-41). You can see the cine view in the T/S/C images. You can draw or edit a contour in the cine view. It may be useful to use the grid in conjunction with the cine view to see how much the volume moves in order to draw or edit the contour.

Figure 2-41: Cine View Options 1.

icon to movie through In any T/S/C image window, click on the Cine View the images. This shows the cine tools in the toolbar and movies through the images. NOTE:

2.

This tool only becomes available when two studysets are loaded.

You can click the Play/Pause

icon to stop/start the cine movie.

OR Manually move the cine playbar.

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icon to adjust the movie speed.

3.

Click on the Cine View Speed

4.

Click on the Save Cine View icon to save the cine movie as an .avi file. You can import saved movies and use them in presentations.

5.

Click on the Image Sets icon to change the image sets shown in the cine. You can select to see All Image Sets or select individual image sets to show.

6.

When you are done, you can click on the Cine View button to minimize the Cine toolbar.

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General Operation and Navigation Image Navigation and View Types DRR Views You can view a DRR in Planning activity. There are three types of DRR views: • • •

BEV [Beam’s Eye View] DRR AP DRR LAT DRR

The AP DRR and LAT DRR are part of a larger window layout set call Virtual Fluoroscopy. These views are typically used for virtual simulation activities. You can also use them as AP and LAT setup beams. All DRR views have optional features you can use to improve or enhance the DRR image. Right-click in any DRR window for these options: Filters Select from five preset filter options to apply to your DRR. Quality Select from three options that affect the quality of the shown and printed DRR. Histogram Equalized Output A DRR post-processing technique where DRR values are rescaled. (See the Online Help for more information.) Show Wireframe Contours (BEV DRR only) Select this option if you want all the contours to show as a wireframe. Show 2D Transparency (BEV DRR only) Select this option if you want all the contours to show in 2D transparency. This option is only available when the contours appear in outline on the DRR and not in wireframe. When you right-click in the DRR window and select an option, you can access these additional options that only apply to DRR images. • • • •

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Show MIP (maximum intensity projection) Show Grid (reticule) DRR Volume of Interest Tool (on the toolbar) Print (see Image Printing Options section)

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types DRR Views (cont.) Show MIP (Maximum Intensity Projection) When you select this option, Monaco changes the DRR to a MIP image. This image highlights areas of high contrast or high density. If you have placed wires or markers on the patient's surface, they are usually highlighted in this view. To show the DRR again, right-click and select the Show DRR option.

DRR

MIP

Figure 2-42: DRR windows

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General Operation and Navigation Image Navigation and View Types DRR Views (cont.) Show Grid (Reticule) When you select this option, Monaco shows the jaw labels and yellow scale with tic marks every 1 cm. To turn the jaw labels and grid display off, right-click in the DRR window and select the Show Grid option. Monaco un-checks the option and removes the grid from the selected window.

Grid Shown

Grid Removed

Figure 2-43: DRR windows with and without Grid lines Removed Jaw Labels This option applies to all BEV and DRR windows. See the Treatment Units option under Appendix C. Settings to define your jaw labels.

Figure 2-44: DRR Window with Jaw Labels 2-68

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General Operation and Navigation Image Navigation and View Types DRR Views (cont.) DRR Volume of Interest Tool This option applies to all DRR windows. You use it to digitally remove patient data to render a more clinically useful DRR.

1.

Click the DRR Volume of InterestI Tool button on the Plan Options tab to place a purple box around the transverse image.

2.

Resize the purple VOI box to remove patient data as needed.

This example demonstrates how you can use the VOI box to create a sagittal DRR image that shows the vertebral body more clearly. Essentially, Monaco digitally removed all the image information outside of the VOI box so that only the volume of interest shows on the window.

Figure 2-45: Image without using the DRR VOI Tool

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General Operation and Navigation Image Navigation and View Types DRR Views DRR Volume of Interest Tool (cont.)

Figure 2-46: Image using the DRR VOI Tool

Display Synth. CT The Display Synth. CT option lets you see an image with Forced Electron Densities, rather than the MR intensities. You can select Display Synth. CT for Transverse CT and Transverse MR studysets when you are in Planning and Plan Review mode. Click

option on the Workspace tab to show a the Display Synth. CT Synthetic CT instead of the MR image.

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General Operation and Navigation Image Navigation and View Types DRR Views Display Synth. CT (cont.)

Figure 2-47: Synthetic CT of the Pelvis

Room’s Eye View The Room’s Eye View (REV) image below gives real-time virtual simulation with patient and treatment machine visualization. You can select Room’s Eye View in Planning and Plan Review activities. The REV option is only available when beams are present.

Figure 2-48: Rooms Eye View (REV) Image

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General Operation and Navigation Image Navigation and View Types Room’s Eye View (cont.) Room’s Eye View-Display Options Room’s Eye View is available in any window. Elekta, Varian, and generic machines are shown in REV based on the machine you selected in your plan. If more than one machine is selected, REV shows the machine associated with the active beam. You can rotate, pan, and zoom the REV image. 1.

Right-click in a window.

2.

Select View Type | REV.

In REV, the current transverse slice image is shown with the structures turned on in the Structure Control dialog box. The Transverse W/L setting is applied to REV. You can use the 3D transparency settings to adjust the structures’ transparencies in REV. Room’s Eye View-Menu You can control REV display options in the right-click drop-down menu. Check/uncheck display options to show/hide in the REV window. You can view the following attributes in REV: • • • • • • • • •

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Treatment Machine The active beam or starting angle of sequence MLC shape Room Lights/Lasers Room Décor Couch CT Images Structures (Contours) Axes

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Image Navigation and View Types Room’s Eye View Room’s Eye View Menu (cont.)

Figure 2-49: Rooms Eye View (REV) Right-click Menu Options

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General Operation and Navigation Additional Navigation and Screen Customization Tools Maximize and Restore a Window You can maximize any window to full screen for better visualization and restore the screen back to a four-window format using these steps. 1.

Right-click in any window and select the Maximize option to maximize the image to full screen.

2.

Right-click in the maximized window and select the Restore option to restore the screen back to a four-window format.

Patient Orientation Icon Each view has a patient orientation icon. This icon depicts the outline of a patient with three colored spheres. Each sphere represents a specific orientation label.

Figure 2-50: Patient Orientation icon Blue - Represents the anterior of the patient Green - Represents the superior of the patient Yellow - Represents the left side of the patient

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General Operation and Navigation Additional Navigation and Screen Customization Tools (cont.) Move Control Dialog Box You can pin/unpin any control dialog box. You can move an unpinned dialog box within the system and re-pin it at the top, bottom, left, or right of the screen. 1.

To move a control dialog box, left-click and hold at the top of the control dialog box.

2.

Drag the control dialog box and place the cursor on one of the arrows that face the location where you want to place the control dialog box. NOTE:

When you hold your cursor over an arrow, the screen highlights in blue where the control dialog box will be placed (Figure 2-51).

Figure 2-51: Moving Control dialog box

Monaco®

3.

Release the mouse to place the control dialog box. Pin/unpin to create a tab.

4.

Click the Unpin

icon to collapse the control dialog box to a tab.

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General Operation and Navigation Additional Navigation and Screen Customization Tools (cont.) Move Control Dialog Box (cont.)

Figure 2-52: Pin\Unpin Control dialog box-tab 5.

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Hover over the tab to show the control. Click the Pin icon at the top of the control dialog box to re-pin the dialog box in the window.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options Within all activities, you can print or export a PDF file of any image view shown on the screen, or you can print the entire screen. You can also print Monaco IMRT plan reports (that is, if the Monaco plan was pulled in using Focal Share), or DICOM plan reports. Refer to Online Help for detailed information about the Reports warning messages. NOTE:

To have your clinic name print on all your printouts (except screen print jobs), in Planning activity, from the Edit drop-down menu, select the Settings option. Select the Clinic Info tab and type the Clinic name you want to appear on your printouts.

Print/Export a Transverse, Sagittal, Coronal, Oblique, or 3D Image 1.

In any image view, right-click and select the Print option to show the Report Comments dialog box.

2.

Type an optional report comment.

3.

Click OK to show the Slice View or 3D View report.

4.

Print the image by clicking the Print dialog box.

button in the upper-left corner of the

OR button to Export the image to a PDF file by clicking the Export Report show the Save PDF File In dialog box. Select a location to save the file and click Save. 5.

Monaco®

Close the Print dialog box.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options (cont.) Print or Export the Screen 1.

Click on the Print Screen button on the Output tab to show the print screen dialog box.

2.

Click the Print button in the upper-left corner of the dialog box to print the image. OR Export the image to a PDF file by clicking the Export Report button to show the Save PDF File In dialog box. Select a location to save the file and click Save.

3.

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Close the Print dialog box.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options (cont.) Print DRRs When printing a DRR, you have several print and display options. This section describes the options for printing these images. Right-click on any window that contains a DRR and select the Print option to show the DRR Print Dialog box.

Figure 2-53: DRR Print Dialog box

Monaco®

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options Print DRRs (cont.) Select the Print Type Print type options are DICOM Print and Windows Print. DICOM print lets you print in DICOM format to a DICOM printer (example, Codonics), a Secondary Capture SCP (example, a record and verify system), or to a local or network file. The Windows Print option lets you print the image on the screen to a Windows type printer. 1.

When you select a DICOM printer or a Secondary Capture SCP, you can select from the drop-down list of available printers or locations next to SCP Name. NOTE:

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Assistance from Systems Support is required to initially set up a DICOM printer or Secondary Capture SCP location.

2.

You can set the DICOM file location when you click the Change Filename button and enter the location where you want to place the file.

3.

If desired, you can override the patient ID for DICOM Print files. Place a checkmark in the Override Patient ID checkbox and type the new ID in the field.

4.

If you select Windows Print, select a printer from the available Windows Printer list. You can edit printer properties. Click the Properties button and make your edits.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options Print DRRs (cont.) Select Options and Copies The options available are Show Annotations, Show Overlays, and Zoom Factor. Zoom factor lets you print your DRR to scale. Calibration is required. 1.

Place a checkmark in the Show Annotations box to show the text that is printed on the DRR regarding the patient name, ID, plan name, etc.

2.

Place a checkmarkin the Show Overlays box to print the Patient Orientation Icon and Grid (graticule) and Jaw Labels on the DRR.

3.

Place a checkmark in the Show Displayed Anatomy box to print the individual contours that you selected to display on the Beam and Structure Control dialog boxes. No structures are printed if this option is not selected. This only affects BEV and DRR views.

4.

Use the Zoom Factor to designate the percentage that the printed image is zoomed (in or out) from the original size. NOTE:

You should establish a calibration factor if you desire scaled printing. First: (1) Print a test image. (2) Measure a 10 cm line on the test image, and call it x. The calibration factor is 10/x. (3) Click the Calibrate button. (4) Type the calibration factor. (5) Click OK to close the dialog box. The scaled magnification of the final image may now be controlled by entering a zoom factor. A single calibration factor is required for each printing device. The calibration factor is independent of the screen image size and paper orientation. It is dependent on paper size

Monaco®

5.

Type the number of copies you would like to print.

6.

Click OK to complete.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options (cont.) Print or Export Monaco IMRT Plan Reports You have two options for printing/exporting reports. You can print/export individual reports, or create a custom report consisting of a group of selected reports and graphic displays. You can print reports or export them to a PDF file. Print/Export Individual Reports 1.

Right-click on a loaded plan in the Patient Workspace Control.

2.

Select Individual Report | .

3.

Optionally, type a Report Comment, and then click OK.

4.

Click the Print Report

button to print the report.

OR Click the Export Report

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button to export the report.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options (cont.) Print or Export Monaco IMRT Plan Reports Print/Export Custom Reports 1.

Right-click on a loaded plan in the Patient Workspace Control.

2.

Select Customized Report to show the Customized Reports.

Figure 2-54: Customized Reports dialog box 3.

Monaco®

Place a checkmark in the box next to each report and graphic display you want to print/export.

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General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options Print or Export Monaco IMRT Plan Reports Print/Export Custom Reports (cont.) 4.

(Optional) Click the Order button if you want to change the order of the printed reports and graphic displays.

Figure 2-55: Customized Reports-Order

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5.

(Optional) Click the Save as… button if you would like this same set of reports and graphic displays to be saved as a template for printing/exporting.

6.

Click Print or Preview. Preview shows the customized report on the screen before printing/exporting. Each report is shown under its own tab. However, the customized report is printed or exported as one continuous document.

General Operation and Navigation Volume I of IV Monaco Training Guide

General Operation and Navigation Printing Options Print or Export Monaco IMRT Plan Reports Print/Export Custom Reports (cont.) 7.

Type an optional Report Comment. Click OK to print, export, or preview the report.

8.

Click the Print Report

button to print the report.

OR Click the Export Report

button to export the report.

Additional IMRT Plan Report Options Print DICOM Coordinates on reports instead of the proprietary system coordinates Place a checkmark next to DICOM Coordinates on the Output tab. When you check this option, all reports print DICOM coordinates. Include Base Dose on Reports for Bias Dose plans Complete these steps if you want to print dose on reports that reflect the composite plan. Place a checkmark next to Include Base Dose on the Output tab. When you check this option, all reports that include dose appear the composite dose of the Base and Current plans.

Print DICOM Plan Report If you have imported a plan into Monaco using DICOM, you can print a DICOM report that shows limited information about the imported plan. The Customized Report option is not available for DICOM Import plans of any modality (electron, photon, proton). 1.

Load an imported plan.

2.

Click on the DICOM Plan button on the Output tab.

3.

To Print the report, click the Print Report

button.

OR To Export the report, click the Export Report

Monaco®

button.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options You can do a full CT Simulation in Monaco within the Planning activity. Planning is flexible enough to accommodate just about any CT Simulation scenario. In addition, Planning offers Virtual Fluoroscopy simulation. Both methods are outlined here. If you plan to use Gammex or LAP lasers for CT Simulation, please see the Monaco Installation Instructions guide for more detailed information.

Determine the Shifts to a Structure Center, Interest Point, Marker, or Beam Isocenter On the CT simulator, you placed fiducial markers on the patient's surface. These procedures demonstrate how to shift from the center of those markers to the center of the target volumes. There are four ways to shift from your original isocenter: (1) (2) (3) (4)

1.

Shift to the center of a structure. Shift to the beam isocenter once a beam has been placed. Shift to an interest point or marker location. Shift to a manually defined isocenter using Virtual Fluoroscopy.

Click the Scan and Setup Reference to show the Setup Reference dialog box. NOTE:

button on the Plan Options tab

In order to determine shifts, you must check the Lock Shift option .

Monaco®

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine the Shifts to a Structure Center, Interest Point, Marker, or Beam Isocenter (cont.) 2.

Scroll through the transverse images to find the fiducial markers. Once located, align the green vertical and horizontal bars on your transverse image window so that they intersect these points. NOTE:

Starting coordinates for the Scan Reference are set to Volume Isocenter.

Figure 3-1: Setup Reference to Determine Scan Reference Point Location 3.

On the Setup Reference dialog box, place a checkmark  in the Lock Scan Reference field. This action locks those coordinates so you do not have to repeat this step for any future shifts.

Figure 3-2: Setup Reference Point dialog box 4.

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Click the Selected Point drop-down menu and choose the contour or interest point, markers, or beam isocenter to where you wish to locate the isocenter.

CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine the Shifts to a Structure Center, Interest Point, Marker, or Beam Isocenter (cont.) 5.

Click the drop-down arrow and select the Patient orientation when scanned.

Figure 3-3: Patient orientation when scanned drop-down list 6.

If you have Gammex lasers, the Autorun option is available. Place a checkmark  in the Autorun box to automatically move the lasers to the new isocenter position. The system shows the shifts in the Shifts (Setup Reference-Scan Reference) box. If you have selected in the Laser System settings to show the Absolute Coordinates for your CT, the system shows those settings under the Absolute Coordinates heading. Refer to the Monaco Installation Instructions for more information regarding the setup of your laser system settings. After you determine the shifts, you can either print the shift information, or send the shift information to a laser marking system.

7.

Click the Print button to print the shift information.

8.

Click the Send to Laser button to send the shift information to the Laser Marking System.

9.

Click the Close button on the Setup Reference window when finished.

10.

You can finish contouring critical structures at this time. NOTE:

Monaco®

For assistance, refer to the various Contouring procedures described in Help.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options (cont.) Determine the Shift using Virtual Fluoroscopy Virtual Fluoroscopy lets you do all the necessary simulation functions on a computergenerated patient image reconstructed from CT data. The "virtual patient" created is an accurate model you can use for treatment setup and planning, and permits visual enhancements such as structural localization and ports for designing conformal therapy. Virtual Fluoroscopy is less time-consuming for patients and clinicians because you can change beam parameters without having to do an entire resimulation. You can use it to do these tasks: • • • •

Localize anatomical structures Provide information for accurate patient marking Optimize beam placement Verify using beam's-eye-view digitally reconstructed radiographs (DRRs)

In the Virtual Fluoroscopy window, a green marker represents the initial scan reference point. Light blue lines and a light blue marker represent the setup field and setup reference point. 1.

In Planning, in any of the windows, right-click and select the Layouts | Virtual Fluoro option from the mouse menu to show an AP and Lateral DRR in the two bottom windows.

Figure 3-4: Virtual Fluoroscopy Layout

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine the Shift using Virtual Fluoroscopy (cont.)

2.

Click the Scan and Setup Reference show the Setup Reference dialog box.

button on the Plan Options tab to

3.

Scroll through the transverse images to find the fiducial markers. Once located, align the green vertical and horizontal bars on your transverse image window so that they intersect these points.

Figure 3-5: Transverse Image window 4.

Relocate the isocenter on the virtual fluoroscopy images by using one of two methods: (1)

When you place your mouse pointer over the viewable DRR, this cursor appears, and lets you pick up and move the treatment field.

(2)

On the field edge of the treatment beam outline, left click on any of the sixperimeter squares and pull outward or inward to adjust to a desired size.

NOTE:

5.

Monaco®

Hold down the Shift key on your computer keyboard while doing this process moves the field asymmetrically.

As you move the center of the field, the setup reference point values automatically update.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine the Shift using Virtual Fluoroscopy (cont.) 6.

When you are done, click the Print button to print the shift values shown.

7.

Click the Close button to close the Setup Reference dialog box.

Determine Shifts in Absolute Coordinates The same instructions apply to creating absolute coordinates as they are for creating relative coordinates. The only difference is the setup in Edit/Settings/Laser System. See the Monaco Installation Instructions topic on entering these setting to show absolute coordinates. The Scan Table Height is the only editable field. Type the actual table height value of the scanner for the final shifted position. This value appears on the printout.

Determine Setup Reference Coordinates Complete these instructions if you know the coordinates for the scan reference point and the shift values/directions and want to determine the setup reference point’s relative coordinates.

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button on the Plan Options tab

1.

Click the Scan and Setup Reference to show the Setup Reference dialog box.

2.

Scroll through the transverse images to find the fiducial markers. Once located, align the green vertical and horizontal bars on your transverse image window so that they intersect these points.

CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine Setup Reference Coordinates (cont.) 3.

On the Setup Reference dialog box, place a checkmark  in the Lock Scan Reference field. This action locks those coordinates so you do not have to repeat this step for any future shifts.

Figure 3-6: Setup Reference Point dialog box 4.

Click the drop-down arrow and select the Patient orientation when scanned.

Figure 3-7: Patient orientation when scanned drop-down list 5.

Remove the checkmark from the Lock Shift option. This lets you edit the shift values.

Figure 3-8: Setup and Lock the Shift

Monaco®

6.

Edit the X, Y, or Z shift values and the shift directions, as needed. The Setup Reference Point Coordinates update as the shift values/directions change.

7.

Click the Print button to print the shift information.

8.

Click the Send to Laser button to send the shift information to the Laser Marking System.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options CT Simulation Options Determine Setup Reference Coordinates (cont.) 9.

Click the Close button on the Setup Reference window when done.

Assign CT-to-ED to Patient Create and Edit a CT-to-ED File (Standalone Users Only) As a standalone user, you may need to create or edit a CT number to electron density conversion file. If you have multiple Monaco workstations, you must make these additions or changes on each workstation as they do not share this information. NOTE:

It is your responsibility to verify that the correct CT-to-ED file is used on the treatment planning systems during dose calculation.

Create and Edit a CT-to-ED File (Monaco with XiO Users) When you use Monaco with XiO, the CT-to-ED files initially transfer from XiO when the server is setup. However, once the XiO CT-to-ED files reside on the Monaco box, they will not be updated if changes are made to them on XiO. Once changes are made in XiO, update the Monaco servers to update the information in Monaco. Updates made in Monaco will not transfer back to XiO. Typically, this CT-to-ED file dialog box is for Standalone users. NOTE:

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It is your responsibility to verify that the correct CT-to-ED file is used on XiO during dose calculation.

CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options Create and Edit a CT-to-ED File Create a New CT-to-ED File 1.

Click the Monaco Application

button. Select Setup

ED files the CT-to-ED Conversion Files dialog box.

| CT-to-

from the menu. Monaco shows

Figure 3-9: CT-to-ED Conversion Files dialog box

Monaco®

2.

Click the drop-down arrows in the Installation and Clinic fields and select an Installation and Clinic name.

3.

Click the Clear Data button if CT-to-ED values are already shown and you would like to start a new table.

4.

(Optional) Type a Description just above the CT-to-ED graph.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options Create and Edit a CT-to-ED File Create a New CT-to-ED File (cont.) 5.

Type CT values and corresponding ED values. Press the Tab key after you type each value. NOTE:

6.

You must type at least three (3) CT-to-ED conversion values to save the file.

Once you have input all the CT and ED values, click the Save As button to show the save CT-to-ED dialog box.

Figure 3-10: Save CT-to-ED dialog box

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7.

Select a Clinic and Manufacturer.

8.

Type a File Name.

9.

Click OK when finished.

10.

(Optional) Click the Print button to print the CT-to-ED file.

11.

Click OK when you are done inputting values.

CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options Create and Edit a CT-to-ED File (cont.) Edit an Existing CT-to-ED File to Create a New CT-to-ED File 1.

Select the Installation, Clinic and Name of the file you want to edit.

2.

Edit the CT and/or ED values. Press the Tab key after each value is input.

3.

Click the Save As button to show the Save CT-to-ED dialog box.

4.

Select a Clinic, Manufacturer and type a new File Name.

5.

Click OK when done.

Assign CT-to-ED to Studyset If you did not already assign a CT-to-ED file to your patient or studyset, or you would like to select a different CT-to-ED file, you can do so using the following steps.

1.

button on the Plan Options tab. Monaco Click the Assign CT to ED shows the Assign CT-to-ED to Studyset dialog box.

Figure 3-11: Assign CT-to-ED dialog box

Monaco®

2.

Select a CT-to-ED file from the list.

3.

Click OK to assign the selected CT-to-ED file to the open studyset or patient.

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CT Simulation Options Volume I of IV Monaco Training Guide

CT Simulation Options Planning on MR Studysets If you plan on an MR Studyset you must use Forced Electron densities in place of a CT-to-ED file. Monaco shows a warning message when you start a new treatment plan.

Figure 3-12: Force ED Warning Message 1.

Click OK to acknowledge the message.

2.

Click the Structures tab on the Planning Control to see a list of the structures.

3.

Type a new Relative ED if you do not want to use the default value.

Figure 3-13: Relative ED field on the Structures tab of the Planning Control

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Overview Fusion is a process that lets you register CT, MRI, and/or PET studysets for the purpose of contouring from either studyset or both studysets. You can also view the dose in Plan Review on fused studysets.

Open a Primary and Secondary Studyset The instructions below demonstrate how to open primary and secondary studyset(s) so you can fuse them. It is assumed that all studysets have been transferred in using the same patient ID and all reside in the local directory. 1.

Select the patient from the Patient Selection dialog box to open it and show both studysets in the Patient Workspace Control.

2.

Click on the studyset that you want to be the primary studyset. This is typically the planning CT.

3.

Click Load.

4.

Right-click on the studyset that you want to be the secondary studyset and select Load/Set as Secondary. If you have not previously fused the images, the system automatically places you in Image Fusion activity. You can load multiple secondary studysets. However, only one can be active at any time. OR Load the primary study set. Then select one or multiple secondary studysets. Right-click and select Load/Set as Secondary. OR Load all the studysets into the workspace as primary studysets (using Ctrl or Shift + selecting multiple studysets). Then, load one of them as a secondary studyset using the right-mouse menu option on the Workspace Control to Load/Set as Secondary.

Monaco®

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Open a Primary and Secondary Studyset (cont.) Studyset Volume Toolbar The Studyset Volume Toolbar controls the visualization for the primary and secondary studysets. Select How to Show the Primary and/or Secondary Studysets You can use the sliderbar in the Studyset Volume Toolbar to choose to view the Primary, Secondary, or blended studyset on the screen.

Figure 4-1: Blended Slidebar Apply a colormap to a Studyset You can use the colormap to replace the grayscale pixel values of an image with different color schemes to enhance the data visualization.

Figure 4-2: Show Images and Colormap options 1.

To apply a colormap to studyset, select the studyset from the drop-down menu.

2.

Select a colormap from the Colormap drop-down list located on the Studyset Volume Toolbar. Colormap Display Options: • Grayscale • Inverse • Green wash • Hot-Iron • Hot-Cold • Magenta wash • Pseudocolor 1 • Pseudocolor 2 • Red wash • Spectrum

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Masking Options (Optional) You can use masks to limit the amount of image data used by the auto registration algorithm to determine the best performance. The masking only defines the registration 3D field-of-view and does not cause changes in the studyset CT images. Each of the options uses a different method to accomplish this. You should only need to choose a mask if you have tried to auto-register the studysets and failed. Always use No Mask first, it is the default option. If you experience a problem with incorrect masking, indicated by erroneous removal of valid patient image data, you can try the other methods. On the Fusion tab, select a Masking option to apply to the primary studyset. On the Fusion tab, select a Masking option to apply to the secondary studyset. These are the available masking options:

Figure 4-3: Masking options

Patient Contours This option resets all pixels outside a user-defined patient contour to a value that does not occur in the original image. You can also use it can to limit the slices included in the volume when one study has many more slices than the other.

Monaco®

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Masking Options (Optional) (cont.) Shape/Intensity Model This option removes the background on CT studies, therefore defining the patient boundary. It uses heuristics and a very fast boundary detector to repeatedly re-contour the patient for a range of CT intensity thresholds. Over some predictable range of CT numbers, the length of these contours does not change appreciably. The contours corresponding to the CT number in the middle of that range is considered the patient boundary. The subsequent mutual information calculation only uses voxels inside these contours to represent the patient.

RE Segmentation This option (relative entropy method) removes the background from the CT studyset images, hence defining the patient boundary. This starts with a flexible contour defined by a parametric function, and the shape is then changed by varying the function parameters. The shape corresponding to the maximum in the RE is then saved. The RE is a type of distance between probability distributions (outside-patient-intensities versus inside-patient-intensities) and it is at its maximum when the patient most completely separates from the background. This method works a little better than shape/intensity for HN cases with a headframe in the image.

No Mask (default) This option does not remove the background and should always be used first before trying the other options.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Create a Registration Manually 1.

Enhance the visualization of the display so that you can better see the individual structures.

(1)

Click the Zoom

(2)

Move the slider bar on the Studyset Volume toolbar between the P (primary image) and S (secondary image) to gradually transition between the two studysets (see the Fusion Display Options for more information).

(3)

Make a selection from the Colormap list to change the pixel color representation of the images in the secondary studyset.

(4)

button to adjust the window and level Click the Window/Level settings for the images in the studyset.

button to view more or less of the image.

Use Translate and Rotate to adjust the position of the secondary studyset. 2.

To translate (move) the secondary studyset, position the pointer over the image inside the translate/rotate circle so that the translate pointer shows on the window, then drag the image to the desired location.

3.

To rotate the secondary studyset, position the pointer over the image outside of the translate/rotate circle so that the rotate pointer shows on the window, then drag clockwise or counterclockwise to rotate the image around the origin of the secondary studyset.

4.

Monaco®

Click the Save button on the toolbar to save the registration or auto register.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration (cont.) Point Registration You can register two images with Point Registration. This method requires you to put three or more points on the corresponding anatomy of the primary and the secondary studysets in order to register the images. When you have placed your points, you can assign them to the related points of the other studyset before registration.

Figure 4-4: Point Registration with primary and secondary image points Add Points in Point Registration

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button on the Fusion tab to open

1.

Click on the Point Registration the Point Registration dialog box.

2.

Place your primary points on any of the T/S/C/O views. The points are shown as a blue cross with a point identifier.

3.

Press the spacebar to change to the secondary points.

4.

Place your secondary points on any of the T/S/C/O views. The points are shown as a red cross with a point identifier.

Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Point Registration (cont.) 5.

(Optional) You can reassign the points in the Point Registration dialog box (Figure 4-5).

Figure 4-5: Point Registration-Assign Points

Monaco®

6.

Click in the Include checkboxes next to each point to not use the points in the registration.

7.

Click on the Start button to begin the registration.

8.

When the registration is complete, click Close to close the dialog box.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Point Registration (cont.) Delete an Individual Point in Point Registration 1. Choose from one of these two options: •

Click on the row in the Point Coordinates table.

•

Click on the point in the studyset. The cursor changes from a crosshair to a circle.

2. Press the Delete button on your keyboard. Delete Multiple Points 1. Right-click on a point in the Point Coordinates dialog box. 2. Choose from one of the options listed in the right-click menu: •

Delete Selected Point

•

Delete Primary Points

•

Delete Secondary Points

•

Delete All Points

Create a Registration using Auto Registration Auto Registration estimates the geometric transformation that best registers corresponding anatomic details in two 3D studysets of the same patient's anatomy. The registration criterion is mutual information and is a measure of the statistical similarity of the overlapping data. The “best registration” is that transformation giving the maximum value of the mutual information. The Mutual Information (MI) algorithm uses the entire patient area to determine the fusion of the images. See the Use the VOI Masking Tool discussion described later in this section to find out how to define your own area.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Create a Registration using Auto Registration (cont.) 1.

Click the Start/Resume Auto Registration button to start the Auto Registration process. While it is running, the Auto Registration button changes to the Stop Automatic Fusion button. The Image Fusion Progress meter appears on the screen, this meter indicates the current mutual information value (MI). Monaco uses the Mutual Information algorithm for the autoregistration process, the MI value continues to rise until the system reaches the best auto registration result.

2.

(Optional) If you would like to stop the process before it is complete, click the Stop Auto Registration

3.

Click the Start/Resume Auto Registration button to restart the process. NOTES:

Monaco®

button.

Visually Verify All Auto Registration Results! Auto Registration may not produce clinically acceptable results. If Auto Registration does not produce clinically acceptable results and you save the registration, plans created using the registration will be inaccurate. To avoid inaccurate plans, visually verify all Auto Registration results before saving the registration. Running Auto Registration repeatedly may yield better results, but takes more time and yields smaller improvements.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Create a Registration using Auto Registration (cont.) Use the VOI Masking Tool The VOI Masking tool is an optional tool you can use during Auto Registration. It lets you define the area that corresponds to the volume that is utilized for the MI registration algorithm. 1.

button to place a purple box Click the VOI Masking around the transverse, sagittal, and coronal images. The box also shows on the 3D image.

Figure 4-6: Transverse, Sagittal, and Coronal images

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2.

Resize the purple VOI box to change the area where the registration algorithm will be applied.

3.

Auto Register the images as usual.

Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Create a Registration Create a Registration using Auto Registration Use the VOI Masking Tool (cont.) 4. You can turn off the VOI Masking tool when you toggle the VOI Masking button to the off position. OR On the Image Fusion Progress dialog box, remove the checkmark in the VOI box.

Figure 4-7: Image Fusion Progress dialog box

Monaco®

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment You must determine the accuracy and applicability of the registration before using it in treatment planning. To do so, you should examine the image alignment on multiple cross sections in at least two of the three orientations. We do not guarantee the absolute accuracy of the registration. Fusion Display Options There are essentially four Fusion Display options that you can use in any activity when fused images are present. These tools enable you to easily review and verify the accuracy of the fusion.

Figure 4-8: Fusion Display options Blended Display The blended option lets you blend the primary and secondary images transparencies to verify the fusion. It is the default Fusion Display Option. If you change the display and would like to get back to the Blended option, use one of these methods. 1.

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Click the Blended

tool on the Fusion Display Options toolbar.

Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment Fusion Display Options (cont.) Transition between Primary and Secondary Images When in Blended Display, use these instructions to change the display of the primary and secondary images. 1.

Move the slider bar on the Studyset Volume toolbar to gradually transition between two studysets. This has the effect of one studyset gradually appearing (fading in) while the other studyset is gradually disappearing (fading out), moving toward the P transitions to the primary studyset, moving toward the S transitions to the secondary studyset. OR On the slider bar, click the P to immediately show the primary or S to immediately show the secondary. OR Right-click in any T/S/C view and select View Primary or View Secondary to immediately show 100% primary or 100% secondary image. OR Press the Home or End keys on the keyboard to immediately show 100% primary or 100% secondary image. Press either of these keys twice to return to 50% of both shown. NOTE:

2.

Monaco®

When the primary or secondary display is set to 100%, the W/L Affects: are automatically set to the corresponding studyset.

You can change the appearance of the secondary studyset when you select a display option to the right of the secondary volume option on the blender bar.

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment Fusion Display Options (cont.) Horizontal, Vertical and Checkerboard Display These three Fusion Display Options are similar in functionality. All affect the display of the secondary image. The Horizontal option shows the secondary image as horizontal stripes. The Vertical option shows the secondary image as Vertical stripes. The Checkerboard option shows the secondary image as a checkerboard pattern. , Vertical or Checkerboard Click the Horizontal tool on the Fusion Display Options toolbar. The lowest number of stripes or checks shows by default. Click the down arrow to the right of the tool to select a different number. NOTE:

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You can customize the number of stripes or checks when you select the Custom option on the drop-down menus that show the number of stripes or checks.

Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment Fusion Display Options (cont.) Pan/Reset Fusion Display Options Use this option to pan Horizontal, Vertical, or Checkerboard displays of the secondary image.

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button on the Fusion Display Options

1.

Click the Pan Checkerboard toolbar.

2.

Hold down your left mouse button in any T/S/C view and drag to pan the secondary image.

3.

Reset the pan. Click the Reset Checkerboard Display Options toolbar.

button on the Fusion

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment (cont.) View/Edit the Transformation Matrix After you fuse the images, you can view the current transformation matrix and edit the translation values, if necessary. 1.

Click the View Current Transform toolbar.

button on the

Figure 4-9: View Transformation MatrixTmpl dialog box

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2.

Edit the X, Y, or Z translation values, if necessary.

3.

Reset the registration back to its last saved values. Click the Reset Registration button.

Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity Verify the Results of the Alignment View/Edit the Transformation Matrix (cont.) 4.

Click OK to save the transformation or Cancel to discard any changes. Only a single transform exists between two studysets. For example, if you fuse study A with study B, you can load either studyset as primary or secondary and they will be fused. The application automatically verifies the transforms that are saved on the disc for the study set, if applicable. The application automatically recognized implicit transforms. If a transform conflict occurs, the application shows the conflict resolution dialog and prompts you to choose the path to use:

Figure 4-10: Transform Paths dialog box The system considers a unity transform for a set of two studysets and shows them as fused if all the following conditions exist:

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•

They have the same frame of reference.

•

They have the same patient position (HFP, HSP, etc.).

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Fusion Activity Volume I of IV Monaco Training Guide

Fusion Activity (Optional) Registering Multiple Studysets If you have multiple studysets for one patient, you can fuse one pair, save the registration, and then fuse the second pair using the same registration. For example, you have a CT studyset and an MRI studyset that has a TI and T2 study that are already paired using the same transform matrix. 1.

Fuse the CT studyset with the MRI T1 studyset and save the registration.

2.

Go back into Planning and load the CT studyset and the MRI T2 studyset. Whatever studyset was loaded as the primary in step 1 must also be loaded as the primary in this step.

3.

Fuse the CT studyset and the MRI T2 studyset. Select the Use Prior button. Monaco shows the Use Prior Registration Registration dialog box.

Figure 4-11: Use Prior Registration dialog box

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4.

Click the drop-down arrow and select the studyset transform that you want to use to register the second set of images.

5

Click OK. Monaco automatically fuses the second set of images to the primary using the same transform registration as the first set.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Overview Planning Activity has a comprehensive set of Contouring tools. The tools let you contour structures using a variety of techniques. This section illustrates how to access and use each of the Contouring tools located on the Contouring ribbon (Figure 5-1).

Figure 5-1: Contouring Ribbon Like most Windows applications, there are many ways to activate contouring tools, besides clicking the button on the ribbon. You can also select contouring tools when you right-click in a transverse, sagittal, coronal, or oblique (T/S/C/O) window and select a contouring tool from the Contour submenu. Some contouring tools have keyboard shortcuts available. Refer to the Monaco Quick Reference card or the Monaco User’s Guide for a complete list of keyboard shortcuts available. For the purposes of this training guide, we refer to the more commonly used methods of contouring tool selections and make note of any anomalies you may encounter.

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Contouring Tools Draw Contour You can use the Draw Contour tool to manually draw a contour. The procedure below walks you through the steps to draw structures using the Draw Contour button on transverse, sagittal, or coronal images. NOTE:

For best contouring results, we recommend that you contour a single structure entirely in a single view (either transverse, sagittal, or coronal) instead of contouring a single structure in multiple views.

1. Click the Contouring tab.

2.

On the Structure Edit panel, select the name of the Structure you wish to contour. OR Type the new name of a structure.

3. Click the Draw Contour

button.

4. (Optional) Select the Drawing Assistant NOTE:

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button.

When you use this tool, the system puts you in edit mode once you draw the contour. But, when you scroll to the subsequent slice, it takes you back to draw mode. If you movie to a slice where you have already drawn a contour with the same structure name, the system places you in edit mode. This is an optional feature that you use in conjunction with the Draw Contour tool.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Draw Contour (cont.) 5. You can contour on transverse, sagittal, coronal, and oblique images when you hold down your left mouse button and trace continuously. OR You can point and click to form the contour. NOTE:

You need to “render” contours drawn/edited in a sagittal or coronal view in the transverse view before the system shows them as outlines in a BEV. Otherwise, the BEV shows the contours in wireframe visualization. To render the structure in the transverse, de-select the active contouring/editing tool or select the structure in the transverse view.

6. Before you close the contour, you can press the Backspace key as many times as needed to erase the drawn contour point by point. 7. To finish the contour, double-click your left mouse button. OR Place the last point in the box that is formed at the start of the contour. NOTE:

While drawing a contour, slide the cursor on the Fusion ribbon to adjust the blending between two fused studysets (P and S).

8. Click Page Up or Page Down to move to the next transverse slice. OR Use the scroll wheel on the mouse to move to the next slice. 9. If you would like to show the contours with thicker lines, click Workspace | Thick Contour Lines lines.

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to show the contours with thicker

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Replace (Contour Editing Tool) The Replace Contour

tool lets you do these tasks:

•

Edit a contour.

•

Replace a section of that contour.

•

Shrink or expand the contour to fit the image structure.

•

Move the contour to match the structure edges.

•

You can edit a contour on a transverse, sagittal, or coronal image.

1. To edit a contour that you have drawn, click the Replace Contour button to place an edit box around the structure you want to edit (Figure 5-2).

Figure 5-2: Replace Contour Edit Box 2. Hold down your left-mouse button and draw to replace a section of your contour. Edit only a section of the contour at a time for best results. You can also hold down your left-mouse button in the corners or on the sides of the edit box to shrink or expand the contour in all directions. You can do this in either width or length direction, asymmetrically, or symmetrically. When you do an asymmetric movement, hold down the Shift key on your computer keyboard. Then, left-click and drag the boxes that are either at the corners of the box or in the middle of each segment.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Replace (Contour Editing Tool) (cont.) 3. If you made an edit and the system replaced the wrong segment, right-click and select Contour | Swap Contour. 4. You can move the contour when you place your mouse pointer in the center of the structure or along the edge of the bounding box, then hold down the left mouse button and drag the contour to a new location. 5. You can rotate the contour when you place your mouse pointer over the dot located just below and to the right of the edit-bounding box. Hold down the leftmouse button and drag to rotate. 6. You can mirror a selected contour right to left in a transverse or coronal view button on the when you click the Mirror Selection contouring ribbon. Click the Mirror button a second time, or right-click and select Edit | Undo to reverse the action. NOTE:

Structures are mirrored and rotated based on the center of the bounding box that surrounds the selected structure, not necessarily the center of the structure volume. The mirror option is not available on the Sagittal view.

7. Right-click in any transverse, sagittal, or coronal window and select Edit. Then, Undo, Cut, Copy, Paste, or Delete to do these actions. NOTE:

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You can only do the cut, copy, and paste functions within the same view. For example, if you cut a structure from a transverse image, you can only paste it in a transverse image.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Replace (Contour Editing Tool) (cont.) Contour Editing Tips When you have contours that overlap or are very close together, use these tips to ensure you select the correct contour for editing. These tips apply anytime you are in edit mode. 1. The edit bounding box is the same color as the contour you want to edit. 2. The sleeve of the mouse pointer hand to click to select a different contour.

changes color so that you know when

3. With one contour selected, click the Tab key on the keyboard to toggle through all the displayed contours until the one you want to edit is selected.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Replace (Contour Editing Tool) (cont.) Guide Radius Use the guide radius display (Figure 5-3) as a visual cue when you want to draw a contour at a specific distance around a structure or target. It helps you determine the size of the guide circle when you use these Contouring tools: •

Drawing Assistant

•

Reshape Contour

•

Draw Contour

•

Replace Contour

•

Paintbrush

Figure 5-3: Guide Radius The guide circle is a circle that appears around the mouse pointer when you use any of the above tools. You use it to create a contour that is a given distance away from another object or represents the size of the contouring paintbrush. 1. To increase the guide radius value, press the up arrow , right arrow greater than sign > on your computer keyboard. 2. To decrease the guide radius, press the down arrow , left arrow than sign < on your computer keyboard.

, or the , or the less

3. You can also use the keyboard/mouse combination of shift+ mouse scroll to adjust the size of the guide radius.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Reshape Contour (Contour Editing Tool) This tool lets you edit a contour by stretching a defined section of a contour on a transverse, sagittal, or coronal image. 1. To edit a contour that you have drawn, click the Reshape Contour button. 2. Use the guide radius value to determine the length in cm of the segment of the contour you would like to stretch.

Contour by Shapes The Shapes button lets you create contours based on four basic shapes: circle, square, rectangle, and ellipse. Select the shape from the drop down menu. Click on a transverse slice to place the shape. You can resize and edit it just like any other contour. You can create contours by shape on transverse, sagittal, or coronal images. NOTE:

For best contouring results, we recommend that you contour a single structure entirely in a single view (either transverse, sagittal, or coronal) instead of contouring a single structure in multiple views.

1. Click the down-arrow next to the Shapes shapes from where you can make a selection.

button to show a list of

2. Left-click on a shape to select it. The system places a checkmark next to the name of the shape and changes the mouse pointer to a cross. 3. In any transverse, sagittal, or coronal image window, hold down your left-mouse button and drag to create the shape in the size you want. 4. Continue this process and add more shapes to the currently shown slice. OR Move to a new slice and add the selected shape.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush The Paintbrush tool lets you fill in (paint) an area in the transverse, sagittal, or coronal view that you want to contour as a structure. You can also edit and smooth any existing structure when you use this tool. A plus (+) sign on the paintbrush tool pointer indicates you intend to draw. The minus (–) sign indicates you intend to erase. The paintbrush is resizable, and you can paint/erase with an opaque, transparent, or outline brush.

Contour Using the Paintbrush Tool 1. Select the structure name that you want to contour/edit in the Structure field on the Contour ribbon. 2. Click the Paintbrush

button.

3. In any transverse, sagittal, or coronal image window, hold down your left-mouse button and drag the mouse using slow smooth strokes to paint a structure. NOTES:

1) For best contouring results, we recommend that you contour a single structure entirely in a single view (either transverse sagittal, or coronal) instead of contouring a single structure in multiple views. 2) The Drawing Assistant is disabled when you use the Paintbrush tool, since this tool lets you draw and edit immediately without the need to select another tool.

4. The guide radius value determines the size of the paintbrush. Range is 0.1 to 10 cm in steps of 0.1 cm. Change the value as described in the Guide Radius topic earlier in this section.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Smoothing Contours Using the Paintbrush Tool Use the paintbrush tool as a smoothing tool to push out or push in the contour you are drawing. 1.

Click the Paintbrush NOTE:

button.

When you check the Erase option, the paintbrush erases the contours.

Place your mouse cursor on the edge of a contour. If the guide radius is mostly inside the contour and the + sign is in the middle of the paintbrush pointer when you hold down the left mouse, the system adds or smoothes from the inside, pushing the contour out. If the guide radius is mostly outside the contour and the – sign is in the middle of the paintbrush pointer when you hold down the left mouse, the system erases or smoothes from the outside, pushing the contour in. If you are in the process of pushing out the contour and want to switch to pushing in (or vice versa), you can hold down the Ctrl key, move your mouse in or out of the contour, then release the Ctrl key, all without releasing the left mouse.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Change the Transparency of the Painted Area You have the option to use a paintbrush stroke that is outline, opaque (solid), or transparent. Left-click on the down arrow at the bottom of the Paintbrush button to select a transparency option (Figure 5-4).

Outline

Opaque

Transparent

Figure 5-4: Transparency of Painted Area

Erase the Painted Contour You can erase all or part of any contour when you use one of these methods. 1. Left-click on the down at the bottom of the Paintbrush button and select Erase Mode. OR Hold down the Shift key on the keyboard along with the left mouse button. 2. In the image window where you want to edit, hold down your left mouse button and drag the mouse using slow smooth strokes to erase the painted structure.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools You can use Edge Detection and Structure Avoidance in a variety of combinations (separate, together, and with other paintbrush features) and scenarios. Edge Detection Tool enhances the paintbrush tool because it gives you Edge Detection the capability to quickly delineate structures on CT or MR images. As you delineate a structure, the paintbrush tool detects the interface of the delineated structure and adjacent tissue as it samples the image’s pixel values. Structure Avoidance Tool enhances the paintbrush tool because it Structure Avoidance lets you stay away from adjacent structures as you delineate a new structure with the paintbrush tool. Edge Detection Sensitivity

tool defines how strictly the The Edge Detection Sensitivity paintbrush tool follows the pixel values of the image (as it detects differences in image pixel values). The sensitivity tool values range from 100% - 0%: 

100%: Represents normal paintbrush tool activity, therefore, no detection in differences of image pixel values occur



0%:

Uses strictest detection of pixel values

Lower sensitivity percentages behave stricter and are “more sensitive” to differences in image densities. The recommended starting value is 10% - 20%.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools (cont.) Considerations When Using Paintbrush Enhancement Tools 1. Refer to previous sections for Paintbrush properties and functions. 2. Select or create the structure to delineate. NOTE:

Monaco software does not currently support ring-shaped delineations.

3. Make note of adjacent structures to avoid. 4. Evaluate image characteristics of the structures for optimal use of the tool. NOTE:

You can better delineate some structures than others, in part, based on image characteristics.

Desirable Image Characteristics of Structures: Well-defined interface to adjacent structure •

Brain (skull interface)

•

Lung (chest wall interface)

Homogeneous, non-grainy •

Heart

•

Liver

Less Desirable Image Characteristics of Structures: Grainy-rendered structures

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•

Rectum

•

Brain

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools Considerations When Using Paintbrush Enhancement Tools (cont.) There may be significant density variations within structures, such as structures that have an inner portion and outer portion. In these cases, use caution to keep the crosshair “+” of the paintbrush tool within the outer density of the structure. •

Bone (femur, pelvis)

•

Kidney

5. Adjust the window/level (gray-scale) for uniform density to the desired structure. Using Structure Avoidance with Paintbrush Tool Use this example if you plan to delineate a structure adjacent to a previously delineated structure. 1. Review the Considerations When Using Paintbrush Enhancement Tools discussed in the previous section. 2. Select Structure Avoidance NOTE:

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.

Do not close the Structure Avoidance Properties dialog box, as this action deactivates Structure Avoidance capability. Select “Minimize” to maintain Structure Avoidance activity (Figure 5-5).

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools Using Structure Avoidance with Paintbrush Tool (cont.)

Figure 5-5: Structure Avoidance Properties dialog box 3. Refer to the table below to do the listed functions inside the Structure Avoidance Properties dialog box. Table 5-1: Structure Avoidance Properties functions and instructions Function a) Add structure to be avoided b) Delete a structure from the Properties list c) Save a Template File for group of avoidance structures d) Apply + or – margin to the structure

Instructions Click on and select desired structure. Right-click on the structure to delete and select Remove. Select Save As and create an identifiable name. Type the desired margin in the designated location within the dialog box.

4. Continue with remainder of structure delineation.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools Using Structure Avoidance with Edge Detection Use this example if you intend to delineate a structure adjacent to one of these: •

A previously-delineated structure (contained in Structure list)

•

A non-delineated structure (not contained in Structure list)

1. Use Considerations When Using Paintbrush Enhancement Tools and pay close attention to the desirable image characteristics. 2. Review the previous section about the Edge Detection Sensitivity Tool. 3. Create Structure Avoidance parameters as described in previous example. NOTE:

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Do not close the Structure Avoidance Properties dialog box, as this action deactivates the Structure Avoidance capability. Select “Minimize” to maintain Structure Avoidance activity (Figure 5-5).

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools Using Structure Avoidance with Edge Detection (cont.) 4. Select Edge Detection from the Manual Contouring Panel. OR Right-click Contour | Paintbrush | Edge Detection. 5. Set Sensitivity Tool at starting position of 10% - 20%. Adjust, if necessary, as you delineate the structure. For this example, we used 15% (Figure 5-6).

Figure 5-6: Edge Detection Sensitivity Tool 6. If the structure is too grainy, you can do one or both of these actions: Adjust the sensitivity to a higher value. But, note that the new structure “pulls in” from the adjacent structure (non-delineated) OR Adjust the Window/Level (gray scale) to minimize graininess. But, this adjustment may degrade anatomy visualization. 7. Delineate the new structure and evaluate the system’s ability to avoid these issues: A previously delineated structure(s) listed in Structure Avoidance Properties dialog box OR An adjacent non-delineated structure

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Paintbrush (cont.) Paintbrush Enhancement Tools Using Structure Avoidance with Edge Detection (cont.)

Figure 5-7:

Example of the a) Edge Detection Tool as it detects the skull/brain interface, and b) Structure Avoidance Tool as it avoids the previously delineated target (PTV)

8. Continue with remainder of structure delineation.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Auto Contouring EZ Sketch Tool

The EZ Sketch button is a contouring tool that gives you the ability to quickly and effectively create a 3D structure on transverse images. You can select this tool on the Auto Contouring panel (Figure 5.8). The EZ Sketch tool uses a sphere to sample the pixel data used to create the 3D structure. This tool may work better with homogeneous, non-grainy structures, such as, brain and lung.

Figure 5-8: EZ Sketch EZ Sketch – Initial Creation

1. Click the EZ Sketch Start/Stop NOTE:

button on the Auto Contouring Panel.

The Global Edit option on the EZ Sketch dropdown list is always highlighted during the initial creation of a contour.

2. Select the structure you want to contour. Determine the center of the structure in your T/S/C views. NOTE:

You can use the Quick Locator method to update the images.

3. Draw a sketch line inside the structure in two or more T/S/C views. The sphere is red when you draw inside the structure.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Auto Contouring EZ Sketch Tool EZ Sketch – Initial Creation (cont.)

Figure 5-9: EZ Sketch – Draw Inside of Structure 4. Hold down the Shift key and draw a sketch line around the outside of the structure. When you hold down the Shift key, the sphere turns blue.

Figure 5-10: EZ Sketch – Sketch Outside of Structure 5. (Optional) You can click the Undo Reset drawn.

button on the Contour Edit panel or the

button on the Auto Contouring panel to undo what you have

6. EZClean removes all contours smaller than the volume defined in EZClean on the Auto Contouring panel.

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Contouring Tools Auto Contouring EZ Sketch EZ Sketch – Initial Creation (cont.) 7. Click the EZSketch Execute button on the Auto Contouring panel. This generates the structure contour (Figure 5-11).

Figure 5-11: EZ Sketch – Contour Generated 8. To accept you contour, click the EZ Sketch Start/Stop

button.

EZ Sketch Edit Mode – Refine Contour You are automatically placed in edit mode after the initial contour creation. When you are in EZ Sketch edit mode, you can refine a small portion of the contour you need to modify. EZ Sketch edit mode lets you add more sketches to refine your initial contour. 1. Change the Edit Radius on the Auto Contouring panel, if needed. The default value is 2.0. NOTE:

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The option to change the radius diameter is only available if you are in edit mode and when Global Edit is not selected.

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Contouring Tools Auto Contouring EZ Sketch (Cont.) EZ Sketch Edit Mode – Refine Contour (cont.) 2. Use the EZ Sketch sphere to draw inside/outside along your previously created sketch lines where it is needed (Figure 5-12).

After Initial Execution

After Addition of New Sketch Line

Figure 5-12: EZ Sketch Edit Mode – Refine Contour 3. Click the EZ Sketch Execute button on the Auto Contouring panel, once you add the new stroke lines on the inside/outside of the structure to create the edited contour. 4. Click the EZ Sketch Start/Stop

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button to accept your changes.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Auto Contouring EZ Sketch (Cont.) EZ Sketch Edit Mode – Global Edit If you want to re-create the entire contour and use new sketches, click the Global Edit option when the initial creation of the sketches are complete. You can add new sketches to your existing sketches, or click on the Reset sketches.

button to draw new

EZ Sketch – Quick Scheme You can select the Quick Scheme option in the initial creation or edit mode. This option has a coarse resolution to provide a faster creation of a contour. You should only use this option for larger structures, such as, patient. Using Other Editing Tools After you accept your EZ Sketch contour, you can use any of the editing tools to fine tune the contour. The Edge Detection tool is a good tool to edit/smooth your contour after you accept your EZ Sketch contour.

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Contouring Tools Copy Structure The copy structure tool lets you copy and rename an entire structure from a primary studyset to a primary studyset, or from a primary studyset to a secondary studyset. To copy a contour from a primary studyset to a secondary studyset, you must first fuse the primary and secondary studysets loaded. Otherwise, the copy steps are the same. NOTE:

If you create a contour in a sagittal or coronal view, then want to use the Copy Structure option, you must “render” the structure in the transverse before the new contour name appears on the Copy Structure list. To render the structure in the transverse, de-select the active contouring/editing tool, or select the structure in the transverse view.

1. Open a studyset (or fused studysets) with existing contours. NOTE:

If you draw the structures on a secondary studyset (example, an MRI), and you want to copy those structures to the primary CT, you must load the MRI as the primary and copy the contours to the Secondary (CT). When you are ready to plan, open the CT as the primary and the MRI as the secondary. All copies of the structures from the MRI show on the CT.

2. Click the Contouring tab. 3. Click the Copy Structure Structures dialog box (Figure 5-13).

Figure 5-13: Copy Structures dialog box

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button to show the Copy

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Copy Structure (cont.) 4. New Structure Names are editable. Click on a new structure name and type a new name, if desired. 5. Select the structure(s) you want to copy by placing a checkmark in the checkbox in the copy column. 6. Click OK to copy the structures. OR Click Cancel to discard your selections. The system adds Contours to the Primary or Secondary studyset, depending on your selection. NOTE:

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Contours may not look the same when copied onto the new studyset. See the online help topic Copy a Contour for more information about how to create copied contours.

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Contouring Tools Copy Superior/Inferior, Anterior/Posterior or Right/Left This exercise demonstrates how to: •

Copy a single contour to the next superior or inferior slice on a transverse view

•

Copy to the next anterior or posterior slice on a coronal view

•

Copy to the next right or left slice on a sagittal view

Copy Superior and Inferior Transverse View 1. Click the Contouring tab. 2. Click drop-down arrow in the Structure field and select the structure you want to contour, or type a new name. 3. Contour a structure on one transverse slice. or Copy Inferior 4. Click the Copy Superior button on the contouring ribbon to copy that contour to the next superior or inferior slice. OR Right-click in the transverse window and select either the Copy Superior or Copy Inferior option.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Copy Superior and Inferior (cont.) Sagittal View 1. Click the drop-down arrow in the Structures field and select the structure you want to contour. OR Type a new name. 2. Contour a structure on one sagittal slice. Right-click in the sagittal window and select either the Copy Left or Copy Right option. OR Use Ctrl + L or Ctrl + R keyboard shortcuts to copy to patient’s left or right, respectively.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Copy Superior and Inferior (cont.) Coronal View 1. Click the drop-down arrow in the Structures field and select the structure to be contoured. OR Type a new name. 2. Contour a structure on one coronal slice. 3. Right-click in the coronal window, then select the Copy Anterior or Copy Posterior option. OR Use Ctrl + A or Ctrl + P keyboard shortcuts to copy to patient’s anterior or posterior respectively.

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Interpolation This exercise demonstrates how to interpolate contours between slices on any transverse, sagittal, or coronal views. 1. Click the drop-down arrow in the structures field and select the structure you want to contour. OR Type a new name. 2. Contour the structure on the starting and ending cross-sections using any method you choose. button to interpolate all the slices 3. Click the Interpolate Contour in between the ones drawn to create a solid contour. NOTE:

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You can only interpolate in a sagittal or coronal view when Draw, Replace /Reshape or Paintbrush is also selected. If you did not interpolate while in Draw mode, you have to select one Replace or Reshape. Then, select the contour (to get the edit bounding box) in the view for which you want to do the interpolation

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Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Auto Threshold This exercise demonstrates how to create a contour with Auto Threshold. Auto Threshold is a process where a curve is created around a highly contrasted structure. The amount of image contrast is user-definable. Auto Threshold is a tool you use to quickly create contours on transverse studysets, such as the patient surface, lung, spinal cord, or any other highly contrasted structure. 1. Select the contour name Patient. 2. Click the auto Threshold box (Figure 5-14).

button to show the Auto Threshold dialog

Figure 5-14: Auto Threshold dialog box 3. Choose AutoSkin in the Window/Level Presets drop-down menu or type in the Window and Level values to provide a good level of contrast between the air and the patient surface. 4. In the sagittal window, close the yellow box on the posterior of the patient to remove the table from the area to be contoured. To do this, hold down your left mouse button and drag the yellow box edge. 5. On the transverse image, left-click a point (anterior to the area to be contoured, but inside the yellow box). The system propagates this point to all slices, and renders the patient contour on all slices. 6. Verify the contours are correct on the sagittal/coronal images. If the contours are not correct, place a checkmark  in the Delete Existing Contours on Affected Slices box. 7. Click a new point to replace all existing contours and creates new ones. 8. Click the Close button. 5-30

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Contouring Tools Auto Segmentation This exercise shows you how to create a contour using Auto Segmentation. Auto Segmentation is a process where a curve is automatically generated around a structure with fairly uniform density. Structures on which you may consider using auto segmentation are liver, kidneys, spleen, and possibly the bladder. 1. On a CT studyset, choose an appropriate contour name. 2. Click the auto Segment dialog box (Figure 5-15).

button to show the Auto Segmentation

Figure 5-15: Auto Segmentation dialog box 3. Select Single Slice mode. 4. Define a sample area. First, you create a sample contour. This is usually a square or triangular sample of the tissue. The auto segmentation algorithm locates the edges of the structure and grows the shape out to match the structure edges. NOTES:

For additional information, go to the Create Contours Using Auto Segmentation link in the Online Help. Use the Page Up and Page Down keys on your computer keyboard to repeat the above steps on another slice.

5. Once you complete contouring in Auto Segmentation, click the Close button.

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Contouring Tools Auto Margin Auto Margin lets you automatically create contours in three dimensions based on a combination of existing structures. You can set margins around structures and create structure combinations. You can accomplish this through "including" and "excluding" specific structures plus a margin distance from those structures. There is an Advanced Margin tool which supports a template that lets you calculate the isotropic margin from the CTV to the PTV necessary to deliver at least X% of the prescription dose to the CTV for Y% of the population. Monaco comes with the default template: LUNG SBRT1. You use this as a starting point to build your own templates with the data obtained in your clinic. The LUNG SBRT template is only a starting point. The local practice for each institution should determine the data needed for Margin Recipe. You can save the templates with empty cells to account for the patient specific errors. You can also create and save common margin templates to use on any patient. For more information on Workflow Scenario for Margin Recipe Usage, refer to the Appendix of this guide.

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Contouring Tools Auto Margin Create an Auto Margin 1. Click the Auto Margins

button on the Contouring panel.

Figure 5-16: Auto Margin dialog box 2. Click the drop-down arrow in the New Structure Name field and select a new structure name from the list. OR Type a new structure name. NOTES:

You can sort the structure selection list by study or by structure. When you select By Structure, you need to click the expansion icon of the structure and select the Structure Set.

3. Click By Study

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Contouring Tools Auto Margin Create an Auto Margin (cont.) 4. Click on a structure name in the Structure Selection List. 5. Click the Add button to add that structure to the Selected Structures list with a plus-sign in front of it. OR Click on a structure name in the Structure Selection List. Click the Subtract button to add that structure to the Selected Structures list with a minus sign in front of it. NOTES:

A plus sign signifies that the structure is to be included. A minus sign signifies that the structure is to be excluded.

6. If you would like to remove a structure that you added to the Selected Structures list, click the structure you want to remove to highlight it. Click the Remove button below the list to remove it. When creating margins around structures, you have the capability to set variable or uniform margins. 7. To make a variable margin, type margin distances in the S (superior), I (inferior), L (left), R (right), A (anterior), and P (posterior) fields in the Margins at (cm) area. These margin distances determine how far the new contour is from the structure selected (highlighted) in the Selected Structures list. NOTE:

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If you type a value in one of the fields in the Margins at (cm) area (S, I, L, R, A, or P) with the Link button shown, the system automatically fills the related field with the same value. To type different values in paired fields, click the Link button so that it changes to the Unlink button. Type the values. For example, if the system shows the Link button, type 2.0 in the L field. The system puts 2.0 automatically in the R field. If you click the Link button so that it button, you can type 0.5 in the L field changes to the Unlink without automatically changing the R field.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Auto Margin Create an Auto Margin (cont.) 8. To create a uniform margin around a structure, check the box Uniform Margin (Negative Allowed) option. 9. Type the value for the uniform margin you would like to create. It is possible to create negative uniform margins. To do so, type a negative value for the margin (Figure 5-17).

Figure 5-17: Creating a Negative Uniform Margin 10. Click the Create button to create the new contour. 11. (Optional) If you would like to clip the contour at the patient's surface, check the box next to Clip at Patient Surface. When you select this option, the system lets you to clip the contour inside the patient surface by a specific amount. Type this value in the Clip Inside By (cm) box.

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Contouring Tools Auto Margin Common Margin Templates You can create and save common auto margin templates to use on future patients. However, you can only apply a saved template to the same selected structures and the structures must be included or excluded as they were when the template was created. Save a Template 1. After you create an auto margin or define margins, you can save it as a template when you click the Save as button. 2. Type a unique name for the template. 3. Click Save on the Save as Template dialog box. 4. If you make additional changes to this template and want to save over the existing name, click Save on the Auto Margin dialog box to save the changes.

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Contouring Tools Auto Margin Common Margin Templates (cont.) Apply a Template

1. Click the Margins

button on the Contouring tab.

2. Click the drop-down arrow in the New Structure Name field and select a new structure name from the list. OR Type a new structure name. 3. Add the structure(s) to the Selected Structures list. Include or Exclude as appropriate. 4. Click the drop-down arrow in the Apply Margin Template field and select the margin you want to apply. NOTE:

When you place the mouse cursor over the template name, the system lists the structures and margin saved with that template.

5. Click Create to create the new margin.

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Contouring Tools Auto Margin Using Advanced Margins The advanced margin tool is probability-based margin and calculates the PTV margin required to deliver at least X% of a prescription dose to the CTV for Y% of the population. The approach is based on the margin recipe of van Herk et al. The advanced margin tool lets you account for systematic and random errors during patient preparation and planning and customize the input values2. You can also save advanced margin templates to use on future patients. The application uses the formula below to calculate the prescribed PTV Margin (M) in single dimension, necessary to deliver at least X% of the prescription dose to the CTV for Y% of the population:

M PTV , X %,Y % [cm] = α Y Σ + β X σ 2 + σ p2 − β X σ p Where:

αY

Unitless constant related to the percentage of the population for

Σ

Standard deviation (cm) of the systematic errors (see white paper in Online Help)

σ

Standard deviation (cm) of the random errors (see white paper in Online Help)

Σ≡

which the desired margin applies (see table below for α Y values assuming perfect conformation in 3D)

i

∑Σ

2

Si

The sum in quadrature over all systematic errors

n =1

βX

Unitless constant related to the isodose level which should cover the “moving” CTV (see table below for β X values ) i

σ ≡ ∑ σ 2 Ri

The sum of the squares of all random errors

σp

Width of the penumbra modeled by a cumulative Gaussian

n =1

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Contouring Tools Auto Margin Using Advanced Margins (cont)

NOTE:

For prostate, the σ p value used in the ‘classic van Herk’ margin formula is 0.32 cm. This corresponds to an 8 MV beam in water. In lung with an assumed homogeneous density = 0.25 g/cm3, the σ p value used is 0.64 cm. This is also for an 8 MV beam. For simplicity, it is assumed the tumor is the same density as the lung and there are no adjacent solid tissues.

Below α Y and β X based on the van Herk at al. data. Confidence Level (% of patients)

α Y 3D

Dose Level (% Rx Line)

βx

80%

2.16

80%

0.84

85%

2.31

85%

1.03

90%

2.50

90%

1.28

95%

2.79

95%

1.64

99%

3.36

99%

2.34

NOTE:

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You can find multiple references regarding this margin recipe in the Online Help for the white paper on this product.

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Contouring Tools Auto Margin (cont.) Create an Advanced Margin 1. Click the auto Margins

button on the Contouring tab.

2. Click the drop-down arrow in the Structure: field and select a structure name from the list. OR Type a new structure name. 3. Add the structure(s) to the Selected Structures list. Include or Exclude as appropriate. 4. Click the Advanced Margin button to open the Advanced Margin dialog box.

Figure 5-18: Advanced Margin dialog box

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Contouring Tools Auto Margin Create an Advanced Margin (cont.) 5. Select the Alpha Table you would like to use from the Alpha Table Selector dialog box. 6. Edit the Confidence Level (%), which is the percent of the population that receives at least X% of the prescription dose. The Alpha value updates automatically based on the Alpha Table selected. 7. Select the Beta Table you would like to use from the Beta Table Selector dialog box. 8. Edit the Prescription Line (%), which is the percentage of the prescription dose to the CTV for Y% of the population. The Beta value updates automatically based on the Beta Table selected. 9. Edit the Sigma Penumbra value, which describes the width of the penumbra modeled by a cumulative Gaussian. 10. The Independent Multiplier option refers to the multiplier values in the Systematic and Random Component Tables. If you would like to define multipliers for each direction independently, place a checkmark next to the Independent Multiplier option. This lets you type in different multiplier values for each direction. The default value is unchecked, since typically the same multiplier is used for each direction.

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Contouring Tools Auto Margin Create an Advanced Margin (cont.) 11. Edit the Systematic and Random Components for each direction. Edit the Multiplier for each. (Fields can be left blank and stored blank in a template for patient specific data.) Systematic Components are as follows: •

Localization Accuracy-Systematic Localization Error

•

Intrafx-Systematic Intra-fraction Variability

•

Delineation- Tumor Delineation Uncertainty

Random Components are as follows: •

Localization Accuracy- Random Localization Error

•

Intrafx- Random Intra-fraction Variability

•

Resp Motion- Respiratory Motion

12. (Optional) Add additional Systematic or Random Components. Click the and type a new component name and corresponding direction and multiplier information. You can also remove the components when you select Remove from the right-mouse menu and click on the row you want to remove. You can also rename each of the components, if necessary. 13. As you edit each field, the system dynamically updates the margins for each direction in the MARGIN (cm) fields. 14. Click OK to close the Advanced Margin dialog box. The advanced margin values automatically populate in the Margins (cm) fields on the Auto Margin dialog box. 15. Click Create on the Auto Margin dialog box to create the advanced margin contour on the patient.

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Contouring Tools Auto Margin (cont.) Save an Advanced Margin Template 1. Set up an advanced margin as described in the previous steps. 2. Before you leave the Advanced Margin dialog box to create it, click the Save as Template button. 3. Type a new template name. This template is now available for all future use of the advanced margin tool. 4. If you make additional changes to this template and want to save over the existing name, you can click Save on the Auto Margin dialog box to save the changes. Apply an Advanced Margin Template 1. Click the auto Margins

button on the Contouring tab.

2. Click the drop-down arrow in the Structure: field and select a structure name from the list. OR Type a new structure name. 3. Add the structure(s) to the Selected Structures list. Include or Exclude as appropriate. 4. Click the Advanced Margin button to open the Advanced Margin dialog box. 5. Select an Advanced Margin Template from the drop-down list. 6. Click OK to close the Advanced Margin dialog box. The advanced margin values automatically populate in the Margins (cm) fields on the Auto Margin dialog box. 7. Click Create on the Auto Margin dialog box to create the advanced margin contour on the patient.

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Contouring Tools Auto Margin (cont.) Print a Margin Report Once you create a margin on a patient, you can print the Auto Margin report. Click the Print button on the Auto Margin dialog box. NOTE:

You can only print the margin report after you create the margin and before you close the Auto Margin dialog box.

EZClean You can remove contours smaller than a volume you define in the EZClean dialog box (Figure 5-19). You can remove the small contours for the active contour selected or for all of the contours in the studyset.

Figure 5-19: EZClean dialog box 1. Click on the EZClean

icon on the Auto Contouring panel.

2. Type a value in the Remove volumes smaller than ____ cm3. NOTE:

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The value you type is linked between the PET Threshold Contouring, EZClean, and EZSketch EZClean options. If you type a value in the PET Threshold Contouring dialog box or in the EZClean option on the Auto Contouring panel, it becomes the default value that appears for subsequent patients.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools EZClean (cont.) 3. Click the Clean All Structures button to remove all of the contours less than or equal to the value you typed for all structures in the studyset. OR Click the Clean Structure button to remove all of the contours less than or equal to the value you typed for just the active structure. 4. When you are done, click the Close button.

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Contouring Tools Select and Group Contours and Structures Occasionally, you may want to select and group contours or structures so that you can do specific edit functions on them as a whole. 1. Select Replace Contour to place you in edit mode. 2.

(For Contours) Select individual contours to group. Hold down the Ctrl key on your computer keyboard and left-click on each contour to select. The system places a dashed-line bounding box around each contour selected.

3.

(For Structures) Right-click in an image window and select Selecting. Then, Select All from the drop-down menu. The system places a solid-line bounding box around each structure. OR Select individual structures to group. Hold down the Ctrl+Shift keys on your computer keyboard and left-click on each contour to select them. The system places a solid-line bounding box around each structure selected.

4. With contours or structures selected, right-click in the same image window and select Grouping then Group. A single solid-line bounding box encompasses all the contours. 5. The edit functions Cut, Copy, Paste, Undo, Resize, Move, Rotate and Mirror apply to the entire group of contours or structures. The Replace tool still works on individual contours within the grouped set of contours or structures. NOTES:

(1) Groups of structures or contours are mirrored and rotated based on the center of the bounding box surrounding the selected structure. (2) If you copy and paste structure(s) to the same studyset, the structure name already exists. So, the new structure name is a combination of the original structure name and a consecutive number (ex. GTV1, GTV2…). You can rename the new structure, if desired.

6. To ungroup a set of contours or structures, right-click in an image window and select Selecting, then Select All. Right-click in the same image window and select Grouping, then Ungroup. NOTE:

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If you leave edit mode, then return, you are able to select contours individually for editing. However, if you Select All again, the contours or structures remain grouped.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Delete Contours or Structures This exercise shows you how to delete individual contours or entire structures. Use this method to delete an individual contour. 1. Click the Replace Contour

button.

2. Select the contour you want to delete. 3. Press the Delete key on your computer keyboard.

Use this method to delete an entire structure. 1. Select the structure you want to delete in the structure name box on the Contour panel. 2. Click the Delete Structure

button on the Structure Edit panel.

OR Click the Shift and Delete keys on your computer keyboard. NOTE:

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Prior to deleting the structure, the system provides you with a warning message that asks: Are you sure you want to clear all contours from structure?

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Contouring Tools Anatomical Groups You can create, copy, and delete anatomical groups as well as delete structures in an anatomical group.

Create an Anatomical Group 1. Click on the Tools tab.

2. Click on the Anatomical Groups

button.

3. Click on the Create New Anatomical Group button. 4. Type a name in the Input New Anatomical Group Name dialog box. 5. Choose one of these two options: •

Click OK to save your changes.

•

Click Cancel to exit this dialog box without saving.

6. Click on to add a new structure. 7. Modify the structure’s properties. 8. You must click Apply | OK to save your changes.

Copy Anatomical Group 1. Click on the drop-down arrow under Anatomical Group Name to select the anatomical group you want to copy. 2. Click on the Copy Anatomical Group button. 3. Type a name in the Input New Anatomical Group Name dialog box. 4. Click on to add a new structure. 5. Modify the structure’s properties. 6. When you have made your changes, click Apply | OK to save.

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Contouring Tools Anatomical Groups (cont.) Delete Anatomical Group 1. Click on the drop-down arrow under Anatomical Group Name to select the anatomical group you want to delete. 2. Click the Delete Anatomical Group button. 3. Choose one of these two options: •

Click Yes to delete the anatomical group listed.

•

Click No to cancel.

NOTE:

When you click Yes, the anatomical group is permanently deleted.

Apply Anatomical Groups You can predefine structure names during the contouring process when you add an anatomical group. 1. Click the Contouring tab. 2. Click the Apply Anatomical Group

button.

3. Select the groups you want to add. Left-click on them to highlight. 4. Click OK to close the dialog box. The system shows the contours associated with the selected group(s) in the structures list.

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Contouring Tools PET Tools SUV Calculation You use the SUV Calculation icon to calculate the SUV value of a PET image set. You can click on the SUV Calculation drop-down menu to select one of the SUV normalization options for the displayed PET image. (For detailed information about the formulas used to calculate the SUV values, refer to About PET Imaging in Online Help). NOTE:

Any patient imported before version 3.30 does not enable SUV Calculation. Therefore, a cursor value appears without units.

The SUV value normalization options include: •

Body Weight (g/ml)

•

Body Surface (cm2/ml)

•

Lean Body Mass (g/ml)

In addition, you can show the Philips SUV if you have a Philips scanner and the appropriate Philips private tags. (Refer to the DICOM Conformance Statement for details.)

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Contouring Tools PET Tools SUV Calculation (cont.) You can select one of these options as the default SUV normalization in the SUV Calculation drop-down menu. The Body Weight (g/ml) option is the system default.

Figure 5-20: SUV Calculation Drop-Down Menu

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Contouring Tools PET Tools (cont.) SUV Calculation (cont.) DICOM Editor for SUV The information in the DICOM SUV Editor for SUV dialog box (Figure 5-21) is automatically sent with the PET DICOM files. The system reads this information from the first slice in the studyset. You can update or type in missing information needed for the SUV calculation. This information is used to calculate the SUV.

Figure 5-21: DICOM SUV Editor 1. Select SUV Calculation | DICOM Editor for SUV. 2. Select a normalization type in the SUV: drop-down box.

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Contouring Tools PET Tools SUV Calculation DICOM Editor for SUV (cont.) 3. Select the weight units in kilograms (kg) or pounds (lbs). 4. Type in the Weight at the time of the PET scan. 5. Select the height units in meters (m) or inches (in). 6. Type in the Height at the time of the PET scan. 7. If you choose the Lean Body Mass normalization option, you have to select a Sex. 8. Click the drop-down arrow in the Acquisition Date field to select a date in the calendar. The system automatically populates this value from the first image in the image set. 9. Type the Acquisition Time. You can click on the up/down arrows to adjust the time. The system automatically populates this value from the first image in the image set. When you process data for GE scanners, the system uses the GE Private Attribute as the Acquisition Time. (See the DICOM Conformance Statement for more information.) NOTE:

You cannot calculate SUV if the Acquisition Date/Time is before RadiopharmaceuticalStart Date/Time.

10. Type a Radionuclide Half-Life in seconds. 11. Type in a Radionuclide Total Dose. Select unit: MBq or Ci. 12. Type a Radiopharmaceutical Start Date. Click the drop-down arrow in the field to select a date in the calendar. 13. Type a Radiopharmaceutical Start Time. You can click on the up/down arrows to adjust the time.

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Contouring Tools PET Tools (cont.) SUV Calculation DICOM Editor for SUV (cont.) 14. Click the Reset to DICOM Values to change the dialog box back to the values from the DICOM file. 15. Click Calculate to accept the values and calculate the SUV. The dialog box remains open. OR Click Close to discard your changes and close the dialog box.

PET Threshold Contouring You can use the PET Threshold Contouring tool to create contours for PET studysets. In the PET Threshold Contouring tool dialog box, you can choose to define the volume of interest (VOI) as a sphere or a cuboid. 1. Use the Locate option to find the center of the target.

icon and select the VOI Sphere 2. Click on the PET Threshold Contouring or VOI Cuboid. The PET Threshold Contouring dialog box opens. (Figure 522). OR Press the S key to change the VOI shape when the tool is open.

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Contouring Tools PET Tools PET Threshold Contouring (cont.)

Figure 5-22: PET Threshold Contouring dialog box 3. Drag the VOI to adjust the location or size in a T/S/C view while the PET Threshold Contouring dialog box is open (Figure 5-22). The max. Value within the VOI updates as you move the VOI. 4. Click Tools | Jump to Point | Center of VOI. This places the center of the T/S/C views to the center of the VOI.

Figure 5-23: Jump to Point button – Center of VOI option

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Contouring Tools PET Tools PET Threshold Contouring (cont.) 5. Type a value in the Percent: or Absolute: field to define the threshold value. You can also slide the threshold slider bar to adjust the threshold values. Move the slider bar to the right to increase the threshold, or move it to the left to decrease the threshold.

Figure 5-24: PET Threshold Slider Bar NOTE:

If the SUV Calculation option is selected, the units are shown as SUVbw, SUVbsa, SUVlbm or SUV (if Philips SUV is used). If the SUV Calculation option is deselected, the units are shown as Bq/ml, CNTS. If no units are shown, units other than CNTS or Bq/ml were used, or the patient was imported from a software release prior to 3.30).

6. (Optional) Click in the Threshold Color: box to change the threshold color. 7. Mark if you want to Use Active Primary, or Use Secondary Studyset if you have two PET studysets loaded. 8. Check the Delete Existing Contours box to delete any contours with the same name as the PET contour. The system deletes the existing contour after you click Create in the PET Threshold Contouring dialog box. 9. Check the Remove volumes smaller than __ cm3 box to delete any contours smaller than or equal to the value you typed in the field. 10. Click the Create button to generate the contour.

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Contouring Tools PET Tools (cont.) Click on RAW icon to select PET Image Type You can click the Raw Image Display button to switch between interpolated and pixelated images (Figure 5-25). Monaco creates a contour based on the image type.

Pixelated/Raw Image

Interpolated Image

Figure 5-25: PET Image Types

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Contouring Tools Import Treatment Couchtop This tool lets you add imported contoured treatment couches or other external accessories onto any studyset, plan, or QA phantom. This lets the algorithm accurately account for dose when a beam travels through this device. Use the same tools to contour the couch structures as you use to contour patient anatomy. NOTE:

When you add a treatment couchtop to a studyset that has existing calculated plans, this action does not invalidate the existing plans.

Prerequisites •

DICOM import couchtop images into the system.

•

When you contour the couchtop structures, designate the structure type as Couch and assign the electron density value on the structures tab in the planning control (Figure 5-26).

Figure 5-26: Planning Control | Structures tab •

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Save contoured couchtops into the Treatment Couch Library. Select Monaco Application Menu | Treatment Couch | Save as Treatment Couch.

Contouring Tools Volume I of IV Monaco Training Guide

Contouring Tools Import Treatment Couchtop Prerequisites (cont.) 1. Click the Plan Options tab. 2. Click the Import Positioning Device

button.

3. Select the Couchtop or other device you want to add to your patient (Figure 5-27).

Figure 5-27: Import Treatment Couch 4. (Optional) If you have existing couch structures and you want to replace them with the one you selected here, place a check in the Remove Existing Couch Structures box. 5. Click OK. The system adds the entire scanned couchtop to the patient. You now have the opportunity to position the table or accessory on/under your patient.

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Contouring Tools Import Treatment Couchtop Prerequisites (cont.) 6. On the Treatment Couch Position dialog box (Figure 5-28), you can type shift values or use the up/down buttons.

Figure 5-28: Treatment Couch Position dialog box OR You can move the couch with the mouse in the transverse, sagittal, or coronal image window. NOTE:

You only have one opportunity to position the couch. If you want to reposition the couch, delete the current couch and re-import a new one.

7. Click Done. The system crops the couchtop superiorly and inferiorly and creates a wireframe contour of the couchtop that matches the slice spacing of the plan’s CT studyset. The system adds the couchtop structure names to the structure control.

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Contouring Tools Import Treatment Couchtop Prerequisites (cont.) 8. If necessary, you can edit the couchtop structures just like any structure in the structure control. 9. You must assign a couch to the beams in order for the dose calculation to take it into account. This option is on the Treatment Aids section of the Beams tab on the Planning control.

Figure 5-29: Beams Control | Treatment Aids Window

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Contouring Tools Generate Bolus You can create a bolus structure type on Transverse studysets, in the Structures spreadsheet. (Figure 5-30). You must create a bolus structure type in order to activate the Generate Bolus icon.

Figure 5-30: Structure Spreadsheet 1. Type a name in the Structure field on the Contouring tab. OR Add a bolus structure in the Structures spreadsheet. You must create a bolus structure type in order to activate the Bolus button.

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Contouring Tools Generate Bolus (cont.) In Monaco, you can use the Generate Bolus tool to create a bolus structure in Planning activity. Complete these steps to create a uniform surface bolus with a desired thickness. This example assumes a 1.0 cm bolus. 1. Click on the Bolus (Figure 5-31).

button. This opens the Generate Bolus dialog box

Figure 5-31: Generate Bolus dialog box 2. You can modify the description in the Bolus Description option. 3. Select a structure in the Base Structure drop-down list. The system default is the external structure. You can select another structure in the drop-down menu, for example, bolus as the base structure. Monaco warns you if you do not select the patient contour as the base structure (Figure 5-32).

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Contouring Tools Generate Bolus (cont.)

Figure 5-32: Base Structure warning message 4. Type a value in the Thickness (cm). The default value is 1.00. 5. Type a value in the Relative ED option. Click the Monaco Application button. You can set up the default value in Settings | Ports and Materials. 6. In the transverse view, put the bolus start and end points on the base structure. For studysets in the Feet First orientation, the system creates bolus counterclockwise from the start point to the end point. For studysets in the Head First orientation, the system creates bolus clockwise from the start to end point. 7. (Optional): You can move the mouse over the point and press the Delete key on the keyboard to remove it. 8. You can put the top and bottom points to define the bolus in any of the T/S/C or BEV views. 9. In the Generate Bolus dialog box, click Generate to make the bolus. 10. Click Close to close the dialog box. 11. (Optional): You can update the description, thickness, or density. Re-open the dialog box and type the new value. Click Update to make the changes.

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Contouring Tools Generate Bolus (cont.) Generate Bolus – Fill VOI You can use the Fill VOI option to make a non-uniform area a flat surface (Figure 533).

Figure 5-33: Fill VOI 1. Create a Bolus structure in structure properties. 2. Click on the Generate Bolus dialog box. 3. Select a structure in the Base Structure drop-down list. 4. Type a value in the Electron Density option. 5. Place a checkmark in the Fill VOI box. 6. Adjust the VOI box in the T/S/C views. 7. Click Generate to create the bolus. 8. Click Close to close the dialog box.

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Contouring Tools Generate Bolus (Cont.) Bolus – Editing Tools After you generate your Bolus contour, you can use any of the editing tools to adjust the bolus contour.

Structure Planning Control Structure Properties refers to specific properties that relate to each individual structure. You can view / edit the structure properties below from the Planning Control. 1. Click the Structure tab on the Planning Control (Figure 5-34). NOTE:

You can pin and move the Planning Control tabs. If necessary, click the Workspace tab | Reset Controls.

Figure 5-34: Planning Control | Structure Tab 2. You can rename a contour when you highlight a structure in the Name column and type a new name. 3. Left click on the Color field to open the Color palette and change the color of the structure. NOTE:

XiO supports a limited color palette and uses the next closest color to the one selected here when plans are sent and opened in that product. Upon return to Monaco, the color selected here is used.

4. Check the box in the Visible column to toggle the structure contour on and off. Clicking the column header will toggle the visibility of all structures on or off. 5. Volume (cm3) is a display-only field.

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Contouring Tools Structure Planning Control (cont.) 6. Select a Structure Type. Options are: •

Internal - use for all internal structures

•

External - use only for the patient contour

•

Couch - use only for couchtop or accessory structures imported through the couchtop tool.

•

Bolus – use for creation of bolus outside the patient contour

7. You can define the Electron Density of the structure when you type a Force ED density value. 8. (Optional) Check the box next to Fill ED if you want to fill the structure with the representation of the Electron Density. 9. Check the Show 2D outline box to view the structure outline. When you click the column header, this toggles the outlines on or off for all of the structures. 10. You can use the slider bar to increase or decrease both 2D Transparency and 3D Transparency. The slider bar controls the transparency of structures in the transverse, sagittal, coronal, and EV windows. This tool is available in all activities. Structures created in Monaco are automatically assigned a 2D and 3D transparency of 50%.

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Planning Tools Overview This section discusses all of the Planning tools that are available in this activity (that is, except Contouring). The format is such that you can walk through the software and follow along with the steps in each section.

Start a Sim Plan using Templates To start a plan, you select a template. There is a range of default templates from where you can make a selection. However, once you begin planning, you can create and save your own templates. Information saved in a template includes these: •

Number of Beams

•

Beam Geometry Information

•

Treatment Machine Information

•

Algorithm

Other preferences are saved per workstation. See the Settings section in the Appendix section of this guide for more information. NOTE:

The default templates given to you are only available to get you started. Specifically, these templates were created using machines that you will not have in your clinic. Therefore, upon first use, select a default template. Next, select a machine that is available in your clinic. Once you create the plan, save it as a template so that you can use it for future planning.

Complete these steps to start a Sim plan.

1.

Click the Plans

button to show the Plan Template dialog box.

OR Right-click on the studyset in the workspace control where you want to add the plan. Select New Sim Plan to show the Plan Template dialog box.

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Start a Sim Plan using Templates (cont.)

Figure 6-1: Plan Template dialog box 2.

Select a template from the drop-down list. The number of beams associated with that template appears automatically. NOTES:

There is a special case for Sim templates saved with multiple beam energies. It is possible to save a template where multiple beam energies are used. However, if you change the machine on the Select Template page, all the beams will be assigned the new machine energy. You cannot use MR Studysets to create a Sim Plan.

3.

Select the isocenter. OR Type the isocenter coordinates.

4.

Select a machine file from the drop-down list.

5.

(Optional) If you want to plan the patient with the feet towards the gantry, place a checkmarkin the box next to the option. NOTE:

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When you select the feet towards the gantry option, the transverse image shows as if you are looking from the head of the patient to the foot. Sagittal, Coronal, 3D and BEV images shows with the foot of the patient pointing toward the top of the window. This holds true for all activities except Fusion Activity.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Start a Sim Plan using Templates (cont.) 6.

(Optional) If you want to auto conform the ports to a specific structure, place a checkmark  in the box next to auto conform.

7.

Select the structure to which you want to conform your ports.

8.

If the ports are to be MLC ports, place a checkmark  in the box next to MLC.

9.

Type the value for the margin.

10.

Click OK to show the selected template’s beam arrangement and ports.

Save a Template To save your own templates, you must first add an existing template to your patient. Make changes to the beam arrangement and number of beams until your plan is set up the way you want it. Complete these steps. button.

1.

Click on the Monaco Application Menu

2.

Select the Save Template As option to show the Save as Template dialog box.

3.

Type the template name. Click OK. OR

1.

To overwrite an existing template, click on the Monaco Application Menu button.

2.

Select the Save Template option to show a dialog box asking if you are sure you want to save this template.

3.

Click Yes if you would like to overwrite the selected template with the new beam arrangement. OR Click No to cancel.

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Planning Tools Manipulate Beams This section walks you through the process manipulating beams and their parameters.

Beam Toolbar

Figure 6-2: Beam Tools When you use these tools (Figure 6-2), you can do these tasks: • • • • • • • • •

Start a New Plan - This option lets you create a new Sim or Monaco plan. When you choose a Monaco plan, you can create a 3D or IMRT plan. Close Plan - This option closes the currently loaded plan. Delete Plan - This option deletes the currently loaded plan. Import Plan Template - This option lets you select a plan template to start a new plan. Add a New Beam - This option creates a new beam. Duplicate Beam - This option makes a copy of the active beam. Duplicate and Oppose Beam - This option makes a mirror image copy of the active beam. Delete Beam - This option deletes the active beam. Edit Beam - This option lets you move the beam using the mouse.

There are three ways to manipulate beam parameters in Planning Activity:

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•

Edit/Change Values in the Beam Spreadsheet

•

Move the Beam Isocenter for a Single Beam or Group of Beams

•

Change the Gantry or Collimator Using the Mouse

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Manipulate Beams (cont.) Beam Visibility Use the Beam Visibility Control (Figure 6-3) to turn selected beams on and off in transverse, sagittal, coronal, and 3D windows. The beam highlighted in red is the one currently shown in the BEV. • • •

•

• Figure 6-3: Beam Visibility Control •

Click on an individual beam name to turn the selected beam on or off. Click on the heading Plan/Rx/Beam to toggle all beams on or off. Click on a specific prescription to turn the beams on and off for the prescription. Click the Current button to show only the current beam selected in the BEV. Click the + next to the prescription to show a list of the beams in that prescription. Click the – next to the prescription to close the list of beams for the prescription.

Move the Beam Isocenter You can move a single beam to a new isocenter or a set of multiple beams to a new isocenter. This tool is not available for rotational arc beams.

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Planning Tools Manipulate Beams (cont.) Move the Beam Isocenter Move a Single Beam

1.

Click the Edit Beam button on the Planning tab. Click on the link icon on the Isocenter Location column to unlink the isocenters. This lets you move the current beam by default. OR Leave the isocenter location linked so you can move all the beams’ isocenter to the same location at once.

2.

On the transverse, coronal, or sagittal view, move the beam isocenter. Hold down your left mouse button and drag the four-way arrow on the center of the beam.

when it appears

Move Multiple Beams as a Group (for all types of plans) To move beams as a group, they must all share the same isocenter. 1.

icon is From the Beams tab on the Planning Control, make sure the link closed to move the isocenter of all the beams that share the same isocenter, regardless of the beams’ display status.

2.

On the transverse, coronal, sagittal or beams-eye view, move the beam isocenter for the group of beams that share the same isocenter. Hold down your left mouse button and drag the four-way arrow of the beam.

when it is shown on the center

OR On the Beam Spreadsheet, change the isocenter location for the selected beam. This automatically changes the isocenter for all beams that share the same isocenter.

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Manipulate Beams Change the Gantry or Collimator Using the Mouse You can only change the gantry or collimator for a single beam using the mouse. Rotate the Gantry or Collimator Using the Mouse 1.

On the beam spreadsheet, select the beam that you want to adjust the gantry or collimator with the mouse.

2.

Click the Move Beam

3.

On the transverse or sagittal view, rotate the gantry. Hold down your left mouse

button on the Beams tab on the Planning Control.

button and drag to rotate the circular arrow icon beam. NOTE:

4.

The axis of the beam moves within a plane that passes through the isocenter and is perpendicular to the axis of rotation of the gantry. Therefore, beam rotation is never available in the Coronal view, because the plane of rotation is always perpendicular to that view. Whether it is available in the Transverse or Sagittal view at any given time depends on the couch angle, but is always available in at least one of them.

On the beams-eye view, rotate the collimator. Hold down your left mouse button and drag to rotate the circular arrow icon beam.

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(when it is shown) on the

when it is shown on the

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Planning Tools Manipulate Beams (cont.) Edit/Change Values on the Beam Spreadsheet Click the Beams tab on the Planning Control and type the new values in the Beams dialog box. This dialog box provides you with global beam editing.

Figure 6-4: Beams dialog box NOTE:

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You can use the left and right arrow keys to move left and right. You can use the Tab key to move right. You can use the up and down arrow keys to go up and down. You can use the Enter key to move down.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Beam Spreadsheet – Sim Plans The beam spreadsheet for sim plans has four tabs: • • • •

General Geometry Treatment Aids All

You can add, edit, or delete beams as well as modify beam properties. When you load a sim template, the beams from the template populate in this dialog box. You can edit the loaded beams in the Beam Spreadsheet. NOTE:

Monaco®

The beam spreadsheet updates in real time. Any change you make is reflected immediately. We recommend that you save your plan before you make any updates to avoid loss of data.

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Beam Spreadsheet for Sim Plans – General Tab In the Beam Spreadsheet for Sim plans, you can add, edit, and delete beams. You can also edit the following beam properties in the General Tab: • • • • • • • • • •

Beam Description Field ID Machine ID Delivery Total Weight (Gy) Algorithm Setup Isocenter Location X, Y, Z coordinates

Figure 6-5: Beams dialog box – General tab

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Beam Spreadsheet for Sim Plans – General Tab (cont.) Add/Edit/Delete Beams 1.

Click on the Beams tab on the Planning Control.

2.

To add a new beam, left click the New Beam words .

3.

Type a unique Description for each beam.

4.

Select a Machine, if applicable.

5.

Select Total Weight(Gy) for each beam.

6.

In the Algorithm column, select Monte Carlo Photon or Pencil Beam Photon.

7.

Select SAD or SSD in the Setup column.

8.

Select the Isocenter Location for the each beam. The system shows the Isocenter Coordinates each beam.

9.

Click Close when you have added all your beams.

button or left click on the

Copy a Beam 1.

Left-click to highlight the beam you want to copy.

2.

Click the Duplicate Beam

button to show the copied beam.

Delete a Beam

Monaco®

1.

Left-click to highlight the beam you want to delete.

2.

Click the Delete Beam

button to delete the selected beam.

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Planning Tools Beam Spreadsheet for Sim Plans – General Tab (cont.) Renumber Beams 1.

Left-click to highlight the beam you want to renumber.

2.

Type the new number in the Beam column for the current beam.

NOTE:

If you type a beam number that is used within the plan or another prescription, the 2 beam numbers are switched.

Reorder Beams 1.

Left-click to highlight the beam you want to move.

2.

Click the Beam Up on the list.

or the Beam Down

button to reorder the beams

Number Beams Consecutively 1.

You can reorder the beams in the list when you add or remove a beam/sequence.

2.

Add/remove a beam in the beam spreadsheet list.

3.

Left-click on the Beam heading. The beams are renumbered in the list in ascending order.

Link Machine ID and/or Isocenter Location You can plan with multiple isocenters and machines. You can save templates with multiple isocenters and machines. You have the ability to reset all the beams to a the link above the Isocenter Location column on the common isocenter. Restore Beam Spreadsheet dialog box, then select the desired isocenter location for one of the beams in the Isocenter Location column. The remaining beams’ isocenter locations update to match the isocenter location you selected.

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Planning Tools Beam Spreadsheet for Sim Plans – General Tab Link Machine ID and/or Isocenter Location (cont.) You can assign different isocenter locations to each beam or a group of beams. Break in the Isocenter Location column to modify the desired beam isocenter the link locations. You can restore the link when you have set the desired location for each beam in the list. The beams with a common isocenter link (Figure 6-6) updates when you change the isocenter location of any beam in that group.

Figure 6-6: Beams – Isocenter Location link You can reset the beams to a common machine. Restore the link above the Machine ID column on the Beams dialog box, then select the desired machine ID for one of the beams in the Machine ID column. The remaining beams’ machines update to match the machine ID you selected. You can assign different machine IDs to each in the Machine ID column (Figure 6-7) beam or a group of beams. Break the link to modify the desired beam machine ID. You can restore the link when you have set the desired machine for each beam in the Machine ID Link.

Figure 6-7: Beams – Machine ID Link

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Beam Spreadsheet for Sim Plans – Geometry Tab You can edit these fields on the Beam Spreadsheet for sim plans in the Geometry tab (Figure 6-8): • • • • • • • •

Beam Description Isocenter Location X, Y, Z coordinates Gantry Collimator Couch Jaw Width and Length

You can uncheck the Asym box to set the width and length jaws symmetrically if desired.

Figure 6-8: Beams – Geometry tab

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Planning Tools Beam Spreadsheet for Sim Plans – Treatment Aids Tab The Treatment Aids tab (Figure 6-9) is where you can add, edit, or delete the beam as well as modify the Beam, Description, Isocenter Location, and X, Y, and Z coordinates.

Figure 6-9: Beams – Treatment Aids tab

Beam Spreadsheet for Sim Plans – All Tab The All tab shows the combined information from the General, Geometry, and Treatment Aid tabs.

Print a Beam Summary Report

Monaco®

1.

In the Planning Activity, click the Beam Summary Beam Summary dialog box.

button to open the

2.

Type an optional report comment. Click OK to show the Beam Summary Report.

3.

Click the Print button in the upper left corner of the dialog box.

4.

Close the Print dialog box.

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Feet First Sim Plans Create a Feet First Sim Plan You can create a feet first sim plan in Monaco. The patient orientation represents the position of the patient in the T/S/C, 3D, and BEV images (Figure 6-10). In this example, the patient’s left leg is being treated.

Figure 6-10: Patient Orientation Icon: Feet First Sim Plan

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1.

Double-click on the studyset in the Patient Workspace.

2.

Click the drop-down arrow next to the New Plan type.

3.

Select the New Sim Plan option.

4.

Select the template, isocenter, and machine information in the drop-down menus.

5.

Place a checkmark in the box next to the Plan with Feet Toward Gantry option.

6.

Click OK when done.

button to select a plan

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Change Treatment Orientation for Monaco IMRT Plan Create a Feet First IMRT Plan You can create a feet first IMRT plan in Monaco. You can select the treatment orientation for Monaco IMRT plans in the New Monaco Plan dialog box (Figure 611).

Figure 6-11: Treatment Orientation

Monaco®

1.

Double-click on the studyset name in the workspace control.

2.

Click the drop-down arrow next to the New Plan type.

button to select the plan

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Change Treatment Orientation for Monaco IMRT Plan Create a Feet First IMRT Plan (cont.) 3.

Select New Monaco Plan in the drop-down list.

4.

Type in plan name and description.

5.

Select the template that you want to import.

6.

Select the Treatment Unit, Modality, Algorithm, Energy, and Isocenter Location.

7.

Click on the Head First or Feet First radio button to select the treatment orientation. The scan orientation information is listed above. If you change the treatment orientation so that it differs from the scan orientation, Monaco shows a message for you to verify the information (Figure 6-12).

Figure 6-12: Treatment Orientation warning message 8.

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Click OK when done.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Port Tools Port tools are only available for non-IMRT plans in Planning activity. You can draw ports manually, or you can create ports using the AutoPort tool. These are the port tools available in Planning activity (Figure 6-13).

Figure 6-13: Port Tools • •

Create/Edit Ports/MLC Snap Jaws to Port

Auto Conform a Port This section demonstrates how to create an auto-conformed port around an existing structure using blocks, apertures, or MLCs in the Create/Edit Ports dialog box (Figure 6-14) You can also combine apertures with blocks or MLCs with blocks. 1.

Click the Create and Edit Ports

button on the Planning tab.

Figure 6-14: Create/Edit Ports dialog box

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Planning Tools Port Tools Auto Conform a Port (cont.) 2.

The Current Port field defaults to NEW PORT. Ports are numbered automatically as they are created.

3.

Select a Port type: Block, Aperture or MLC. Click the associated radio button.

4.

If you selected MLC, edit the Leaf Insertion and Closed Leaf Position, if necessary.

5.

If you selected Aperture or Block, you can edit the Port Properties. Click the Port Properties button (Figure 6-15).

Figure 6-15: Port Properties dialog box

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6.

Click the drop-down arrow in the Structure field and select a structure name around which you want to conform.

7.

Type a Margin value in the Margin field. This represents the margin you want to have around the structure.

8.

(For Apertures and MLCs) If you want the collimator jaws to snap to the port extents, check the box next to Snap Jaws to Port or click the Snap Jaws to Port button.

9.

(For Apertures and Blocks) If you want to rotate the port along with any collimator rotation, check the box next to Rotate Port with Collimator.

10.

Click Close when you are done.

11.

If you do not want the Port to update with the beam movement after it is autoconformed to the structure, select NONE in the Structure field on the Create/Edit Ports dialog box.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Port Tools (cont.) Draw a Port You can manually draw a port using the mouse. The port drawing tool works the same as the contour drawing tool. 1. Complete steps 1-5 above. 2. On a BEV, hold down the left mouse button and draw the port shape. 3. (For Apertures and Blocks) If you want the collimator jaws to snap to the port extents, check the box next to Snap Jaws to Port. NOTE:

This option only affects the length jaw for machines with width jaw that track the MLC.

4. (For Apertures and Blocks) If you want to rotate the port along with any collimator rotation, check the box next to Rotate Port with Collimator. 5. Click Close when you are done.

Edit a Port or MLC This exercise shows you how to edit a port when you use these methods. • • • • • •

Monaco®

Replacing a segment of the port/MLC Resizing the port/MLC Moving the port/MLC Editing individual MLC leaves Use the Leaf Table to edit the port Editing the Closed Leaf Position

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Planning Tools Port Tools Edit a Port or MLC (cont.) Replace a Segment of the Port/MLC 1.

Click on the Create and Edit Ports port or MLC is

2.

button. The mouse cursor for editing a

.

Select the port you want to edit from the Current Port drop down list. OR Click on the port on the BEV window.

3.

Hold down your left-mouse button at the start of the replacement segment and drag the mouse to the end of the replacement segment. Move the mouse (always in the same direction) by clicking to place a series of points and dragging to create curves. When you release the mouse button, the system replaces the segment on the screen.

4.

If you made an edit and replaced the wrong segment, right-click and select the Swap Block option (available only for Aperture/Block). OR Click the Swap Block button on the Planning tab.

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Planning Tools Port Tools Edit a Port or MLC (cont.) Resize the Port/MLC 1.

Click the Create and Edit Ports

2.

Select the port you want to resize from the Current Port drop down list.

button.

OR Click on the port on the BEV window. 3.

On the edit bounding box, move the pointer to a resize handle at one of the corners so that the pointer becomes either a or a .

4.

To make the port smaller, drag toward the center. OR To make the port larger, drag away from the center.

5.

To resize asymmetrically, hold down the shift key on your computer keyboard and move the pointer to a resize handle at one of the corners so that the pointer becomes either a or a .

OR 1.

Move the pointer to a resize handle on one of the box's edges so that the pointer becomes either a or a

2.

.

To make the port smaller, drag toward the center. OR To make the port larger, drag away from the center.

3.

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To resize asymmetrically, hold down the Shift key on your computer keyboard and move the pointer to a resize handle at one of the edges so that the pointer becomes either a or a .

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Planning Tools Port Tools Edit a Port or MLC (cont.) Move the Port/MLC 1.

Click the Create and Edit Ports

2.

Select the port you want to move from the Current Port drop down list.

button.

OR Click on the port on the BEV window. 3.

Click a point inside the bounding box, but not on the border. The mouse pointer becomes a four-pointed arrow

.

4.

Drag the mouse to the new location.

5.

Release the mouse button at the new location to refresh the window.

6.

You can rotate the port when you place the mouse over the dot at the lower-right corner and drag it around.

Edit Individual MLC Leaves button.

1.

Click on the Create and Edit Ports

2.

Select the port you want to edit from the Current Port drop down list. OR Click on the port on the BEV window.

3.

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Hold down your left mouse button outside the yellow edit box boundary and drag any leaf to a new position. The collimator drags open, if necessary.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Port Tools Edit a Port or MLC (cont.) Use the Leaf Table to edit the port 1. Select Create and Edit Ports. 2. In the Create/Edit Ports dialog box, click the Show Leaf Table button.

Figure 6-16: Show Leaf Table button 3. The leaf table shows: •

The pair number for the MLCs

•

The position of the left and right leaf for a specific pair. You can edit the positions. Type in the position value for the leaf.

•

The Parked column is read-only. It shows which leaf pairs are used in the port shape. A check mark in the Parked column for a leaf pair means it is not being used in the port shape.

Figure 6-17: Leaf Table 4. Click the Hide Leaf Table button to close the leaf table.

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Planning Tools Port Tools Edit a Port or MLC (cont.) Edit the Close Leaf Position 1.

Click on the Create and Edit Ports

2.

Select the port you want to edit from the Current Port drop down list.

button.

OR Click on the port on the BEV window. 3.

Edit the value for the Closed Leaf Position. The edited value will set the top and bottom closed leaves to the entered value. OR Edit the closed leaves with the mouse. Hold down your left mouse and drag any closed leaf that is not immediately adjacent to the field opening. Each set of closed leaves (top and bottom) move independently.

Delete a Port Click on the Create and Edit Ports

2.

Select the port you want to delete from the Current Port drop down list. OR Click on the port on the BEV window.

3.

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button.

1.

Press the Delete button on the keyboard.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Port Tools Maintain Field Borders This option lets you maintain the field borders or maintain the isocenter location when you switch from asymmetric to symmetric jaws. The option is located in Planning activity on the Planning tab. button, (the icon is highlighted in When you click on the Maintain Field Borders orange) and change an asymmetric field to a symmetric field by un-checking the Asymmetric box on the Beams tab on the Planning Control, field borders are maintained and the isocenter is moved to the geometric center of the field. When Maintain Field Borders is off and an asymmetric field is changed to a symmetric field by un-checking the Asymmetric box on the Beams tab on the Planning Control, the system maintains the current isocenter and moves the field borders to the symmetric field size shown on the beam.

Measure Tool The Measure tool lets you take measurements on any transverse, sagittal, coronal, or oblique image. You can apply more than one ruler to the images. The measure tool is available in all activities.

Use the Measure Tool 1. Click on the Measure Tool

button on the Tools tab.

2. On any transverse, sagittal, coronal, or oblique image, hold down your left mouse button and drag to create a measurement ruler that shows the length as the ruler is drawn.

Remove the Measurement Rulers Click the Remove Measure Graphics

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button.

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Planning Tools Interest Points and Markers You can place interest points or markers on transverse, sagittal, coronal, and oblique slices in a variety of ways (and in any activity, except Fusion). You can add Interest Points and Markers in Planning and Plan Review activities. You can also print an interest point and marker report.

Place Interest Points or Markers 1.

Click the Interest Points/Markers button on the toolbar. Monaco shows the Interest Points& Markers dialog box (Figure 6-18).

Figure 6-18: Interest Points & Markers dialog box 2.

Click the New Interest Point or New Marker button to add a point or marker to the center of the patient. The point or marker number and coordinates show on the Interest Points & Markers dialog box. OR Place an Interest Point. Left-click anywhere on a transverse, sagittal, coronal, or oblique image to place the point. OR

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Planning Tools Interest Points and Markers Place Interest Points or Markers (cont.) Place a Marker. Left-click anywhere on a transverse, sagittal, coronal, or oblique image while you hold down the Shift key on the keyboard. NOTE:

When you add Interest Points or Markers, the software forces slice mode, so points and markers are always placed on real transverse slices.

3.

Type a Description for the point or marker next to its coordinates in the Interest Points & Markers dialog box.

4.

Move the point on a transverse, sagittal, coronal, or oblique image. To do this, place the mouse pointer over the point or marker. (The mouse pointer visually .) Hold down your left mouse button and drag the changes to look like this point or marker to a new location. OR Type new coordinates for the point or marker in the dialog box. NOTE:

5.

Monaco®

The interest point or marker’s new location may re-order the list if the Y value is less than the interest points and markers that are already made.

Click Done when complete.

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Planning Tools Interest Points and Markers (cont.) Verify an Interest Point or Marker Use this tool to verify which point is shown on a transverse slice. 1.

Open the Interest Points and Markers dialog box.

2.

Place your mouse cursor over the Interest Point or Marker. (The mouse pointer visually changes to look like this name.

.) A tool tip shows the point number and

Figure 6-19: Transverse slice with an Interest Point

Locate an Interest Point or Marker To easily locate an interest point or marker you have placed, open the Interest Point and Marker dialog box. Select the interest point or marker. Click on it to highlight in the dialog box. Click the Jump to Point button. The system updates all image views to show the interest point or marker.

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Planning Tools Interest Points and Markers (cont.) Delete an Interest Point or Marker To delete interest points or markers, open the Interest Points & Markers dialog box. Click on a point or marker in the list to select it. Then, click the Delete button on the dialog box. OR Place your mouse pointer over the point or marker. (The mouse pointer will change to look like this

). Then, press the Delete key on your computer keyboard.

Print the Interest Point and Marker Report From the Interest Point and Marker dialog box, click the Print option. Type an optional Report Comment and click OK. The report shows as a preview on the screen. Click the Print button to print it

Dose Reference Points (Plans from Monaco IMRT only) Dose reference points (DRP) are computed in Monaco and represent point doses to user-defined locations on a per-beam basis. The information represented in dose reference points can be reported or exported to external systems for the purpose of independent MU calculation checks or dose tracking in a record & verify system. You can click on the Dose Reference Points tab on the Planning Control to view the dose reference point dialog box in Planning or Plan Review activities. You cannot edit dose reference points in Monaco Sim.

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Planning Tools Image Statistics You can view the image statistics for all loaded datasets. Select the Image Statistics button from the Tools section of the Tools tab. Monaco shows the Image Statistics dialog box. Monaco also shows a yellow region of interest tool in all loaded studysets.

Figure 6-20: Image Statistics dialog box

Figure 6-21: Region of Interest Tool in All Loaded Studysets 1.

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Click Show Image Statistics For Other Loaded And Registered Studysets to show the statistics for all studysets you have loaded. The upper section of the Image Statistics shows the information for the active studyset. You can select the additional studyset for which you want to view the information when you select the studyset name on the lower section of the Image Statistics.

Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Image Statistics (cont.) Monaco shows the image statistics information by default within user defined (size and the position) Volume of Interest (appears as a yellow sphere on the T/S/C views). 2.

To add a structure to the statistics list, click on .

3.

To change the structure, click on the Structure’s field and change the selection.

4.

To remove the structure, right-click on the corresponding Structure field and select Remove.

5.

Use the mouse to move the region of interest around the displayed images. Use the mouse or type a value in the VOI Diameter (cm) field to shrink or enlarge the VOI. Monaco shows the VOI on all studysets selected for the display on the Image Statistics. Monaco shows the Min, Max, Mean, Median, Standard Deviation and Volume for all loaded studysets. These values are determined from all voxels which are completely contained within the structure or VOI. The Volume shown for the VOI is calculated using the user-defined VOI Diameter. Monaco shows units for these values for PET image sets if the studyset is imported in the version 3.3 or later. For SUV values, the units correspond to the units of the SUV normalization used (for example for Body Weight normalization, you see SUVbw). See the SUV Calculation section for more information on the SUV. You do not see units if the studyset originated in an earlier version of Monaco. For CT studysets, the displayed units are HU (Hounsfield Units) and ED (Electron Density). For MR study, no units are shown. Generally, the same units appear on the image statistics as on the Volume Cursor. Monaco only calculates Peak Value for PET studysets. Peak Value is the largest possible mean value of a user defined size spherical VOI (default diameter is 1.2 cm) positioned within a structure or VOI. The Peak Value calculation is a four step process: a. System calculated the peak mask.

Monaco®

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Image Statistics (cont.) b.

Monaco iteratively centers a sphere with the diameter set to the value defined in the Set Peak Value Sphere Diameter to: field on the Settings dialog box over all the voxels in the structure or VOI in such way that it includes only the voxels fully encompassed by the structure/VOI. This shows one of all possible peak-value spheres positions. The diameter of the sphere defaults to 1.2 cm. You can change this value if you have administrator privileges. This sphere is independent of the sphere used in the VOI calculations. Monaco overlays this sphere on a cube which has been sub-divided into voxels. Monaco sets the voxel size equal to the resolution of the PET images. Monaco determines what % of each voxel is contained within this sphere.

Figure 6-22: Tumor volume (shaded) overlaid with mask and grid The above graphic shows the Tumor volume (shaded area) overlaid with the mask and grid. The dark grey voxel is the current location where the Peak Value is being calculated.

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Planning Tools Volume I of IV Monaco Training Guide

Planning Tools Image Statistics (cont.) c.

Monaco calculates for each voxel, the product of the mask value times the PET value. The sphere must fit completely inside the structure or VOI and all voxels covered by the peak sphere are fully included in the structure/VOI. Monaco will report N/A in the Peak Value field if this is not the case. For example, if the Diameter of the VOI is less than the diameter of the Peak Value Diameter, you will see N/A in the Peak Value field.

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=

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c: a x b

Figure 6-23: Weighted Average of the Values Calculation d.

Monaco®

The last step is to calculate the weighted average of the values to determine the final Peak Value. Monaco sums the PET SUV values from (c:) and divides it by the sum of the Mask values in (a:) to get the Peak Value. In this example, 4820/39 gives a Peak Value for the shaded cell of 123.6.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Overview Plan Review lets you evaluate and compare treatment plans utilizing a dedicated set of user-friendly tools. You can evaluate plans which were created in Monaco. You can also evaluate plans which were imported from another system, including proton spot plans.

Open Plan(s) into Plan Review It is assumed that you have already selected a patient with calculated and saved plans, and that this patient's studyset(s) and plans appear in the Patient Workspace.

Figure 7-1: Patient Workspace 1.

Select and load plans. Right-click on each in the Workspace Control and select Load/Activate. OR Load multiple plans at one time. Hold down the Ctrl key and left-click on each plan you want to load. Then, right-click and select Load Into Plan Review.

Monaco®

2.

(Optional) Load a fused secondary studyset. Right-click on the studyset and select Load/Set as Secondary.

3.

If you have multiple plans loaded, you can change the active plan. Double-click on its name on the Workspace Control, or select Load/Activate from the right mouse menu.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the Isodose Display In plan review, you can change the isodose display to one of five options. You can select the options from the bottom of the Isodose Control panel The Grid Volume section on the Planning tab has the options to show Dose or Raw Dose (which shows un-interpolated dose distribution).

Figure 7-2: Change the Grid Type See the Help for more information about these options. Figure 7-3: Colorwash consists of a continuous band of color from dark red (highest dose) to dark blue (lowest dose) shown transparently on the CT data. This option automatically allocates the colors based on a higher and lower limit entered in the Isodose Control panel. No dose appears below the lower limit.

Figure 7-4: Isofill consists of regions of distinct colors that represent the dose ranges. A list of dose values and colors associated with them appear in the Isodose Control panel. The dose levels on the Isodose Control panel represent the lower boundary, that is, a given color shows doses greater than or equal to the value in the legend.

Figure 7-5: Isobands consists of bands of distinct colors that represent the dose ranges. The Isodose Control panel shows a list of dose values, colors associated with them, and checkboxes to turn each isoband on and off. Dose shows in the bands that are greater than or equal to the value in the legend, plus the user-definable Thickness % of the normalized dose.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the Isodose Display (cont.) Figure 7-6: Isolines are lines around the border of the individual isodose levels that indicate the isodose colors. This shows in the Isodose Control panel a list of dose values, colors associated with them, and checkboxes to turn each isoline on and off.

Figure 7-7: Reference Dose shading gives a visual representation of the dose distribution associated with the placement of the hot (red) and cold (blue) reference dose cursors on the DVH graph. Dose values in between the hot and cold reference doses appear in tan. Move the reference dose cursors on the DVH graph to change the distribution of the dose on the image.

Change the Transparency of the Dose Display Use the Grid Volume toolbar to change the dose transparency shown on the primary studyset. 1.

On the Planning tab, select Dose or Dose Raw grid type option.

2.

Position your mouse pointer on the Grid Volume slider bar. The dose intensity applies to the colorwash, isofill, and isobands display. It does not affect the display of isolines, which always show at full intensity.

3.

Click and drag the pointer all the way to SS (studyset) on the left side of the fader. NOTE:

4.

Click and drag the pointer all the way to G (dose grid) on the right side of the fader. NOTE:

Monaco®

When you move the pointer towards SS, the dose transparency increases. When it is all the way to SS, no color wash dose overlay is visible.

When you move the pointer towards G, the dose transparency decreases. When it is all the way to G, the color wash dose overlay is at maximum visibility.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Save an Isodose Template You can save customized isodose settings for the IsoFill, IsoBand, and IsoLine mode (Figure 7-8). You can type in values and choose the DVH line colors and click on Save As to save the customized settings. You can select the Default template, to reset the values and colors.

Figure 7-8: Save an Isodose Template 1. Type in values for each isodose line you want to change. 2. Change the color next to the isodose line. 3. Choose one of these two options:

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•

Click on the drop-down arrow in the 2D column to turn the 2D visibility off for individual isodose lines.

•

Click on the All 2D Off button to turn off all isodose lines in the 2D view.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Save an Isodose Template (cont.) 4. Choose one of these two options: •

Click on the drop-down arrow in the 3D column to select a transparency style for individual isodose lines.

•

Click on the All 3D Off button to turn off all isodose lines in the 3D view.

5. Click on the Save As button when you have made your changes to save the template. 6. Choose one of these two options: •

Type in a name in the Template Name field.

•

Click on the drop-down arrow to select an existing template name.

7. Click Save to create the template. 8. (Optional) Select the Default template to reset the values. 9. The isodoses which are displayed, the dose value on the Normalization Panel, and the Rx Dose on the Prescription panel are all linked together. If you use a Default Isodose Template and update the Rx Dose, the Dose Normalization and the displayed Isodoses also updates. However, if you use a Custom Template, or make an edit to the Default Template, this link breaks. You can reselect the Default Isodose Template to restore the link between the Normalization Dose, Rx Dose, and isodose display. See the Rescale by Modifying Fractional Dose heading in this section for more information.

(Optional) Transition between Two Studysets This option is only available if you purchased Fusion and selected a fused set of images to view in Plan Review. Use the Studyset Volume toolbar to transition between the primary and secondary studysets.

Monaco®

1.

On the Fusion tab, select the secondary studyset name in the Show Images drop-down menu.

2.

Adjust your isodose display option, if needed.

3.

Position your mouse pointer on the Primary/Secondary slider bar to gradually transition between the two studysets. This has the effect of one studyset gradually appearing (fading in) while the other studyset is gradually disappearing (fading out), moving towards the P transitions to the primary studyset, moving towards the S transitions to the secondary studyset. Shortcut keys on the keyboard are Home and End. Press either of these keys twice to return to 50% of both shown. 7-5

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity (Optional) Transition between Two Studysets (cont.) 4.

You can change the appearance of the secondary studyset in the as: drop-down menu to the right of the secondary studyset name on Show Images menu. See Fusion Activity section for more information on this topic.

Beam Visibility Control 1.

In Single Plan mode, use the Beam Visibility Control to turn selected beams on and off in transverse, sagittal, coronal, and 3D windows.

Figure 7-9: Beam Visibility Control

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2.

Click on an individual beam/sequence name to turn the selected beam/sequence on or off.

3.

Click on the heading Plan/Rx/Beam to toggle all beams/sequences on or off.

4.

Uncheck the box below Dose for each beam or Rx to toggle dose off.

5.

Click on the heading Dose to toggle all beams/sequences on or off.

6.

If you plan with Bias Dose, the base plan name appears on the Beam Visibility Control to let you toggle the dose on or off.

7.

When you have multiple plans in view, you can toggle all beams on or off. If one of the plans is a bias dose plan, you can toggle Base Dose on or off.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Beam Summary 1.

Click the Plan Options tab, then the Beam Summary Beam Summary dialog box.

button to show the

Figure 7-10: Beam Summary dialog box

Monaco®

2.

When multiple plans are loaded, click the down arrow next to the Plan box to show a list of plans. If you click on another plan, Monaco shows the beam summary for that plan.

3.

Click OK.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Structure Control The Structure Control shows a color-coded list of all the contoured structures for this patient.

Toggle Structure On and Off You can turn structures on or off, one-by-one, on this control when you click on the contour name(s). OR You can click on the heading Structure to toggle all beams on or off.

Figure 7-11: Structure Visibility

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity View Images from XiO If you captured images in XiO and saved them with your XiO plan, you can view them in Plan Review. For more information on capturing bitmap images in XiO, see the XiO Training Guide.

button to show the

1.

Click on the Plan Options tab, then the Image Viewer dialog box with images associated with the shown plan(s).

2.

Select a plan from column on the right to show the thumbnail images that are available for the selected plan.

3.

Select a single thumbnail image. Double-click on the image.

4.

Click on Browse to search for images.

5.

Select multiple images. Hold down the Shift key on the keyboard and left-click the first and last image of the set, then click the Open Images button. OR Hold down the Ctrl key on the keyboard and select several images. Left-click on each one, then click the Open Images button.

6.

Monaco®

Click Done when complete.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties From the DVH group on the Plan Options tab, you can edit DVH display properties, view DVH statistics, and create structure combinations (Figure 7-12).

Figure 7-12: DVH Group

DVH Statistics-Statistics Tab The DVH Statistics dialog box is an interactive dialog box that gives statistical information that relates to the structures that appear on the Total Volume DVH graph. To see the hot and cold statistical information, you can either directly type in hot and cold reference dose values or type in % volumes or cm3 for each structure on the DVH Statistics-Statistics tab, or move the red (hot) and blue (cold) reference dose cursors on the DVH Graph to show the hot and cold doses and volumes on the DVH Statistics-Statistics tab. NOTE:

For multiple prescription plans, the DVH Statistics report shows information only for the prescription doses that are checked in the Beam Visibility dialog box.

Figure 7-13: DVH Statistics - Statistics tab % in Volume For Monaco plans, this value is always 100% for all structures. For imported plans where the calculation grid is user defined, the value may not be 100% if the structure is outside of the defined calculation grid volume.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Statistics – Statistics Tab (cont.) Is in SS This column represents structures within the studyset. This value is always yes for structures that do not extend to the first or last slice image. Edit the Reference Doses and % Volumes on the DVH Statistics Dialog Box You can edit the reference dose values and % volumes for individual structures directly on the DVH Statistics dialog box. 1.

Click the DVH Statistics

button on the Plan Options tab.

OR Right-click in the DVH window and select the Statistics option to show the DVH Statistics dialog box. 2.

Left-click anywhere along the row of the structure where you want to put a reference dose value or % volume. The row is highlighted in blue.

3.

Left-click in the Cold or Hot reference dose or volume field for the selected structure and type the value you want to show, then press the Tab key. An associated reference dose cursor appears on the DVH graph and represents the position of the value you input. NOTE:

4.

Monaco®

If you typed in the ref dose or the % volume, the field where you typed your value appears in a lighter (highlighted) shade of red or blue.

You can sort and resize any column as needed.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Statistics (cont.) Edit the Reference Doses and % Volumes on the DVH Graph You can edit the reference dose values and % volumes for individual structures directly on the DVH Graph. Or, you can type values into the Reference Dose Control. 1.

Change the Isodose display to Reference Dose on the isodose control panel.

Figure 7-14: Isodose Display as Reference Dose 2.

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Figure 7-15: Reference Dose Cursors on the DVH Graph

Select a structure name from the drop-down list on the Reference Dose Control for which you would like to set the dose cursors.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Statistics Edit the Reference Doses and % Volumes on the DVH Graph (cont.) 3.

Use one of the methods below to update the reference doses: On the DVH Graph, hold down your left mouse button and drag the red and blue reference dose cursors. OR Move the hot (red) or cold (blue) slider bars on the Reference Dose Control. OR Type in hot and cold dose values or % volumes on the Reference Dose Control. NOTE:

4.

The DVH Statistics dialog box is automatically updated with the selected cursor values and reference doses. NOTE:

Monaco®

If you want to switch the value that you put on the Reference Dose Control from dose to % volume, you must open the DVH Statistics dialog box and highlight the dose or % volume field for the selected structure. The heading in the Reference Dose Control changes to the selected value.

You can open or close the Statistics dialog box when you set the Reference Doses. When the statistics dialog box is open, the application shows the updates in real time.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties (cont.) DVH Statistics – Display Tab The Display tab lists all of the contoured structures in your plan. You can check the Enabled box to view a structure in the Statistics tab. The structures used in the prescription are automatically enabled. You can also view and manipulate the Heterogeneity and Conformity Index values in the Display tab. These indices provide information along with the hot and cold statistical information relating to the structures shown on the Total Volume DVH graph. You can use these tools to evaluate plans in the DVH statistics.

Figure 7-16: DVH Statistics Display Tab Heterogeneity Index The Heterogeneity Index (HI) gives information regarding the dose uniformity within the target volume(s). You can also view this information on the Statistics tab. The Heterogeneity Index is directly calculated from the DVH statistics. Change the High Dose Ref. (%) and Min. Dose Ref (%) values to manipulate the Heterogeneity Index value. The High Dose Ref. (%) uses the dose that covers the hottest percentage of the tissue based on the value you type in this field. The Min. Dose Ref. (%) uses the minimum dose that covers the percentage of the tissue based on the value you enter. Heterogeneity Index= [Dose that covers x% of tissue (x= High Dose Ref. %)/Dose that covers y% of tissue (y=Min. Dose Ref)]

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Statistics – Display Tab (cont.) Conformity Index The Conformity Index gives information that describes the degree to which prescribed isodose volume conforms to the shape and size of the target volume(s). You can also view this information on the Statistics tab (Figure 7-17). Prescribed V. (cm3) is the target volume of tissue that receives the prescription dose. Target V. (cm3) is the target structure volume. This value defaults from the structure properties. You can change the Prescribed Dose (Gy) to manipulate the Conformity Index and Prescribed V. (cm3) values. (Refer to online help and published references for detailed information about the Conformity Indices equation.) TV12 = (Volume of Target that receives the Prescription dose) 2 TV = Target Volume VR1= Total Volume of the Prescription Isodose: (You must convert the isodose to a structure in order to show the VR1 value.) Conformity Index =

TV12 TV * VR1

Figure 7-17: DVH Statistics-Indices on Statistics Tab

Monaco®

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Statistics – Display Tab (cont.) Print/Export the DVH Statistics button on the Plan Options tab.

1.

Click the DVH Statistics

2.

Print or Export the DVH statistics report. Click the Print button to show a Report Comment dialog box. NOTE:

If you have multiple plans shown, the system prompts you to choose a single plan or all plans for which you want to print the statistics report.

3.

Type an optional Report Comment that you would like Monaco to add to the printed Statistics page.

4.

Click OK to show the DVH Statistics Report.

5.

You can print this report. Click the Printer

button. You can Export the

report to file in PDF format when you click the Export Report the upper left corner of the dialog box. 6.

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Click OK to close the DVH statistics dialog box.

button in

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties (cont.) DVH Color Setup Set the background color for the DVH Graph. 1.

Click the DVH Color Setup

button on the Plan Options tab

OR Position your mouse cursor in the DVH window. Right-click and select the Background Color option from the menu to show the Grid Color dialog box below that lets you select from any of 16 colors.

Figure 7-18: DVH Color Setup

Monaco®

2.

Click on a color box to select the DVH Background color.

3.

Click OK to accept the background color change.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties (cont.) DVH Properties Setup The DVH Properties dialog box is where you can edit specific DVH properties, such as the dose/percent and volume maximums, grid style, DVH line thickness, resolution and bin width. Refer to Online Help for detailed information about Single Plan and Multiple Plan DVH warning messages. 1.

Click the DVH Properties Setup tab.

button on the Plan Options

OR Position your mouse cursor in the DVH graph area. Right-click and select the Properties option from the menu list. The system shows the DVH Properties dialog box (Figure 7-19). NOTE:

The DVH Properties setup dialog box is slightly different and depends on your normalization option. If you select Absolute normalization, the field in the upper-left corner of the dialog box represents dose. If you select Percent normalization, the field in the upper left corner of the dialog box represents percent dose.

Figure 7-19: DVH Properties dialog box

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Change the DVH Display Properties DVH Properties Setup (cont.) 2.

Select the Dose Maximum value for the X-axis. Options are Plan Maximum, or you can select a User Specified dose/percent value.

3.

Select the Display Volume As value for the Y-axis. You can choose to show the volume in Percent or Absolute (cm3).

4.

Select a User Specified percent, or cm3 for the Volume Maximum based on the display type you chose as the Display Volume As value.

5.

Click on the Horizontal and Vertical checkboxes to set the DVH display with both vertical and horizontal grid lines.

6.

Select the Grid Line Style you would like for the system to show.

7.

Edit the Thickness of the DVH line by typing a pixel value of 2-11. NOTE:

8.

Edit the Resolution of the DVH graph by typing a value in centimeters. The range is 0.1 to 1.0. NOTE:

Monaco®

The values for Thickness, Resolution, and Bin Width are applied to plans not created with an older template (Monaco 1.02or earlier) that do not contain default values or imported plans. If you have a template from Monaco 3.20, or earlier with the Pixel Thickness as 1, the value changes to two (2) due to the updated range.

The Total DVH and corresponding DVH Statistics will be interpolated from the dose grid using the DVH Resolution. To minimize the effect of this interpolation, use a DVH Resolution that is equal to or an even multiple of the dose grid size. For example, if you have a 4 mm dose grid size, use a 2 or 4 mm DVH Resolution.

9.

Edit the Dose Bin for the DVH graph. Type the Bin Width. The range is 1.050.0. The Bin Width is applied to the shown DVH and to the exported DVH.

10.

Click OK to save the changes.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Create Structure Combinations for the DVH This tool lets you create structure combinations for use with the DVH. You can add or subtract structures, show the DVH for only the intersection of two structures, or use these options in combination. For example, you may want to add both lungs together and subtract out a lung tumor to show the DVH of the healthy lung tissue. Use (+) to add structures, (-) to subtract structures, and (*) to show the intersection of structures.

Add Structures 1.

Click the Structure Combinations Plan Options tab.

button on the

OR Right-click in the DVH window and select the Structure Combinations option to show the Structure Combination Editor dialog box (Figure 7-20).

Figure 7-20: Structure Combination Editor dialog box

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2.

Combine structures for the DVH. Click the drop-down arrow in the Make new combination field and select a structure.

3.

Click the radio button next to the + sign.

4.

Select a second structure. Click the same drop-down arrow and select a second structure.

5.

Type a name for the new structure combination.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Create Structure Combinations for the DVH Add Structures (cont.) 6.

Click the Color button and select a color for this structure combination.

7.

Click the Accept button when you are done to show the structure combination in the Review/delete combinations field.

8.

(Optional) Click the Delete button if you would like to delete the shown structure combination.

9.

Click OK when finished.

Export the DVH Values You can export cumulative or differential DVH values of a shown DVH as a text file (*.txt) or a comma separated values (*.csv) file.

1.

Click the DVH Export

button on the Output tab.

OR Right-click in the DVH window and select Export DVH.

Monaco®

2.

In the Save DVH File In dialog box, select a location where you want to save the file.

3.

Type/edit a file name and select a file type (*.txt or *.csv).

4.

Select an Export style of Cumulative or Differential.

5.

Click Save.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Create Structure Combinations for the DVH Add Structures (cont.) Print or Export the DVH View You can print or export any shown DVH view. 1.

Right-click in the DVH window and select Print.

2.

Type an optional report comment. Click OK to show the DVH View dialog box.

3.

To print, click the Print Report button to show the Print Setup dialog box. Type the appropriate information for your printer, and then click OK. OR To export to a PDF file, click the Export Report button to show the Save PDF File In dialog box. Select a location to save the file and click Save.

Measure Dose Intensity at a Point 1.

Click the Volume Cursor

2.

Position the cursor over one of the CT images and hold down your left-mouse button to show the dose at the cursor point. NOTES:

button on the Planning tab.

If more than one plan is shown (Multiple Plan Mode), the dose at the same point appears on each plan. If more than one plan is shown and the Dose Difference or Dose Summation is shown, the cursor shows the difference in or sum of dose between the two plans.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Measure Dose Intensity at a Point (cont.)

Monaco®

3.

Hold down your left mouse button and drag the mouse. The dose dynamically shows at each pixel as the cursor moves over it. (You see pixel value and electron density information for Primary Volumes.)

4.

Hold down your Shift key and left mouse button simultaneously and drag across the image. The dose and point coordinates appear at each pixel as the cursor moves across it.

5.

Click the Volume Cursor button on the Main toolbar to turn off the volume cursor.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Set the Normalization Parameters Use the Dose Normalization group (Figure 7-21) on the Plan Options tab to change the normalization of your plan to absolute or percent dose. You can also change the dose display to cGy or Gy. 1.

Place a checkmark in the box to the left of Relative mode.

Figure 7-21: Dose Normalization Group 2.

Type 10.00 as the dose for normalization. NOTE:

3.

Press the Tab key. This changes the normalized dose to 10.00. NOTE:

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If you chose Absolute as the normalization mode, the system grays out this field.

The default is the global maximum value, which is the highest dose value in the opened active plan. If a Monaco Plan is loaded, the default value corresponds to the Target EUD isoconstraint.

4.

Type 50.00 as the dose for normalization.

5.

Press the Tab key. This changes the normalized dose to 50.00.

6.

Click the drop-down arrow located to the right of Gy and select cGy or Gy as the shown units.

7.

Type 95 in the box next to the % sign. This action adjusts the isodose line that receives this dose.

8.

Click the drop-down arrow in the Norm field and select the Absolute option to change the normalization mode to Absolute. Notice the change to the DVH labeling and Isodose Control.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Show Dose Extents If you want to see a graphical representation of the calculation volume on the transverse, sagittal and coronal views, click on the Plan Options tab then the Show Dose Extents

button.

Measure and Interest Points Tools The Measure and Interest Point Tools are available in all activities.

Figure 7- 22: Measure and Interest Points Toolbar

See the Planning Tools section for more detailed information on the use of these tools.

Dose Reference Points You can click on the Dose Reference Points tab on the Planning Control to view dose reference point information for Monaco plans in Plan Review activity. For more information about dose reference points, see the Planning Tools section of this training guide.

Monaco®

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Single Plan Display and Multiple Plan Display In Plan Review, you can show a Single Plan where the transverse, sagittal, coronal images, and the DVH of the selected plan are shown. You can change plans when you double click on the plan in the Workspace Control or choose Load/Activate option from the right-mouse menu of the selected plan. The active plan appears in blue bolded italic underlined font (Figure 7-23).

Figure 7-23: Workspace Control: Load Single Plan You can also show Multiple Plans in Plan Review. Each image window shows the same SPV (either transverse, sagittal, or coronal) for all plans and the DVH represents up to three plans using solid, dashed, and dotted lines to represent the different plans.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Measure and Interest Points Tools Switch from Single Plan Mode to Multiple Plan Mode Right-click in any transverse, sagittal, or coronal window and select Multiple Plans. This makes the Multiplan Navigation option available in the Controls drop-down menu on the Workspace tab.

Navigation Tools in Multiple Plan Mode 1.

Left-click on a transverse, sagittal, or coronal thumbnail image to change the SPV shown in the main windows.

2.

Hold down your left-mouse button and drag the T-bars on the thumbnail images to change the shown slice in the main window. OR Press the upper case and lower case L key while pointing with the mouse over the required location on one of the views in Multiplan Navigation Control. (For more information on Quick Locator, refer to Quick Locator section in this guide.)

3.

Monaco®

The system shows the name of the plan, image set, and structure set at the top of each of the three main image windows together with the Maximum Dose information for this plan. Click the drop-down arrow next to the plan name and select a different plan to change the plan shown in any window.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Show the Dose Difference or Dose Summation between Plans In Plan Review, you can subtract dose to highlight dose differences between two selected plans. You can also add plans if you would like to see a result of dose summation of two or more plans. Follow these instructions to set up a window that shows a dose difference or summation. 1.

Select the plans you want to add or subtract in the Patient Workspace. To do this, hold down the Ctrl key and select the plans with the mouse.

2.

Right click and select - for a subtraction plan. The system loads the two original plans along with the subtraction plan in the lower right window. OR Right-click and select Sum Plans for dose summation.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Modify the Dose Difference or Dose Summation Display When you select a dose difference or dose summation, the system shows a Summation or Subtraction control so you can adjust the isodose values shown in the difference or summation window. Note, that the shown Dose Control is dependent on the active plan. If a summation plan is active, then only the Summation Dose Control appears. Below are examples of the default controls:

Figure 7-24: Summation Dose Control

Figure 7-25: Subtraction Dose Control

lsoDose Summation When you add plans together, the Summation control shows the dose range of the summed plans. However, this range is editable when you type new values followed by the Tab key. You can also change how the isodoses appear. Options are Isoband, Isofill, IsoLine, and Colorwash. The Thickness value only applies to the Isoband option. The Cutoff value does not apply to summations. When you show a summation plan, the DVH for the summation plan is also shown. Therefore, you can show the DVH Statistics for a summation plan and apply reference dose cursors. You can sum multiple plans in a single operation.

Monaco®

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Modify the Dose Difference or Dose Summation Display (cont.) Dose Difference When you subtract plans, it becomes important to review the difference dose between plans. The Subtraction control shows a default range of percentages. However, this range is editable when you type new values followed by the Tab key. You can change the default normalization to Absolute to see the absolute dose difference. You can also change how the isodoses appear. Options are Isoband, Isofill, IsoLine, or Colorwash. The Thickness value only applies to the Isoband option. The value entered for Cutoff represents the differences that are greater or less than the absolute value. You can only subtract two plans in a single operation. NOTE:

For summation or difference plans where the calculation grids of the original plans are not the same, you see a warning message in the summation or difference window.

Save the Summation or Difference Plan You can save a Summation or Difference plan. Select File | Save Summation/Difference Plan. This saved plan appears in the Patient Workspace Control. This tool is useful if you want to sum (or find a difference of) more than two plans. After you save the result of summation/subtraction, you can add/subtract additional plans.

Figure 7-26: Patient Workspace NOTE:

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You cannot export summation or difference plans.

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Review the Patient in 3D 1.

Right-click in any image window and select the View Type, 3D option. If you are in Single Plan Mode, the 3D image appears in the selected window. If you are in Multiple Plan Mode, the 3D image appears in all windows. The 3D view is available at any time during the plan review process.

2.

Select the Isofill, Isoband, or Isoline viewing option to view dose on the 3D image sets. When the Isoline option is turned on for 3D, you can also see the isolines in the BEV. Once you select one of these options, the Isodose Control bar changes to look like this one:

Figure 7-27: Isodose Control

Monaco®

3.

Click the All 3D On button to turn all isodoses on in the 3D view.

4.

Select S for solid, T25 –T 75 for transparent, or W for wireframe in the field next to any isodose line value under the 3D heading to turn on individual isodoses. A dashed line in this field indicates that the selected isodose line does not appear in the 3D view.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Review the Patient in 3D (cont.) Convert Isodose to Structure In Planning activity, you can create a structure from an isodose line on the Isodose Control (Figure 7-28). The Convert Isodose to Structure button is only available if you are in IsoLine mode or if the Isolines option is checked in ColorWash, IsoFill, or IsoBand mode. You can DICOM export the structures created from this tool.

Figure 7-28: Isodose to Structure Option 1.

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Click on the Convert Isodose to Structure icon next to the isodose line for which you want to create a structure. This action opens the Create Structure from Isodose dialog box (Figure 7-29).

Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Review the Patient in 3D Convert Isodose to Structure (cont.)

Figure 7-29: Create Structure from Isodose dialog box

Monaco®

2.

Type in a structure name in the New Structure Name option.

3.

Left-click on the Structure Color field to open the Color palette and change the color of the structure.

4.

Type in a Symmetric Margin value. The range is -4.00 to 9.90 cm. The structure in the images update in real time when you type a value.

5.

Type in a value for the Minimum Volume size. The range is 0.100 cm3 to 10.000 cm3.

6.

The information for the Number of Contours, Number of Non-contiguous Volumes, Total Volume of New Structure, and Total Volume to Be Discarded are read-only and update based on the information you type in the Symmetric Margin and Minimum Volume options.

7.

Click Cancel to discard your changes.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Review the Patient in 3D Convert Isodose to Structure (cont.) 8.

Click OK to save the structure and close the dialog box. NOTE:

If the structure volume is smaller than the minimum volume, a warning message about the minimum volume appears when you click OK.

Figure 7-30: Structure Volume warning message

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Approve a Calculated Plan In Plan Approval, you can approve plans and type or review comments. You can see these approval statuses and comments on XiO or Monaco. You can approve plans in:

1.

•

Planning Activity

•

Plan Review Activity Right-click over the loaded plan in the workspace control where you want to approve the plan. OR Click the Plan Approval

button on the Planning tab.

2.

The reviewer and planner can leave comments about the plan.

3.

In the Plan Approval dialog box, check the Approved box to approve the plan.

4.

You (the reviewer) must type a valid user name and password in the User Validation dialog box. (To create a user name and password in User Authorization, see Appendix A. User Authorization).

5.

The plan approval status updates in Reviewer and Reviewer Date (Figure 7-31).

Figure 7-31: Plan Approval-Reviewer and Review Date

Monaco®

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Approve a Calculated Plan (cont.) 6.

If you are ready to approve the plan, click OK. NOTE:

The plan approval status, reviewer name, and review date are DICOM exported and listed in all reports.

7.

To unapproved the plan, uncheck the Approved and re-enter your username and password.

8.

Click OK.

9.

Click Done to exit the Plan Approval dialog box. NOTE:

Plan Approval is not available for Summation/Subtraction Plans. When you approve a bias dose plan, the system only approves the current plan.

This feature is only available when you have dose calculation abilities.

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Rescale by Number of Fractions You can change the Rx Dose of a calculated plan by editing the Number of Fractions in the Physician’s Intent. When you edit the Number of Fractions, the Rx Dose, and the total doses in all views update. The dose per fraction and MU per fraction remains constant. This is only available when you have segments and calculated monitor units. These options are located on the Prescription Tab (Figure 7-32).

Figure 7-32: Prescription Tab If you have just optimized a plan and you edit Number of Fractions, Monaco will inform you that the optimizer will be reset if you are intending to run further optimizations. See Figure 7-33.

Figure 7-33: Number of Fractions warning message

Rescale by modifying Fractional Dose

Monaco®

1.

In Planning activity, click on the Prescription tab on the Planning Control.

2.

Type the new value in the Number of Fractions field first. Next edit the Rx Dose (Gy) field. The Fractional Dose will update to reflect the new values entered.

3.

For optimized plans, Monaco calculates the ratio of the fractional dose change and uses this ratio to update the MU/Fx. For consistency, Monaco also updates the Rescale dose value to equal the Rx Dose value (Gy).

4.

Use the isodose curves and DVH to evaluate the new dose values. 7-37

Plan Review Volume I of IV Monaco Training Guide

5.

The Plan report shows the rescaled number of fractions under the Normalization heading.

6.

If you change the Rx Dose for a plan which you optimized and created segments, then the system: • Shows a warning that the MU/Fx will update (Figure 7-34) • Updates the dose value in the Dose Normalization panel if you are in Absolute Dose Mode • Updates the displayed isodose lines, if you are using the Default Isodose template

Figure 7-34: Rescale warning message 7.

Use the Reset button to return the Rx Dose and MU/Fx to the last saved status. If you have not saved your plan, Monaco sets the values back to the status before rescale. If you are using the Default Isodose Template, then the Isodoses and dose value on the Dose Normalization panel are also reset. If you are using a Custom Isodose Template, neither the isodose display nor the dose value on the Normalization panel reset.

8.

Use the Absolute Dose Mode and select the Default Isodose Template to have edits to the Rx Dose update both the displayed isodose values and the dose value on the Normalization panel.

Figure 7-35: Prescription Tab with Reset option

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Plan Review Volume I of IV Monaco Training Guide

Plan Review Activity Practice Exercise – Plan Review Tools This exercise lets you practice using the plan review tools available in Monaco. It is assumed that you reviewed the section Plan Review Activity. You can use it as a reference as you practice with these tools.

Monaco®

•

Open Monaco and Select the Patient ID HeadandNeck

•

Select and Load the three plans MonPlan1, MonPlan2 and TONSIL

•

Change the Isodose Display

•

Change the Dose Transparency

•

Show/Review Beam Summary

•

Show/Hide Structures

•

Use Reference Doses, DVH cursors and DVH Statistics

•

Create Structure Combinations

•

Change to Multiple Plan Display

•

Show/Modify a Dose Subtraction

•

Show/Modify a Dose Summation

•

Show/Modify Dose on a 3D image

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Practice Exercises Volume I of IV Monaco Training Guide

Practice Exercises Practice Exercise 1. General Operation and Navigation Use the exercises in this section before you come to class, or use it with the lecture below in the classroom discussion on each area described.

Practice Exercise 1. General Operation and Navigation This exercise lets you practice the use of the general operation and navigation tools available in Monaco. It is assumed that you have reviewed the section General Operation and Navigation. You can use it as a reference as you practice with these tools.

Monaco®

•

Open Monaco and Select the Patient Fusion Prostate

•

Load the Studyset CT (no cont)

•

Navigate through T/S/C Images - Use the Color-Coded T-bars - Use the Scroll Wheel on the Mouse - Use the Quick Locator tool - Use the Reference Plane Indicator Toolbar - Use the Page Up/Page Down keys (transverse images only)

•

Adjust the Window and Level - Use the Mouse - Use the Window/Level Toolbar - Use the Window/Level Presets

•

Use the Zoom and Pan tools on transverse, sagittal, and coronal image types

•

Turn on a 3D image and practice using the Zoom and Pan tools - Pan - Zoom - Rotate - Translate - Reset

•

Select V.Fluoro Layout (to show a DRR) - Practice using MIP - Show/Hide Grid - Use the DRR Volume of Interest Tool

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Practice Exercises Volume I of IV Monaco Training Guide

Practice Exercises Practice Exercise 1. General Operation and Navigation (cont.) •

Maximize and Restore a window

•

Print Images - Print a T/S/C View - Print a DRR

Practice Exercise 2. Fusion, Contouring, and Beam Manipulation This exercise lets you practice with the fusion and contouring tools available in Monaco. It is assumed that you have reviewed the sections Contouring Tools and Fusion Activity. You can use them as references as you practice the use of these tools. If you do not have Fusion or do not want to practice using fused images, you can open the patient, skip the Fusion section and start with the Contouring section. Fusion

8-2

•

Open Monaco and Select the Patient Fusion Prostate.

•

Load the Studyset CTClean as the Primary and the Studyset MR1 as the Secondary

•

Register the studysets in Fusion Use Manual Registration tools Use Auto Registration Use Point Registration

•

Visually verify the Results Use the Blender Bar Use the Measure Tool Use all the Fusion Display Options

•

Save the Registration

Practice Exercises Volume I of IV Monaco Training Guide

Practice Exercises Practice Exercise 2. Fusion, Contouring, and Beam Manipulation (cont.) Contouring •

Contour all Structures in the Prostate Patient Blend from the CT to the MRI during Contouring Draw Contours Manually (ex. Prostate) Change the Guide Radius Use the Drawing Assistant Mirror and Rotate a structure Edit Contours using Replace and Reshape Use the Swap Contour feature Use the Contouring by Shapes Tool (ex. Cord) Use the Paintbrush Tool (ex. Prostate) Use the Copy Structure tool Use Copy Superior/Copy Inferior (ex. Cord) Use Interpolate (ex. Cord) Use Auto Segmentation (ex. Bladder) Use Automargin (ex. Create a PTV around the Prostate and SV) Edit Structure Properties Delete Structures

Beam Manipulation •

Add Beams

•

Move Beams Using the Keyboard Using the Mouse · Rotate Gantry · Rotate Collimator · Move Isocenter

•

Copy and Mirror Beams

•

Turn Beam Visibility Off and On

•

Delete Beams

•

Edit Beam Information On the Beam Control

Miscellaneous • • •

Monaco®

Use the Measure Tool Add/Edit/Remove Interest Points and Markers Save the Contours

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Practice Exercises Volume I of IV Monaco Training Guide

Practice Exercises Practice Exercise 3. Plan Review This exercise lets you practice with the plan review tools available in Monaco. It is assumed that you have reviewed the section Plan Review Activity. You can use it as a reference as you practice the use of these tools.

8-4

•

Open Monaco and Select the Patient HeadandNeck

•

Select and Load the three plans MonPlan1, MonPlan2 and tonsil

•

Change the Isodose Display

•

Change the Dose Transparency

•

Show/Review Beam Summary

•

Show/Hide Structures

•

Use Reference Doses, DVH cursors and DVH Statistics

•

Create Structure Combinations

•

Change to Multiple Plan Display

•

Show/Modify a Dose Subtraction

•

Show/Modify a Dose Summation

•

Show/Modify Dose on a 3D image

Treatment Couchtop Inclusion Volume I of IV Monaco Training Guide

Treatment Couchtop Inclusion This exercise shows you how to create, import, and remove a treatment couch within an IMRT or QA plan. This exercise includes these tasks: •

Import a Treatment Couch Structure

•

Edit and Save a Treatment Couch

•

Add Couch to a Plan, a Studyset or a Phantom

Task 1. Import a Treatment Couch Structure You can import a scan of your couchtop just as you import a new patient. You can import structure sets of your couchtop or create the structure in Monaco.

Monaco®

1.

Open the software to automatically show the Patient Selection dialog box.

2.

Click Import New Data.

3.

Click Browse to navigate to the DICOM IMPORT DATA folder setup for this training class and select iBeam.

4.

Click OK to load the patient into the import utility.

5.

Click the down arrow next to the DICOM Patient field and select iBeam.

6.

Click RTSS_1. (This couchtop has contours to import.)

7.

Select Installation as the Local Installation.

8.

Select 0~Clinic as the Local Clinic.

9.

Type NewCouch as the Patient ID.

10.

Type Training Couch as the Patient Name.

11.

Click Add.

12.

Select DICOM3.rocboard as the CTtoED Assignment.

13.

Click Import.

14.

After you complete the Import, click Close to close the DICOM Import dialog box.

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Treatment Couchtop Inclusion Volume I of IV Monaco Training Guide

Treatment Couchtop Inclusion Task 2. Edit and Save a Treatment Couch This task shows you how to edit an imported treatment couch and save it to the Treatment Couch Library.

9-2

1.

Click Monaco Applications Menu | Open Patient to show the Patient Selection dialog box.

2.

Click the Clinic folder.

3.

Select the patient name Training Couch.

4.

Click OK.

5.

Double-click on the studyset CT1 to load.

6.

Click on Foam Core in the structure control.

7.

Select the Structure Type Couch.

8.

(Optional) Edit the color and density of the structure.

9.

Click on Carbon Fiber in the structure control.

10.

Select the Structure Type Couch. It is important to designate your structure as such so that the system recognizes it as a treatment couch structure.

11.

(Optional) Edit the color and density of the structure.

12.

Click Monaco Application Menu | Treatment Couch | Save as Treatment Couch.

13.

Type the Couch Name Trainingcouch.

14.

Click Save. This action saves the couch to the Treatment Couch Library.

15.

Click Monaco Application Menu | Close Patient.

Treatment Couchtop Inclusion Volume I of IV Monaco Training Guide

Treatment Couchtop Inclusion Task 3. Add Couch to a Plan, a Studyset or a Phantom You can add a treatment couch to a plan or a studyset. If you add the treatment couch to a studyset where plans already exist, this action does not force dose recalculation. If you create a QA Plan based on a patient that has a treatment couchtop, the couchtop does not transfer to the phantom. You must add treatment couches to phantoms in the same way you add them to plans or studysets. 1.

Click Monaco Application Menu | Open Patient.

2.

Select Patient Fusion Prostate.

3.

Double-click the studyset CT1 to load.

4.

Click the Plan Options ribbon.

5.

Click the Import Positioning Device

6.

Click Trainingcouch. NOTE:

button.

If treatment couch(s) already exist, click the box next to the Remove Existing Couch Structures to remove them.

7.

Click OK. This loads the couch onto the studyset and shows the Treatment Couch Position dialog box.

8.

(Optional) You can edit the couch position two ways. (1)

Use the dialog box to edit the couch position.

OR (2) 9.

Move the couch with the mouse in any transverse, sagittal, or coronal view.

Click Done. The couch is cropped superiorly and inferiorly and added to the studyset. NOTE:

10.

Monaco®

Once you click done, you cannot edit the couch again. Delete the couch structure(s) and import the couch again.

(Optional) Edit the treatment couch structures properties just as you would any structure property.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Features of 3D Plans Monaco supports static gantry and dynamic gantry 3D delivery options. You can conform Static 3D beams when you use multi-leaf collimators or custom blocks and apertures. The Collapsed Cone algorithm lets you to use soft, physical and motorized wedges. You can use CT studysets and transverse MR studysets to create 3D plans. When a 3D or 3D Static Arc plan is active, you can: •

create and edit beams

•

copy and delete beams

•

create and edit blocks/apertures

•

define MLC shapes

•

select and use wedges

•

select and use stereotactic cones

•

select and use electron and photon machines

•

enter width, length and jaw values

•

make asymmetrical and symmetrical adjustments

•

rescale dose

•

show dose for each beam after calculation in all views

•

use the Collapsed Cone or Monte Carlo algorithm based on the treatment aid

Create a 3D Treatment Plan You create a 3D Treatment plan when you use a stored template.

Monaco®

button. Monaco shows the Patient

1.

Start Monaco and click the Open Patient Selection dialog box.

2.

Double-click the patient you want to use. Monaco loads the patient into the Planning Workspace.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Create a 3D Treatment Plan (cont.) 3.

Type a Plan Name and Plan Description. The Description is optional.

Figure 1-1: New Monaco Plan window 4.

Select an Anatomical Site to filter plan templates specific to an anatomical site.

5.

Select the Template you want to use. This can either be one of the default templates which come with Monaco, or one that you created and saved.

6.

Select the Treatment Unit and beam parameters. You can change all of these during planning.

7.

Click OK. Monaco places the beams and starts the Treatment Plan.

8.

Once you start a treatment plan, you can add, edit, and remove contours when you use the tools on the Contouring Ribbon.

Figure 1-2: Contouring ribbon

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Create a 3D Treatment Plan (cont.) 9.

You can set up the couch and treatment aids when you use the tools on the Plan Options ribbon.

Figure 1-3: Plan Options ribbon 10.

You can edit ports and the plan and calculation parameters when you use the tools on the Planning Ribbon.

Figure 1-4: Planning ribbon 11.

The Planning Control has four tabs: Structures, Prescription, Dose Reference Points, and Beams. You use the Planning Control to manipulate the beams and treatment aids, set the contour densities, overlap properties, and type the treatment intent.

Figure 1-5: Structures window 12.

Monaco®

See the General Operation and Navigation section for more information on Ribbons. See the Planning and Workflow section for more information on the Planning Control. An overview of the Planning Control is given in this section.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Planning Control – Structures You can set the display properties of the structures on the Structures tab. You can override the electron densities of structures when you use the Force ED and Fill ED options. You must use Forced Electron densities if you make a plan on an MR studyset. Click the Force ED option if there is an object in the treatment that needs to maintain a constant mass density. Click the column header to toggle the force density feature on or off for all of the structures. Click the Fill ED option to fill a structure with a minimum electron density. The Relative Electron Density Field is empty until you mark either the Force ED or Fill ED fields. It then shows the default electron density for the structure. You can type in a new value. Monaco lets you use a large range of Relative Electron Values. Type the value which is applicable for the structure you fill. Valid values are: •

Photon Monte Carlo from 0.010 to 15.000

•

Electron Monte Carlo from 0.01 to 2.456

•

Collapsed Cone from 0.01 to 2.456

Planning Control – Prescription Tab: You can type new/update prescription information in the Prescription tab. This information is saved with the plan. You can do the tasks below in the Prescription dialog box:

1-4

•

Update the information for the physician’s intent

•

Rescale Dose

•

Weight the plan’s beams

•

Change the active prescription

•

Add prescriptions to a plan

•

Delete prescriptions from a plan

3D Planning Volume II of IV Monaco Training Guide

3D Planning Physician’s Intent In the Physician’s Intent area of the Prescription dialog box (Figure 1-6), you can update relevant prescription information. If a physician’s intent exists for the plan, all of the fields are pre-populated. You can edit the fields except for the Rx ID and X, Y, and Z coordinates as these are non-editable fields. 3D Plans are calculated to a point which is the Prescribe To point you define. When you edit the Rx Dose (Gy), Monaco updates the dose distribution so the dose at the Prescribe To point equals the Rx Dose (Gy). The Actual Dose value updates to reflect this change.

Figure 1-6: Prescription dialog box 1.

Select an Rx Site from the drop-down menu. You can make the Rx Sites in the Settings dialog box. OR Type in a value in the Rx Site field. When you tab out of the field, the system shows a message and asks if you want to save your Rx Site to the list.

Figure 1-7: Rx Sites message

Monaco®

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Physician’s Intent (cont.) 2.

Click the drop-down arrow next to the Prescribe To drop-down menu to select an interest point or volume. The X, Y, Z coordinate information updates when you select a location. a. For electrons, you can select the Depth of Beam X. b. Type the depth in cm that is clinically related for the energy you chose to calculate. NOTE:

If bolus is assigned to the electron beam, you must think about the bolus thickness when you select a depth.

3.

In the Physician’s Intent, the Rx Dose (Gy) field is the total dose for the Rx Site.

4.

If you wish to edit the fractionation scheme of the plan after calculation, Monaco will calculate and update the new Fractional Dose. Therefore, editing the Rx Dose or Number of Fractions rescales the plan and updates the Actual Dose value to be equal to the Rx Dose (Gy). Monaco also updates the monitor units as needed.

Rx ID If you have a plan with multiple prescriptions, you can change the active prescription from the Rx ID drop-down.

Figure 1-8: Rx ID drop-down

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Add Rx Plans may have multiple prescriptions. The prescriptions can have different delivery type, treatment machines, modality, algorithm, energy, SSD, and isocenter location. 1. If you want to add a prescription to a plan, select Add Rx.

Figure 1-9: Add Rx button 2. The Import Template into Existing Plan window opens.

Figure 1-10: Import Template into Existing Plan 3. Select the plan options. 4. Click OK to import the template into the plan.

Monaco®

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Delete Rx You can delete prescriptions from a plan if you select Delete Rx.

Figure 1-11: Delete Rx 1. Select the prescription you want to delete in the Rx ID drop-down. 2. Select Delete Rx to delete the prescription.

Rescale Dose There are seven options for you to choose from in the Rescale Dose drop-down menu (Figure 1-12). This option is not available during optimization.

Figure: 1-12: Rescale Dose Drop-Down Menu

Name to cover to min dose of structure to mean dose of structure to max dose of structure to dose at point to relative isoline to absolute isoline

1-8

Description % and Structure field appears Structure field appears Structure field appears Structure field appears All available points appears You can type a value for the % isoline in the number field that appears You can type a value for the cGy or Gy isoline in the number field that appears

3D Planning Volume II of IV Monaco Training Guide

3D Planning You can reset the dose back to the original value (Figure 1-13).

Figure 1-13: Reset option for a 3D plan

Beam Weighting You can weight beams by dose or MU in the Prescription dialog box (Figure 1-14). You can move the slider bar or type in a value to adjust the weights.

Figure: 1-14: Prescription dialog box-Beam Weighting 1.

Select a Weight beams by option: Click on the Dose or MU radio button.

2.

You can type in a number in the Beam field.

3.

You can type in a beam description in the Description field.

4.

You can type in a Field ID. NOTE:

5.

Monaco®

When you type in information in Beam, Description, or Field ID, the beam spreadsheet information updates is real time. Any change you make is reflected immediately.

Use the slider bar or type in a value in order to change the beam weights. You can edit beam weights before or after calculation. If you want to lock a beam weight, place a checkmark in the Lock box next to that beam.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Prescription: Segments Tab You can add, edit, copy, and delete segments from a beam. The Segments tab shows when you open the Prescription tab on the Planning Control bar. You can also do the tasks below from this dialog box: •

Select which beam you want to work with

•

Update beam weighting

•

Change the field size

Figure 1-15: Segments tab 1. Select the beam you want to use from the Beam drop-down. The beam in this drop-down is the active beam 2. Select one of the following segment options: •

Add Segments: Lets you add a segment to the current parent beam. The jaw settings default to the parent beam’s open field size. o

•

Select Create and Edit Ports to create the segment.

Copy Segment: Lets you copy an active segment. The default weight of the new segment is zero. This segment shows last on the segment order.

•

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Delete Segment: Lets you delete an active segment. When a segment is deleted, the dose is spread equally to current unlocked segment weights.

3D Planning Volume II of IV Monaco Training Guide

3D Planning Prescription: Segments Tab (cont.) •

Edit Segment: Click this button to make changes to a segment. The Create/Edit Ports dialog box opens if you select an active segment. The BEV updates with information from the active segment.

3. You can select to weight the segments by one of the following methods: •

Equal Weights: Distributes the weight of the unlocked beams equally. The button is disabled when all segments except one are locked.

• %: Defines the percentage of MU that is assigned to a segment. The sum of the segments weights is equal to 100% of the beam MU. o Use the slider bar to adjust the beam weights. Move the slider bar to the left to decrease the percentage. Move the slider bar to the right to increase the percentage. o Type a percentage in the number field to the right of the slider bars. NOTE:

When you change the weight of a segment, you need to recalculate and rescale the plan to get back to the original scaling.

Figure 1-16: Percent Weight sliderbar • MU/Fx: Shows the Monitor Units/Fraction for the segment. You cannot edit the field.

Figure 1-17: MU/Fx

Monaco®

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Prescription: Segments Tab (cont.) • Lock: Click the check box to prevent an automatic update of the beam weight. Remove the checkmark in the check box to let the beam weight update automatically. You can continue to edit a locked weight and MU. The default is not checked.

Figure 1-18: Lock Weights check box 4.

The Segment column lists the segments and identifies the number of segments.

Figure 1-19: Segment Column 5.

You can view the Segments Area (cm2). This shows the size of the segment area in cm2.

Figure 1-20: Segment Area

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Prescription: Segments Tab (cont.) 6.

Width1(cm) and Width2 (cm): Shows the left- and right-width values in centimeters. These fields may be editable based on machine characteristics.

7.

Length1 (cm) and Length2 (cm): Shows the upper- and lower-width values in centimeters. These values may be editable based on machine characteristics.

Figure 1-21: Segment Width Values 8.

Length1 (cm) and Length2 (cm): Shows the upper- and lower-width values in centimeters. You may edit the values based on machine characteristics.

Figure 1-22: Segment Length Values

Segment Light Field Projection You can see a light field projection of a beam or beams’ segments for segmented IMRT and arc-based plans in the 3D view. 1. Use the 3D transparency slider bar on the Structures tab to set the External structure’s transparency to 0%. 2. Turn on the beam or beams in the Beam Visibility dialog box you want to see in the 3D view. 3. Select the beam and click on the segment on the Segments tab to see the segment light field projection in the 3D view.

Monaco®

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Planning Control – Dose Reference Points Use this tab to place, edit, or review Dose Reference Points for Monaco plans. Dose Reference Points are user-defined points where you can view the dose. There is one DRP for each beam. Dose Reference Points are user-defined locations. Monaco reports on individual beam dose contribution at these points. Each beam contains only one DRP. But, multiple beams may share the same DRP location. Monaco saves DRP parameters with the plan. Every new beam automatically has a dose reference point which defaults to the beam's isocenter. You may edit DRP locations or add new dose reference points, but only in the Planning activity. Monaco does not use dose reference points when calculating dose. You may view thier locations in the Planning and Plan Review activities. Monaco calculates dose at each dose reference point during the final dose calculation. If you move a dose reference point, the plan dose remains valid, but Monaco recalculates the beam dose, total dose, and parameters for each dose reference point.

Planning Control – Beams Tab Use this tab to manipulate the beams. The Beams contains sub-tabs: General, Geometry, Treatment Aids and Setup Beams. Use the General tab to add, remove, and edit beams. You set the beam energy and isocenter on this tab.

Figure 1-23: Planning Control – Beams tab Use the Geometry tab to add new beams to a plan. You can also edit the field setup and dimensions from this tab. Use the Setup Beams tab to set up Verification beams. You add the beams and edit their field size, location, and setup parameters on this tab.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Planning Control – Treatment Aids You can add, delete, or edit beams and treatment aids from the Treatment Aids button in the Beams tab when you select Planning | Beams | Treatment Aids (Figure 1-24). You can also see if the beam includes a Port or MLC. The headings are non-editable on the treatment aids sheet. The editable treatment aids available on this tab include: •

Beam Number

•

Description

•

Wedge

•

Applicator ID (Stereo and Electron Cones)

•

Bolus

•

Couch

Figure 1-24: Treatment Aids section of Beams tab

Wedges You can click on the drop-down arrow in the Wedge ID column to select a wedge for a beam. This field shows when a SIM plan, 3D and 3D Static Arc delivery modes are in use. When you select a wedge in this column, the Angle and Orient columns populate with the information associated with the wedge selected. The Angle column shows the angle of the wedge. The Orient column shows a wedge’s directional image: in, out, left or right. You can also view the wedge parameters in Settings if you have physics rights.

Monaco®

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Port /MLC These columns only appear for Sim and 3D treatment plans. The fields are checked if a port or MLC are present on the beam. You cannot edit these fields.

Applicator ID Click the drop-down arrow next to the beam to select an applicator ID in this column. This field shows the cones in the drop-down list if the machine is a photon or electron machine. This option is available for SIM plans and 3D and 3D Static Arc delivery modes. Stereotactic applicators are not available for SIM plans. The figure below shows an example of the applicator menu for Stereotactic Cones. Refer to the Stereotactic Planning section of the Training Guide for more information.

Figure 1-25: Example of the Stereotactic Cone Applicator ID menu

Couch You can place a checkmark in this column to add the couch to a beam if you imported a couchtop into the plan.

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3D Planning Volume II of IV Monaco Training Guide

3D Planning Bolus Once you create a bolus structure, you can assign a bolus to a beam. The calculation engine does not take into account any Bolus structures unless you assign them on the Treatment Aids tab of the Beam Control to the beams. See the Contouring section of the Monaco Sim guide for more information on generating a bolus. If the bolus is imported with anything other than Electron Density, the Density field is blank for that structure. You must type a value on the Structures Control before the Start Optimization option becomes available. 1. Click the Treatment Aids sub-tab on the Beams Control. 2. Click the drop-down arrow in the Bolus column for any beam. 3. Select the bolus in the Treatment Aids tab. This applies the bolus to all of the beams for IMRT plans. For 3D plans, you can add the bolus on per beam basis. The SBD (cm) column shows the Source to Bolus Distance when you select the bolus for the beams. 4.

Monaco®

(Optional): You can print the Beam Summary report to see the bolus information.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Overview Monaco gives you a unique approach to optimization that uses the latest advancements in IMRT and VMAT planning. They are: • • • •

Biological and dose-based cost functions Constrained fluence Pareto and aperture optimization A photon Monte Carlo dose engine integrated into the optimization process

As an alternative to traditional dose-based approaches in IMRT optimization, Monaco implements an intuitive biological model that takes into account the response of tissues to dose per fraction and its particular volume effect. When you describe the tissue-specific increase in dose tolerance with a reduction of irradiated volume, this biological volume effect can define the shape of the optimum dose distribution in normal tissues. You can define each tissue with its particular volume effect. Monaco does not require you to determine weight factors for each structure. Instead, Monaco utilizes a unique time and effortsaving approach where it determines the weight factors for you, internally based on your prescription. Clinicians are able to determine prescriptions when they use not only these biological models, but also standard dose-based models such as maximum dose, overdose DVH, and underdose DVH. You can plan in Monaco with any one of these five types of delivery methods: • • • • •

Monaco®

Step and shoot IMRT dMLC (Dynamic MLC) VMAT (Volumetric Modulated Arc Therapy) Dynamic Conformal Arcs Conformal RT

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Overview (cont.) Key features include: • • • • • • • • •

A comprehensive set of contouring and beam manipulation tools Six delivery modes: Step and Shoot IMRT, dMLC, VMAT, mArc Dynamic Conformal Arcs and Conformal RT Enhanced voxel definition controls - structure layering and properties A spectrum of biological and dose-based cost functions Two optimization modes: Constrained Optimization (Normal Tissue Priority) and Pareto mode (Target Volume Priority) Multicriterial optimization to tighten constraints, if feasible, during optimization Several useful plan analysis tools, like constraint Sensitivities, to guide prescription decision-making Bias Dose Planning XVMC Monte Carlo dose engine or an advanced Pencil Beam integrated into the optimization process

When you complete this section, please go to the Practice Exercise section and complete the exercises ‘Editing IMRT Prescription Elements’ and ‘Optimization and Plan Evaluation’.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Monaco Workflow Fuse Images prior to Contouring*

Contour all Targets and OARs

Select Delivery Mode and Add an IMRT or 3D template

Edit/Add/Delete Beams/Sequences No

Is the Template acceptable?

Yes Enter/Edit Prescription

Enter/Edit Calculation Properties and Sequencing Parameters

No

Do you want to optimize each stage? (DCAT has only one stage if SSO is off)

Yes Batch Optimization

Optimize Fluence (Stage 1)

Edit Prescription or Parameters No

Is the Optimized Plan Acceptable?

If edits are to any other prescription element or parameter

Yes Optimize Segment Shapes (Stage 2) If edits are to Isoconstraints or Multicriterial Edit Prescription or Parameters Is the Segmented Plan Acceptable?

No

Yes Saving acceptable plan Finished Planning? Plan Review

Perform QA

EXIT

Figure 2-1: Monaco Workflow

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Contouring and Beam Manipulation Contour all Targets and Organs at Risk (OARs) Contouring is a very important part of the planning process. Field sizes are smaller and more conformal in modulated plans than in traditional 3D plans, so creating contours that actually represent the volume of the structure is imperative. You should note that any structure for which you intend to deliver dose or restrict dose in the prescription, you must contour and add to the prescription. Dose transition volumes are not required as Monaco lets you easily create dose transition regions through use of specific user-definable properties and parameters. 3D Auto-Margin Generation You can also use 3D auto-margins to create non-variable or variable margins around structures, such as creating a CTV or PTV around a GTV. If you have more than one target, you should create a 3D auto-margin that encompasses all targets. The structure margin is not used in the prescription. It is instead used for isocenter placement. Consideration of Contours outside the Patient You may want to make a structure outside the patient contour. Use the Couch and Bolus structure types for the structures external to the patient. For example, you may want to contour a mask, make a bolus or account for attenuation of the table. To do this, select Couch or Bolus in the Type drop-down list on the Structures tab in the Planning Control. Then place a check mark by Couch/Bolus on the Beams | Treatment Aids tab so you can take the structure into account for the optimization and dose calculation. For a structure in the IMRT Constraints tab, use the Do Not Store Dose option in the Structure Optimization Properties. This only takes the attenuation into account which in turn saves on calculation time. This requires that you use the structure type of Internal for the structure. A constraint for the structure is not necessary. NOTES:

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(1) Refer to the Contouring Tools section for more information about contouring tools.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Contouring and Beam Manipulation (cont.) Beam Manipulation Tools Beams/sequences, machine energies, and calculation algorithms are saved with templates in Monaco. In Planning Activity, you can add/delete beams or edit beam arrangements to suit any patient’s specific requirements. In the Planning activity, you can add/delete beams or sequences using the Beam Control. Monaco supports coplanar and non-coplanar beam arrangements. It is not necessary to set a specific field size before planning. During optimization, Monaco automatically defines the field sizes appropriately based on the target(s) defined. NOTE:

Monaco®

Refer to the Planning Tools or IMRT Tools sections for more information about beam manipulation tools.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates After you complete your contouring, you start your plan. Select a template. Monaco makes use of template-based planning for workflow efficiency. The system provides basic DEFAULT templates. But, you can create and save your own templates at any time. Information saved in a template includes, but is not limited to the ones below: • • • • • • • • • • •

Treatment Machine Information Calculation Algorithm Isocenter Location Calculation Parameters Structure Layering Order Individual Structure Properties Global Structure Parameters Prescription Information Segment Shape Properties Delivery Mode Anatomical Site

Start a Plan Using a Template 1.

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While in the Planning Activity, click the Plans button on the toolbar. Or, right-click on a studyset in the Workspace Control and select New Monaco Plan. Monaco shows the New Monaco Plan dialog box (Figure 22).

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates Start a Plan Using a Template (cont.)

Figure 2-2: New Monaco Plan Template dialog box

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates Start a Plan Using a Template (cont.) 2.

Type in a Plan Name. Monaco does not allow spaces in the plan name.

3.

Type in a Plan Description.

4.

Select a Delivery Mode.

5.

Select an Anatomical Site. When you select a delivery mode and anatomical site, the related templates show in the Select template to import window.

6.

Select the template you want to import from the list. The description information includes the Rx Site, Rx Dose, and number of beams.

7.

Click on the Head First or Feet First radio button to select the treatment orientation. The scan orientation information appears above. If you change the treatment orientation so that it differs from the scan orientation, Monaco shows a message for you to verify the information.

8.

Select a Port option. • • •

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Import Beams Only: Retain Template Beam Shapes: Auto-conform Ports:

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates Start a Plan Using a Template (cont.) 9.

Select the template to apply to your patient.

10.

Number of Beams is a non-editable field that shows the number of beams that are in the selected template.

11.

Select the isocenter location where you want to apply the template. Monaco automatically populates the X, Y and Z coordinates. You can also type in X, Y and Z coordinates directly as the isocenter location. If the template has multiple isocenters, only the first isocenter appears. However, multiple isocenters are applied as defined by the template. NOTE:

Monaco®

The system saves isocenter coordinates as relative coordinate values. It does not save them according to a "center of structure" assigned during beam creation.

12.

Monaco supports plans with multiple isocenters. You can save templates with multiple isocenters. When you select a template that has multiple isocenters, you have the ability to reset all the beams to a common isocenter when you place a checkmark next to Use Common Isocenter. Monaco automatically resets all beams to the isocenter of beam number one.

13.

Select the treatment machine you want to use for this patient’s plan. You can change the machines and energies when you import the template.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates Start a Plan Using a Template (cont.) 14.

Select the Delivery Mode you plan to use. More detail on VMAT and Dynamic Conformal is discussed after the Delivery Mode Table below:

Table 2-1 Delivery Mode Table Gantry Motion while beam on

Gantry Speed

MLC Motion while beam on

Beam Intensity

Dose Rate

Step and Shoot

Static

Constant

Static

Modulated

Constant

Conformal RT (non-IMRT)

Static

Constant

Static

Uniform

Constant

dMLC

Static

Constant

Dynamic

Modulated

VMAT

Dynamic

Variable

Dynamic

Modulated

Dynamic Conformal Arc

Dynamic

Variable

Dynamic

Uniform

Variable Constant or Variable Constant or Variable

mArc

Dynamic

Variable

Static

Modulated

Variable

Delivery Method

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates Start a Plan Using a Template (cont.) VMAT VMAT is a novel form of rotational IMRT where the MLC and gantry move during radiating arc segments. The system uses variable gantry speed and variable dose rates to achieve variable MU per degree. Compared with IMRT, the potential advantages of VMAT include improved dose conformity, improved normal tissue sparing and a reduction in treatment time. Planning with single arcs and multiple arcs are supported and multiple arcs are optimized simultaneously. The Monaco VMAT sequencer is a sweep sequencer for fluence profiles, similar to sliding window sequencers. The basic paradigm of the sweep sequencer is that the leaves move from their start to their end position in a continuous, unidirectional manner. By moving the leaves across the field from one side to the other, and varying the leaf speeds, and thereby the gaps between opposing leaves, the system modulates the intensity of the delivered fluence. Changing the leaf gap is accomplished by either accelerating the leading leaf (more fluence), or the trailing leaf (less fluence). At least one leaf moves at maximum velocity at any given time to provide for the shortest possible delivery time. The Monte Carlo dose engine allows for continuous arc calculation instead of being limited to dose approximations with discrete gantry positions. Dynamic Conformal Arcs When delivering this type of rotational arc therapy, the gantry rotates during treatment. The MLC conforms to the target and avoids any avoidance structures, but the MLCs do not modulate the intensity.

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates (cont.) Creating a Customized Template To customize your work environment, you have to create your own templates. You can edit any existing template or start with the provided generic templates. The software comes with default templates: DEFAULT

Step and Shoot, single beam

DEFAULTSNS

Step and Shoot, 7 beams

DEFAULTCONFRT

Conformal RT, single beam

DEFAULTVMAT

VMAT, single 360 deg arc

VMATTraining

VMAT, single 360 deg arc

DEFAULTdMLC

dMLC, 7 beams

DEFAULTSTEREO

DCAT, 4 beams

ConeLtTrigem

3D Static Arc, 7 beams

DEFAULT3DArc

3D Static Arc, 2 beams

StereoCones

3D Static Arc, 5 beams

DEFAULT3D1beam

3D, 1 beam

DEFAULT3D4beam

3D, 4 beams

These templates have two “generic” structures in the prescription, PTV and SKIN. You must select the isocenter(s) and the machine to use with these templates. Whenever you create a new template, you can save it when you use File | Save Template As. NOTE:

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Only users with Physics rights can overwrite an existing SIM or New Monaco Plan template. All other users can save the template with a new name.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Using Templates (cont.) Deleting a Template You cannot delete templates from within the software. If you would like to delete a template and are not familiar with how to locate files when you use Windows Explorer, you should call customer support for assistance. If you would like to delete the templates yourself, they are located in the FocalData\MonacoTemplates folder. (The location of the FocalData folder varies from site to site. Contact your administrator if you do not know the location of this folder).

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Tools To start a new plan, right-click on a studyset in the Patient Workspace and select New Monaco Plan. From here, you are able to select plan templates. After you select a template, you can begin planning. To add, copy, or delete beams or VMAT sequences, you can select the Tools or the Beam Control option from the Beam Control in the Planning Activity.

Planning Ribbon – Beam Tools

Create, Duplicate, or Oppose Active Beam Close Plan

Delete Plan

Delete Active Beam

Edit Active Beam Create new Monaco or Sim Plan

Import Template into Existing Plan

Figure 2-3: Planning Ribbon – Beam Tools When you use the tools in (Figure 2-3), you can do these tasks:

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•

Start a New Plan – This option lets you create a new Sim or Monaco plan.

•

Close Plan – This option closes the currently loaded plan.

•

Delete Plan – This option deletes the currently loaded plan.

•

Delete QA Plan – This option deletes the currently loaded Monaco QA plan.

•

Add a New Beam – This option creates a new beam.

•

Copy Beam – This option makes a copy of the active beam.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Tools Planning Ribbon – Beam Tools (cont.)

Monaco®

•

Copy Beam Opposing – This option makes a mirror image copy of the active beam.

•

Delete Beam – This option deletes the active beam.

•

Edit Beam – This option lets you move the beam with your mouse.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control The four beam control tabs are: •

General

•

Geometry

•

Treatment Aids

•

Setup Beams

You can add, edit, or delete beam\sequences as well as modify beam properties and add setup beams. When you load a template, the beams from the template populate in this dialog box. You can edit the loaded beams in the Beam Control. If you want to switch the plan from a beam plan to a sequence plan, the system groups all the like beams in the Beam Control dialog box. You must re-enter them. This beam control is available in the Planning activity. NOTE:

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The beam control updates in real time. Any change you make is reflected immediately. We recommend that you save your plan before you make any updates to avoid loss of data.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control | General Tab In the Beam Control | General tab, you can add, edit, and delete beams. You can also edit the beam properties below in the General Tab: • • • • • • •

Beam Description Field ID Delivery Machine ID Isocenter Location X, Y, Z coordinates

Figure 2-4: Beam Control

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control | General Tab (cont.) Add/Edit/Delete Beams in Beam Control 1.

Click Workspace | Controls | Beams.

2.

To add a new beam or sequence, left click the Add New Beam

button.

OR Left-click on the words . 3.

Type a unique Description for each beam.

4.

Type a unique Field ID (up to five characters) that is accepted in MOSAIQ for each beam.

5.

Select a Machine, if applicable.

6.

Select the Isocenter Location for the each beam. Monaco shows the Isocenter Coordinates each beam.

Copy a Beam/Sequence

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1.

Left-click to highlight the beam/sequence you want to copy.

2.

Click the Duplicate Beam beam/sequence.

button to show the copied

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control for IMRT Plans – General Tab Delete a Beam/Sequence 1.

Left-click to highlight the beam/sequence you want to delete.

2.

Click the Delete Beam

button to delete the selected beam/sequence.

Renumber Beams/Sequences 1.

Left-click to highlight the beam/sequence you want to renumber.

2.

Type the new number in the Beam column for the current beam. NOTE:

If you type a beam number that is used in the plan or another prescription, the 2 beam numbers switch.

Reorder Beams/Sequences 1.

Left-click to highlight the beam/sequence you want to move.

2.

Click the Move Beam Up OR the Move Beam Down reorder the beams on the list.

button to

Number Beams/Sequences Consecutively You can reorder the beams/sequences in the list when you add or remove a beam/sequence.

Monaco®

1.

Add/remove a beam/sequence in the beam control list.

2.

Left-click on the Beam heading. Monaco renumbers the beams in the list and shows them in ascending order. The beams/sequences’ orders in the Setup Beams tab are also updated. The setup beam number defaults to the next consecutive number after the treatment beams.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control|General Tab (cont.) Link Machine ID and/or Isocenter Location You can plan with multiple isocenters and machines. You can save templates with multiple isocenters and machines. You have the ability to reset all the beams to a common isocenter. Restore the link above the Isocenter Location column on the Beam Control dialog box, then select the desired isocenter location for one of the beams in the Isocenter Location column. The remaining beams’ isocenter locations update to match the isocenter location you selected. You can assign different isocenter locations to each beam or a group of beams. in the Isocenter Location column to modify the desired beam Break the link isocenter locations. You can restore the link when you have set the desired location for each beam in the list. The beams with a common isocenter link (Figure 2-5) updates when you change the isocenter location of any beam in that group.

Figure 2-5: Beam Control - Common Isocenter When you check the Group Only Visible Beams box, Monaco links all the beams that have the Visible field checked.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |General Tab Link Machine ID and/or Isocenter Location (cont.) You can reset the beams to a common machine. Restore the link above the Machine ID column on the Beam Control dialog box, then select the desired machine ID for one of the beams in the Machine ID column. The remaining beams’ machines update to match the machine ID you selected. You can assign in different machine IDs to each beam or a group of beams. Break the link the Machine ID column to modify the desired beam machine ID. You can restore the link when you set the desired machine for each beam in the list (Figure 2-6).

Figure: 2-6: Machine ID Link

Monaco®

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Geometry Tab In the Beam Control for IMRT Plans-Geometry tab, you can edit the Beam, Description, Couch, Collimator, Gantry, Arc and/or Increment values as needed. Arc and Increment only apply to VMAT sequences.

Figure 2-7: Beam Control |Geometry NOTE:

See Arc Planning Terminology for more information about the definition of terms and further information about sequence setup.

You can also set the Field (field size) to: •

[Auto]: The optimizer determines the field size.

•

Fixed: You can type in the beam/sequence field size.

•

Structure: Ex: Bladder: You can auto-conform with a margin to the structure you select in the Field drop-down menu.

NOTE:

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The Asym column is only available when you select Fixed or Structure. Uncheck the box to make the field jaws symmetric. The defined field size is sent to the optimizer to define the maximum extents.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control|Geometry Tab (cont.) Split Beams When a machine’s carriage restrictions are violated, the beams (parent beams) could split after segmentation (Figure 2-8). These split beams (child beams) are listed on the beam control below the parent beam. The beam names are DICOM exported as B1S1, B1S2, etc.

Figure 2-8: Split Beams Left-click on the Delete Parent Beams button (Figure 2-9) to remove the parent beams. When you delete the parent beams, the optimizer resets and any changes made to the plan restarts the plan from the beginning. NOTE:

Monaco®

A child beam’s field size is automatically set to Fixed. If you recalculate the plan, the field size does not change.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control|Geometry Tab Split Beams (cont.)

Figure 2-9: Delete Parent Beams

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Geometry Tab (cont.) Fixed Jaws You can set fixed jaw settings for beams to avoid a machine’s carriage restrictions. When you select [Fixed], you can define the jaws’ width. 1.

Left-click in the Field column and select [Fixed] in the drop-down menu. If you want to select [Fixed] for individual beams, remember to break the link on the Field column. NOTE:

Since the beam control updates in real time, you can view the jaw settings as you make changes in any of the T/S/C or BEV views.

2.

You can edit the beams’ jaw width and length and uncheck the Asym box if desired. The system maintains the current isocenter and moves the field borders to the symmetric field size shown in the Geometry tab on the beam control.

3.

Click Close when you are done.

Figure 2-10: Fixed Jaws

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control|Geometry Tab Fixed Jaws (cont.) Monaco assigns a dose reference point (DRP) to all Fixed Jaws and Split Fields. The dose reference point (DRP) for each beam/arc is DICOM exported along with these:

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•

SSD to DRP

•

Physical Depth

•

Radiological Depth

•

Beam Dose

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Treatment Aids Tab Planning Control – Treatment Aids You can add, delete, or edit beams and treatment aids from the Treatment Aids button in the Beams tab when you select: Planning | Beams | Treatment Aids (Figure 2-11). You can also see if the beam includes a Port or MLC. The headings are non-editable on the treatment aids sheet. The editable treatment aids available on this tab include: •

Beam Number

•

Description

•

Wedge

•

Applicator ID (Stereo and Electron Cones)

•

Bolus

•

Couch

Figure 2-11: Treatment Aids section of Beams tab

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Treatment Aids Tab Planning Control – Treatment Aids (cont.) Wedges You can click on the drop-down arrow in the Wedge ID column to select a wedge for a beam. This field appears when a SIM plan, 3D and 3D Static Arc delivery modes are in use. When you select a wedge in this column, the Angle and Orient columns populate with the information associated with the wedge selected. The Angle column shows the angle of the wedge. When you change the angle for an Elekta Motorized Wedge, the dose automatically updates. Therefore, recalculation is not required. The Orient column shows a wedge’s directional image: in, out, left or right. You can also view the wedge parameters in Settings if you have physics rights.

Figure 2-12: Beams tab shows Wedge ID, Angle, and Orientation Port This field shows a check mark if the beam contains a Port. This field shows when a SIM plan is in use. This field shows when 3D and 3D Static Arc delivery modes are in use. MLC This field shows a check mark if the beam contains an MLC. This field shows when a SIM plan is in use. This field shows when 3D and 3D Static Arc delivery modes are in use.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Treatment Aids Tab Planning Control – Treatment Aids (cont.) Applicator ID Click on the drop-down arrow next to the beam to select an applicator ID in this column. This field shows the cones in the drop-down list if the machine is a photon or electron machine. This option is available for SIM plans and 3D and 3D Static Arc delivery modes. Stereotactic applicators are not available for SIM plans. The figure below shows an example of the applicator menu for Stereotactic Cones. Refer to the Stereotactic Planning section of the Training Guide for more information.

Figure 2-13: Example of the Stereotactic Cone Applicator ID menu Bolus You can select a bolus from the drop-down for a beam in this column. For 3D and QA plans, you can select a bolus per beam. For IMRT plans, you can select bolus for all or none of the beams. When you select a bolus, the SBD column populates with the skin-to-bolus distance for that beam.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Treatment Aids Tab Planning Control – Treatment Aids (cont.) Couch You can place a place a checkmark in this column to add the couch to a beam when you import a couchtop into the plan. Add Bolus to Beams You can assign bolus to beams in the General tab on the beam spreadsheet for dose calculation. For IMRT plans, you must add bolus to all of the beams or none. If you import the bolus with anything other than Electron Density, the Density field is blank for that structure. You must type in a value before the Start Optimization option becomes available.

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1.

Click the Beams tab in the Planning Control.

2.

Click the drop-down arrow in the Bolus column for any beam.

3.

Click the drop-down arrow to bolus in the Treatment Aids tab. This applies the bolus to all of the beams for IMRT plans. For 3D plans, you can add the bolus on per beam basis. The SBD (cm) column shows the Source to Bolus Distance when you select the bolus for the beams.

4.

(Optional): You can print the Beam Summary report to see the bolus information.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Beam Control |Setup Beams Tab In the Beam Control for IMRT plans, you can add setup static beams or arcs to your plan in the Setup Beams tab (Figure 2-14). You can add, edit, or delete the setup beam/sequences as well as modify the beam/sequence’s properties the same as the treatment beams. The setup beams\sequences are DICOM exported as SETUP.

Figure: 2-14: Beam Control for IMRT Plans-Setup Beams Tab

Edit Beam Options Using Mouse You can use the mouse to edit specific beam options. You can click on Edit Beam button on the Planning tab to make edits with the mouse. As you edit any of the areas in the list below, the beam information updates in Beam Control.

Monaco®



Rotate the gantry on the transverse view and sagittal view (if there is a couch kick)



Move isocenter position on SPVs and BEV



Set field size and rotate collimator on BEV



Set the start/end point for an arc

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Edit Beam Options Using Mouse (cont.) Print a Beam Control Report In Planning Activity, complete these steps. 1.

Click Beam Summary on the Output tab.

2.

Type an optional report comment.

3.

Click OK to show the Beam Summary Report.

4.

Click the Print button in the upper left corner of the dialog box.

5.

Close the Print dialog box.

In Plan Review Activity, complete these steps.

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1.

Click Beam Summary on the Planning Options tab.

2.

Click the Print button in the lower-right corner of the dialog box to show a Report Comment dialog box.

3.

Type an optional report comment.

4.

Click OK to show the Beam Summary Report.

5.

Click the Print button in the upper left corner of the dialog box.

6.

Close the Print dialog box.

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning

Figure 2-15: Beam Control for Arc Planning dialog box

Sequence A sequence is a single defined arc used for arc treatments. You can plan with full or partial arc sequences (Figures 2-16 and 2-17), or with multiple coplanar or non-coplanar sequences. (For detailed information about Beam Control, refer to Section 6: Planning and Workflow: Workflow Diagram, Contouring, Beam, and Delivery Setup.)

Direction You can select the arc rotation’s starting direction on the Dir column in the arc planning beam control. You can select CW or CCW. The default is CW.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning (cont.) Sequence (cont.)

Figure 2-16:Full Arc Sequence

Figure 2-17: Partial Arc Sequence

Gantry The Gantry setting on the Geometry tab in the Beam Control refers to the starting position for the sequence when planning arcs. When setting up the initial gantry angle for a sequence, remember that treatment delivery starts in the direction you defined in the Dir column.

Arc The Arc setting in Geometry in the Beam Control is the total arc rotation you desire for the sequence. For example, you can usually treat prostate plans with a 360 degree arc.

Collimator The typical Collimator setting in Geometry in the Beam Control for arc beams is zero (0). You can adjust this value to meet planning guidelines used in your clinic, and to improve quality of overall treatment plan and delivery.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning (cont.) Increment The Increment setting on the Geometry tab in the Beam Control dialog box controls the number of generated static gantry positions or sectors. Using an increment that is too large, creates fewer sectors which can produce poor quality plans and increase treatment time. Using an increment that is too small, gives you more sectors, but increases planning time and may not significantly improve plan quality. This is consistent with having too few or too many beams in a standard IMRT plan. One method to find a reasonable increment is the “Rule of 3”. This means you add three (3) to the number of static beams you would have used to treat this patient. For example, if you used nine (9) beams to plan a standard IMRT plan, consider creating 12 sectors (9+3) for VMAT. 360 deg arc/12sectors = increment of 30. Increment ↑ Plan Quality ↓ Treatment Time ↑

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning (cont.) Sector Prior to stage one optimization, the system divides a sequence into sectors you use to simulate the arc during stage one optimization. You determine the number of sectors when you divide the total arc degree by the increment. For example, a 360 deg arc with a 30 deg increment equals 12 “static” sectors to optimize. So, on the console, you would see 12 rays created before optimization (Figure 2-18).

Figure 2-18: Console showing ray (sector) creation Figure 2-19 shows a total arc of 360 degrees with a starting angle of 180 degrees and an increment of 30. The system creates sectors in 30 degree increments starting 15 degrees in front of each angle and ending 15 degrees after each angle. In this example, the first sector starts at 165 deg and ends at 195 deg. The treatment starts at 180, so treatment of the first sector is split. Fluence maps generated during stage-one are computed at the increment gantry angles. The fluence profiles extend from midline to midline of consecutive sectors.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning Sector (cont.)

Figure 2-19 Full 360 Deg Arc Figure 2-20 shows a partial 300 degree arc with a starting angle of 195 degrees and a 33.3 increment. So, 300 / 33.3=9 sectors. For partial arcs, the first and last sectors are only half the size as the rest of the sectors. So, 10 sectors appear below to represent this.

Figure 2-20: Partial 300 Deg Arc

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning Sector (cont.) The system generates fluence maps during stage-one and computes them at the increment gantry angles. We recommend that you plan with an even number of sectors to avoid asymmetry of the final dose distribution. Eight to fourteen (8-14) sectors for VMAT seem to be a reasonable range for good plan quality, depending on the defined arc angle.

Sweep Sequencer The basic paradigm of a sweeping leaf sequencer is that the leaves move from their start position to their end position in a continuous, unidirectional manner. When you vary the leaf gap, the system modulates the intensity of the delivered fluence. Beginning with the first sector, the leaves move to the left side of the BEV, then change direction, moving to the right side of the BEV. The leaf movement continues to alternate between sectors. Typically, both ends of the sweep have a small window of leaves open on one side or the other. The minimum width of these end segments is hard coded at 5mm.

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning (cont.) Control Point (VMAT only) The treatment machine uses control point as starting and ending points for movement of the MLCs. Certain Sequencing Parameters directly affect the number of control points generated for a plan. You can see the number of control points generated for a plan in the Console after stage-two optimization is complete. For reasonable treatment time and plan quality, you should look for a number of control points in the range of 75-150.

Arc Segment (VMAT only) The system creates the arc segments during stage two optimization. Arc size and number of monitor units vary from one arc segment to the next, but the dose rate remains constant within each arc segment. When you select Start on the Fluence Toolbar (Figure 2-21), the start angle of an arc segment is represented by a solid line and the end angle of the arc segment is represented by a dashed line (Figure 2-22). When you select End, the start angle is dashed and the end angle is solid.

Figure 2-21: Fluence Toolbar

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning Arc Segment (VMAT only) (cont.)

Figure 2-22: Arc Segment You can recognize arc segments on a BEV as having a uniform fluence (Figure 223). Uniform color varies from segment to segment based on the range of MU for the plan.

Figure: 2-23: BEV of Arc Segment

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Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Volume II of IV Monaco Training Guide

Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup Definition of Terms as They Apply to Arc Planning (cont.) Dynamic Segments with Static Gantry (VMAT only) Dynamic segments at static gantry angles (Figure 2-24) are occasionally generated for arc plans if the number of degrees per control point for an arc segment is less than two. This type of segment is represented by a single solid line on the transverse view and a non-uniform fluence in the BEV (Figure 2-25).

Figure 2-24: Dynamic Segment with Static Gantry

Figure 2-25: BEV of Dynamic Segment with Static Gantry

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Overview This practice exercise builds on the knowledge you gained when you complete the Fusion, Contouring, Beam, and Port Manipulation lessons. This exercise reinforces what you previously learned and shows you how to create 3D plans in Monaco. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. NOTE:

The patient used in this exercise is only available to you in the Training database. The default templates given are only available to get you started. However, you could follow these steps for almost any patient and complete a 3D plan.

When you complete this exercise, you should understand the concepts below and be able to complete the various tasks without additional supervision. • • • • • • • • • • • •

Monaco

Select a patient and open a studyset Contour structures Use Auto Margin to expand a structure Add an interest point in Monaco Set the 3D calculation matrix Create a new beam Add a treatment aid (port) Mirror a beam Edit a port Save a plan Normalize the dose display and review isodoses Review the plan

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise Task 1. Select Patient and Open Studyset This task includes the steps to select a patient and open a studyset. 1.

Open the Monaco software to automatically show the Patient Selection dialog box.

2.

Select the patient 4DLung using one of these methods: Double-click on the patient name. OR Click the name once.

3.

Click the OK button. The system loads the patient information into the Patient Workspace Control.

4.

Select the CT studyset CT1 using one of these methods: Double–click on the studyset name. OR Click the studyset name once, and then click the Load button. The patient appears in the Planning activity.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 2. Create Contours Contour the following structures. • • • • •

Patient (external) Right lung Left lung Spinal cord Tumor (GTV)

You may choose from any of the contouring methods outlined in the Contouring Tools section of this training guide. Refer to those procedures as needed.

Task 3. Use Auto Margin to Expand the Target Volume Use the Auto Margin tool if you would like to combine structures to create a new structure or create positive, negative, or variable margins on structures. Refer to the Contouring Tools section of this training guide for more information on creating 3D auto margins. button on the Contouring ribbon.

1.

Click the Auto Margins

2.

Type the structure name: PTV in the Structure field.

3.

View the Source Selection List By Study.

4.

Select Tumor (GTV) in the Structure Selection List.

5.

Click the Add button.

6.

Type the value 1.5 cm, to create a uniform Margin for Selected Structure.

7.

Click the Create button.

8.

Click Close to close the dialog box.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 4. Start a 3D Plan using Templates This task walks you through the steps to create a 3D plan from a template. 1.

Click the Planning ribbon tab.

2.

button and select Click on the drop-down arrow next to the New Plan New Monaco Plan. This opens the New Monaco Plan dialog box (Figure 3–1).

Figure 3-1: New Monaco Plan Window 3.

3-4

Type in a plan name and description.

3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 4. Start a 3D Plan using Templates (cont.) 4.

Select 3D Delivery.

5.

Select All for Anatomical Site.

6.

Select the Template: DEFAULT3D1beam (Rx Site, Rx Dose: 2.000 Gy, Total Beams: 1).

7.

The Treatment Orientation for scan CT1 is Head First.

8.

Select any Treatment Unit labeled Demo. (Note: The Treatment Units in the training data are associated to specific energies.)

9.

Select the Algorithm Collapsed Cone.

10.

Select an energy for the beam.

11.

Select Center of PTV for the Isocenter Location.

12.

Click OK to load the template and open the patient in Planning Control.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 5. Create Ports 1. Click the Create and Edit Ports Ports dialog box.

button. Monaco shows the Create/Edit

Figure 3-2: Create/Edit Ports dialog box 2. The Port Type for this exercise is MLC. 3. (Optional) Type the distance the MLC leaves intrude into the portal shape, in percentage of total beam width in the Leaf Insertion (%) field. 4. (Optional) Type a new value if you want to change the defaulted Closed Leaf Position.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise Task 5. Create Ports (cont.) 5. Left-click the Auto Conform structure drop arrow, select PTV. 6. Type 1 for the Margin (cm). 7. Click Snap Jaws to Port to conform the collimator to the port shape. 8. Click the Close button.

Task 6. Duplicate and Oppose Beam Use the Duplicate and Oppose Beam option to copy a beam parallel opposed to the original (active) beam. If you have a port on your beam, it will also mirror the port. drop-down menu.

1. Click the New Beam

2. Create a posterior beam Select the Duplicate and Oppose button.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 7. Edit Beam Information If you need to edit your beam information, you can accomplish this in two ways. button, or you You can edit individual beams when you click the Edit Beam can edit one or multiple beams when you click the Beams tab on the Planning Control. You can find additional information about beam manipulation in the Planning Tools section of the training guide. 1.

Open the Beams tab in the Planning Control.

2.

Edit the Description field.

3.

Edit the Field ID.

4.

Edit Beam Geometry.

Task 8. Add Right Posterior Oblique Beam 1.

Add Right Posterior Oblique field, use the option. OR Select the New Beam button

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.

2.

Edit Beam Information. Complete the steps in Task 7.

3.

Create and Edit Port for the Right Posterior Oblique beam. Complete the Task 5 steps.

3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 9. (Optional) Edit a Port The port editing tools enable you to reshape the MLCs of a port or to replace the port. Complete these instructions if you want to manually make edits to your port. 1.

Verify the active port before editing.

2.

Click the Create and Edit Ports

3.

Click the Replace editing tool radio button on the Create and Edit Ports dialog box.

4.

Left-click on the area of the port you want to edit. Hold and drag your mouse to draw the new portal segment. The mouse cursor for editing a port is a

button.

.

5.

Click and drag the yellow edit box around the port to resize the port shape.

6.

Click the Reshape editing tool radio button on the Create and Edit Ports dialog box.

7.

The selected MLC for editing appears in red. The mouse cursor for editing a port is

Monaco

. Click and drag a MLC leaf to the new location.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 10. Add a Wedge 1.

Open the Beams tab in the Planning Control.

2.

Click the Treatment Aids tab (Figure 3-3).

Figure 3-3: Treatment Aids Tab

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3.

Click to activate the beam to which you want to add a wedge.

4.

Click the Wedge ID drop-down menu.

5.

Select the Wedge/Angle to use in your plan.

3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 11. Add an Interest Point In the Tools ribbon, you can place interest points or markers. This task explains how to create interest points in Monaco. For more information on how to place interest points or markers, refer to the Planning Tools section in this training guide. 1.

button on the toolbar. Monaco Click the Interest Points/Markers shows the Interest Points& Markers dialog box (Figure 3-4).

Figure 3-4: Interest Points & Markers dialog box 2.

To place an Interest Point, left-click anywhere on a transverse, sagittal or coronal image to place the point.

3.

Type a Description for the point or marker next to its coordinates.

4.

To move the point on a transverse, sagittal, or coronal image, place the mouse pointer over the point or marker. (The mouse pointer visually .) Hold down your left mouse button and drag changes to look like this the point or marker to a new location. OR Type new coordinates for the point or marker in the dialog box.

5.

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Click Done when complete.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 12. Enter the Prescription This task is only required when you need to edit the prescription from a template. This task should be less frequently used once you create and save your own clinical templates. 1.

Select the Prescription tab on the Planning Control.

2.

Type Lung for RX Site.

3.

Select Plan Isocenter in the Prescribe to Column.

4.

Type 66 in the Rx Dose (Gy) column.

5.

Type 33 in the Number of Fractions column. The Fractional Dose(Gy) column updates with 2.0 as the value.

Figure 3-5: Prescription Control

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 13. Dose Calculation Properties Grid spacing determines the numbers of points calculated in the region. Grid spacing ranges from 0.10 cm to 0.80 cm in units of 0.01 cm. To change the Grid Spacing, complete these steps. 1. Click the Calculation Properties Calculation Properties dialog box opens.

button. The

Figure 3-6: Calculation Properties dialog box 2. Type the voxel size you want to use for Grid Spacing.

Monaco

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 14. Calculate Dose

1. Select the Calculate

button, on the planning ribbon.

Task 15. Evaluate Isodoses and DVH 1. Open the Isodoses Control (Figure 3-7).

Figure 3-7: Isodoses Control dialog box 2. Adjust the Isodose display for your plan. 3. Review the isodoses on T/S/C and 3D views. 4. Right-click on the DVH window and select Statistics from the menu. 5. To review your plan, use the DVH and DVH Statistics.

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 16. Edit Beam Weights 1. Select the Prescription tab on the Planning Control. 2. Use the slider bar adjust the beam weight in percentage.

or numerical entry box to

Task 17. (Optional) Rescale Dose If your plan already has calculated dose, you can adjust the dose from within the Planning activity. Rescaling the dose is not normalization, but a change to the dose itself. 1.

Select the Prescription tab on the Planning Control.

2.

Use the Rescale Dose dialog box drop-down menu to rescale the dose.

Figure 3-8: Rescale Dose dialog box drop-down menu

Task 18. Save the Plan 1. Click the Save

button

OR Type (Ctrl + S) on your keyboard

Monaco

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3D Lung Case Volume II of IV Monaco Training Guide

3D Lung Case Practice Exercise (cont.) Task 19. Save a Template You can do this task at any time in the planning process. However, it is highly beneficial for you to create a prescription before you save a template. You can reuse the saved template for future plans. As you use Monaco, you need to create new beams and prescriptions less often, as this information will upload from your saved customized plan templates.

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1.

and select the Save Template As Click the Monaco Application Menu option to show the Save Template As dialog box.

2.

Type the template name and description TrainProLung.

3.

(Optional) Select an Anatomical Site from the drop-down.

4.

Click Save to save the template.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning You can use two tangential open fields with subfields to create a Field in Field radiation therapy plan. The MLC subfields are constructed based on BEV projections, conforming MLCs to isodose surfaces. This exercise shows you how to apply the Field in Field planning technique for breast with Monaco. This exercise contains all necessary steps to create two tangential beams with multiple subfields. It is assumed that you are already familiar with breast planning. This exercise and the information provided is subject to the disclaimer included on in the Overview section of Volume 1, Section 1. Once you complete this exercise, you should understand these concepts and be able to execute the various tasks without additional supervision.

Monaco

•

Select a patient and open a studyset

•

Contour Structures

•

Manage Structure Display

•

Manage Templates

•

Edit beam Isocenter

•

Create a new beam

•

Create and edit photon ports

•

Create Interest Points

•

Manage Prescription Properties

•

Display and Evaluate isodoses

•

Create Subfields

•

Edit Beam Weighting

•

Manage MU/Fluence Display

•

Save a plan

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 1. Open the Patient button.

1.

Click the Monaco Applications menu

2.

Select Open Patient

3.

Select the patient BreastTRN. Use one of these methods:

.

Double-click on the patient name. OR Click the name once and click OK. 4.

The system loads the patient information into the Patient Workspace Control.

5.

Select the CT studyset CT1. Use one of these methods: Double – click on the studyset name. OR Click the studyset name once, and then click the Load button. The patient data appears in the Planning activity.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 2. Create Contours Contour the following structures: •

Patient (external)

•

Right lung

•

Left lung

•

Spinal cord

• •

Heart Lumpectomy_PTV

You may choose from any of the contouring methods outlined in the Contouring Tools section of this training guide. Refer to those procedures as needed.

Task 3. Use Auto Margin to Expand the Target Volume Use the Auto Margin tool if you would like to combine structures to create a new structure or create positive, negative, or variable margins on structures. Refer to the Contouring Tools section of this training guide for more information on creating 3-D auto margins.

.

1.

On the Contouring ribbon click Auto Margins

2.

Type the structure name: Lumpectomy_PTV in the Structure field.

3.

View the Source Selection List By Study.

4.

Select OP Bed in the Structure Selection List.

5.

Click the Add button.

6.

Make sure Uniform Margin is checked.

7.

Type the value 1.0 cm next to Superior.

8.

Click the Create button.

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 4. New Plan from Template 1.

Click the drop-down arrow next to the New Plan

2.

Select New Monaco Plan in the drop-down list. •

This opens the New Monaco Plan dialog box (Figure 4–1).

Figure 4-1: New Monaco Plan dialog box

4-4

.

3.

Type a plan name and description: FIFLtBreast.

4.

Select 3D Delivery.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 4. New Plan from Template (cont.) 5.

Select All for Anatomical Site.

6.

Select the Template: DEFAULT3D1beam (Rx Site , Rx Dose: 2.000 Gy, Total Beams: 1).

7.

The Treatment Orientation for this plan is Head First. The Scan Orientation is indicated as Head First Supine.

8.

Select the Treatment Unit labeled Demo Synergy – 6MV. NOTE:

The Treatment Units in the training data are associated to specific energies.

9.

Select the Algorithm Collapsed Cone.

10.

Select 6.0 MV for the beam energy.

11.

Select any option in the Isocenter Location column. This exercise guides you to change the location of the isocenter in Task 5.

12.

Click OK to load the template and open the patient in Planning Control. The Patient orientation icon shows the head pointing toward the top of the screen.

Figure 4-2: Head First Patient Orientation Icon

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 5. Edit Beam Isocenter 1.

Click the Planning Ribbon tab.

2.

Click Edit Beam.

3.

Position the mouse cursor over the central crossmark on the isocentric plan. The mouse pointer looks like this:

(Figure 4-3).

Figure 4-3: Mouse Cursor to Move Isocenter

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 5. Edit Beam Isocenter (cont.) 4.

Click and drag the crossmark to a new isocenter location close to the chest wall. (Figure 4-4)

Figure 4-4: Isocenter Location NOTE:

Monaco

You can also change the isocenter when you type the X, Y, and Z coordinates for the new isocenter location on the beam tab in the Planning Control. Select Beams on the Planning Control Bar | General.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 6. Edit Gantry Angle 1.

Your Edit Beam

button should still be selected.

2.

Position the mouse cursor over the active beam’s central ray. The mouse pointer (Figure 4-5). looks like this:

3.

Left-click and move the mouse in a circular motion until you achieve your desired medial tangent gantry angle.

Figure 4-5: Mouse Cursor to Rotate Gantry NOTE:

4-8

You can also change the Gantry, Collimator, and Couch angles by navigating to the Planning Control. Select Beams on the Planning Control Bar| Geometry.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 7. Manage Structure Display 1.

Open the Structure Visibility Control. In the default location, the control appears on the right side of your screen.

2.

(Optional) If you cannot find the Structures Control, reset your controls.

3.

Click the Column Header: Structure to turn all structures off. When all structures are off, the Structure Visibility window is gray.

4.

Click Breast_PTV_EVAL to show your target volume. NOTE:

Monaco

You can also manage structure’s visibility on the Structures tab on the Planning Control Bar. Select and unselect the Visible box.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Forward Planning (cont.) Task 8. Edit Field Size 1.

Left-click in the Beam’s Eye View (BEV) to activate window.

2.

Right-click and select Maximize.

3.

Toggle the MLC display off. Right-click in the BEV, unselect Show MLC. Your Edit Beam button should still be selected.

4.

Position your mouse pointer over the collimator jaw position lines so that the mouse pointer looks like this:

5.

(Figure 4-6).

Increase the field length so that the field covers the whole target. Move the mouse while you hold down the left-mouse button to adjust the collimator jaw position line to the desired position.

Figure 4-6: Mouse Cursor to Edit Field Size NOTE:

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You can also change the Field Size in the Planning Control when you select Beams on the Planning Control Bar | Geometry.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 9. Create and Edit Port 1.

Turn on your MLC display. Right-click in the BEV window and select Show when the MLC. Monaco places a checkmark in the menu MLCs appear.

2.

Select the Create and Edit Ports

3.

In the Create/Edit Ports dialog box, select MLC as the Port.

4.

Use the mouse cursor

5.

(Optional) Edit individual MLC leafs. When you hover your mouse over the MLCs, the selected MLC for editing appears in red. The mouse cursor for editing a MLC is a

6.

Monaco

button.

to draw a Medial Tangent port.

. Click and drag a MLC leaf to the new location.

Close the Create and Edit Ports dialog box when the previous step is complete.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 10. Duplicate and Oppose Beam to Create Lateral Tangent 1.

Click the New Beam

2.

Select Duplicate and Oppose.

drop-down. .

Task 11. Edit Beam Descriptions in the Beam Control 1.

Open the Beams tab on the Planning Control. NOTE:

2.

You can Reset the location of the Planning Control by selecting Workspace | Reset Controls. If the Beams tab is not visible select Workspace| Controls | Beams. The Beams tab should then become visible on the Planning Control Bar.

On the General tab of the Beam Control, edit the Beam Descriptions and Field IDs (Figure 4-7).

Figure 4-7: Beam Description and Field ID

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 12. Line up Superior Edge of the Fields There are different techniques on how to line up the Superior field edge to get rid of divergence. This is just one way to demonstrate this. 1.

While looking at the 3D View change the Couch angle on the Beams tab| Geometry to line up the superior edge of the field. The couch angle moves the superior edge of the field superior to inferior.

2.

While looking at the 3D View change the collimator angle on the Beams tab| Geometry. The collimator angle tilts the beam edge left to right. NOTE:

You may line up the superior edge if you are going to treat a half beam block supra clavicular field.

Figure 4-8: Zero Couch Rotation (left) and Zero Collimator Rotation (right)

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 12. Line up Superior Edge of the Fields (cont.)

Figure 4-9: Couch and Collimator rotation to get rid of superior edge divergence

Figure 4-10: Beam Data for Couch and Collimator Rotation

Task 13. Re-evaluate the Ports

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1.

Since the Couch and Collimator have moved you want to re-evaluate your ports to make sure they are covering everything.

2.

If changes need to be made select Create and Edit Ports and make the edits.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 14. Add an Interest Point In the Tools ribbon, you can place interest points or markers. This task explains how to create interest points in Monaco. For more information on how to place interest points or markers, refer to the Planning Tools section in this training guide. 1.

button on the Tools tab. Monaco shows Click the Interest Points/Markers the Interest Points& Markers dialog box (Figure 4-11).

Figure 4-11: Interest Points & Markers dialog box 2.

To place an Interest Point, select New Interest Point •

.

An interest point appears on the studyset (Figure 4-12)

Figure 4-12: Interest Point

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 14. Add an Interest Point (cont.) 3.

Type a Description for the Interest Point next to its coordinates.

4.

Move the point on a transverse, sagittal, or coronal image. To do this, place the mouse pointer over the point or marker. (The mouse pointer visually changes to look like this new location.

.) Hold down your left mouse button and drag the point to a

OR Type new coordinates for the point or marker in the dialog box. 5.

Click Done when complete. NOTE:

Try to keep the interest point 2cm away from the field edge if you are using it as a weight point. This will keep it out of the penumbra region. You can use the Measure tool on the Tools tab if you need to measure the distance. (Figure 4-13)

Figure 4-13: Measure distance for Interest Point

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 15. Enter Prescription 1.

Click the Prescription tab on the Planning Control.

2.

Type LtBREAST as the Rx Site. Monaco asks if you want to add the LtBREAST site to the list of Rx Sites.

Figure: 4-14: Add to the List of Rx Sites dialog box 3.

Click Yes.

4.

Select the Prescribe To point. This could be the Interest Point you just created.

5.

Type an Rx Dose (Gy) of 48.6.

6.

Type 27 Number of Fractions. The Fractional Dose updates to 1.8 Gy.

7.

Equally Weight the Prescription dose between the Medial Tangent and Lateral Tangent, Fields 1 and 2 in the example below (Figure 4-15).

Figure 4-15: Beam Weights

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 16. Calculate Dose 1.

Click the Planning ribbon.

2.

Click Calculate

.

Task 17. Evaluate Dose 1.

Open Isodoses Control. The default location for this control is on the left side of your screen. (Figure 4-16)

Figure 4-16: Isodose Control 2.

(Optional) To Locate your Isodoses Control:

3.

Click Workspace | Reset Controls. OR Click Workspace | Controls| Isodoses.

4.

4-18

Adjust Isodose levels as needed.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 17. Evaluate Dose (cont.) 5.

Monaco

Review the 100% isodose line to make sure it adequately covers the breast and does not intrude into the lung. If it does not adequately cover the breast, return to Task 2 and increase the field sizes and/or rotate the gantry until you are satisfied with the coverage. You may also need to scale your Prescription.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 18. Edit Beam Weighting and Plan Normalization 1.

Click the Prescription tab in the Planning Control.

2.

(Optional) Adjust the beam weighting for the Tangent fields 1and 2 to achieve best isodose display.

3.

Rescale the Dose: 48.6Gy to Cover 97% of Breast_PTV_EVAL (Figure 4-17).

Figure 4-17: Rescale Dose

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 19. Display 3D Isodose for Field in Field Planning 1.

Open the Isodoses Control (see task 17).

2.

Pin the Isodose Control. To do this, click the thumb tack

3.

In the first Isodose value box, type the first overdose value you want to remove.

4.

Click the 3D drop- down arrow for the first isodose value box.

5.

Select an option. (Figure 4-18)

button.

Figure 4-18: Isodoses Control 3D Column

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning Task 20. Manage MU/Fluence Display 1.

Right-click in the BEV. Select Maximize from the submenu.

2.

Right-click in the BEV. Select Show MU / Fluence from the submenu. You should now only see the 3D dose display and MLCs on the BEV (Figure 419). •

As you add new sub fields the system freezes the dose from the previous calculation so the isodose is still visible when you add create the fields.

Figure 4-19: BEV 3D Dose Display The above window shows the 118% hotspot in the BEV of your medial tangent. You use this to create the first subfield.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 21. Create First Medial Sub-Field 1.

Open and pin the Beams tab on the Planning Control Bar. (Figure 4-20)

Figure 4-20: Beams tab on the Planning Control Bar 2.

Select the medial tangent field (LtMed Tang).

3.

On the Planning ribbon, select Duplicate Beam from the New Beam drop-down. (Figure 4-21)

Figure 4-21: Duplicate Beam 4.

Rename the Field ID (1B).

5.

Click Calculate so dose becomes visible.

6.

On the Planning ribbon click Create and Edit Ports

Monaco

.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 21. Create First Medial Sub-Field (cont.) 7.

Edit the MLC’s to block the overdose region displayed as a 3D isodose. You may allow flash around the parts of the breast where you are not doing any modulation. (Figure 4-22)

8.

Click Close on the Create/Edit Ports dialog box when previous step is complete.

Figure 4-22: BEV Blocking Hotspot

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 22. Calculate Dose and Adjust Beam Weighting for First Medial Subfield 1.

On the Planning ribbon, click Calculate

.

2.

On the Prescription tab you can adjust the weight of the new sub field. First, Lock the weight of the Lt Lat Tang Field, to prevent loss of dose from this field. (Figure 4-23) Next, adjust the weight for the new sub-field using the slider bar or by typing in the weight value, until the overdose 3D isodose disappears. (Figure 4-23 and Figure 4-24)

Figure 4-23: Locking and Beam Weighting

Figure 4-24: Beam Weight First Medial Sub Field

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 23. Create First Lateral Subfield 1.

Edit the 3D isodose display to a value approximately 2-5% less than its current value. (Figure 4-25)

Figure 4-25: 2-5% less hot spot Isodose 2.

Open Beams tab on the Planning Control Bar.

3.

Select the lateral tangent field (Lt Lat Tang).

4.

On the Planning ribbon, select Duplicate Beam from the New Beam drop-down. (Figure 4-26)

Figure 4-26: Duplicate Beam

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning Task 23. Create First Lateral Subfield (cont.) 5.

Rename the Field ID (2B).

6.

Click Calculate so dose becomes visible. (Figure 4-27)

Figure 4-27: Isodose seen on BEV 7.

Monaco

On the Planning ribbon, click Create and Edit Ports

.

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning Task 23. Create First Lateral Subfield (cont.) 8.

Edit the MLC’s to block the overdose region displayed as a 3D isodose. You may allow flash around the parts of the breast where you are not doing any modulation. (Figure 4-28)

Figure 4-28: Subfield covers Hot Spot Isodose 9.

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Click Close on the Create and Edit Ports dialog box when previous step is complete.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning Task 24. Calculate Dose and Adjust Beam Weighting for First Lateral Subfield 1.

On the Planning ribbon, click Calculate

.

2.

On the Prescription tab you can adjust the weight of the new sub field. First Lock the weight of the Lt Med Tang Field and LT med Tang sub field, to prevent loss of dose from these fields. (Figure 4-29) Next, adjust the weight for the new sub-field using the slider bar or by typing in the weight value, until the overdose 3D isodose disappears. (Figure 4-29 and 430)

Figure 4-29: Beam Weight First Lateral Sub Field

Figure 4-30: BEV

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Field in Field Planning (cont.) Task 25. 1.

Calculate Dose and Adjust Beam Weighting for Remaining Subfields

Alternating between the Medial and Lateral Tangent fields, repeat the same procedure as previously described above to eliminate other hotspots until you reach your desired isodose distribution. Be aware of the location of your calculation point that it is not being covered by the block, otherwise you are not able to calculate.

Task 26. Add Setup Beams 1.

Open the Beams tab on the Planning Control.

2.

Click the Setup Beams tab.

3.

Click .

4.

Edit the beam Description, ID, and Geometry an Anterior Posterior (AP) setup field.

5.

Click .

6.

Edit the beam Description, ID, and Geometry to create a Left Lateral setup field.

Task 27. Save Plan 1.

Select the Save tool in the Quick Access toolbar OR

2.

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Select the Monaco Application button and select Save.

3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Create a Supraclavicular (SCV) Plan Task 1. Add another Beam 1. Select Beams | General | Add Beams tool. OR 2. Select Planning ribbon | New Beam tool.

Task 2. Save Plan As 1. From the Monaco Application drop-down, select Save Plan As. a. Do this so you do not change the FIF plan but you can use the beams as guidance for lining up the SCV field. 2. Type in a Plan Name. a. Example-SCVplan 3. Type in a Plan Description. a. Example- SCVplan 4. Click Save.

Task 3. Setup the Beam 1. Go to the Planning Control bar| Beams | General. a. Type in the Beam Description (example-SCV). b. Deliver is 3D. c. Select the Treatment Machine. d. Modality-Photon e. Algorithm-Collapsed Cone f.

Evergy-6.0 MV

g. Setup-SAD

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Create a Supraclavicular (SCV) Plan (cont.) Task 3. Setup the Beam (cont.) 2. Go to the Planning Control bar| Beams | Geometry. a. Adjust the SCV field gantry rotation so it is off the cord. i. Example-345 degrees. b. Adjust the Collimator rotation to be 0. c. Adjust the Couch rotation to be 0. d. Adjust the Length 2 border (LL) to be 0.

Task 4. Find Isocenter Location 1. First, Unlink the Isocenter Location. 2. Take the Length 1 (UL) length of 1 of the tangent fields (Figure 4-31) and add this to the Y coordinate of the tangent field to get the Y coordinate of the SCV field.

Figure 4-31: Upper Length Tangent Field

Figure 4-32: Y Coordinate of Tangent Field a. Example- 10.20 + 10.20 = 20.40

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Create a Supraclavicular (SCV) Plan (cont.) Task 4. Find Isocenter Location (cont.) 3. Your beams should look similar to Figure 4-33 in 3D view.

Figure 4-33: 3D View

Task 5. Edit the Port 1. Select Create and Edit Ports. 2. The Create and Edit Ports dialog box opens. 3. Draw the SCV field in BEV according to your physician’s specifications. a. Example Figure 4-34.

Figure 4-34: SCV BEV

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Create a Supraclavicular (SCV) Plan (cont.) Task 5. Edit the Port (cont.) 4. Click Close. a. Double check the port to make sure there is no overlap with the tangent fields.

Task 6. Create a Calculation Point 1. Go to the Tools ribbon | Interest Points and Markers. 2. The Interest Points and Markers window opens. 3. Select New interest Point. 4. Type in a Description (example-SCV calc pt). 5. Move the SCV calc pt to the center of the field and to the appropriate depth for your clinic. (Figure 4-35) a. Use the Jump to Point to easily locate the interest point to move it.

Figure 4-35: Calculation Point for the SCV

Task 7. Create a Prescription 1. Go to the Planning Control Bar| Prescription tab. 2. Select the Prescribe to Point. a. Example: SCV calc pt

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Create a Supraclavicular (SCV) Plan (cont.) Task 7. Create a Prescription (cont.) 3. Type in the RX Dose. a. Example: 5040cGy 4. Type in the Number of Fractions. a. Example: 28 fractions

Task 8. Delete Tangent Beams 1. Go to the Beams tab on the Planning Control bar. 2. Select the Lt Med Tang field. 3. Select the Delete Beam option. 4. Select the Lt Lat Tang. 5. Select the Delete Beam option.

Task 9. Calculate Dose 1. Click the Planning ribbon. 2. Click the Calculate

button.

Task 10. Evaluate Doses 1. Open the Isodoses Control. 2. Review the isodose display and adjust Isodose levels as necessary.

Monaco

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3D Breast Case Volume II of IV Monaco Training Guide

3D Breast Case Plan Summation Task 1. Sum Plans 1. Monaco lets you combine plans regardless of dose calculation matrix variations. Monaco creates a new, independent dose matrix for plan summation. 2. In the workspace control, left click to highlight the FIFBreast plan you created. 3. Hold down the Control key and left mouse click on the ElectronBoost plan you created. 4. Right-click and select Sum Plans from the menu. 5. The sum plan should now appear in Plan Review and the Workspace.

Figure 4-36: Locking and Beam Weighting

Task 2. Plan Summation Review 1. Use the Multiplan Navigation control and the slice mode indicator to reveal the area of interest. 2. Adjust the color ranges in the isodose control. 3. Review the DVH, the summed plans adopt Absolute normalization mode. Percent normalization is not available for summation plans.

Task 3. Save the Plan Summation 1. Click the Save button. OR 2. Type (Ctrl + S) on your keyboard.

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise When you complete the first two interactive treatment plans in this series, you should be familiar with most of the procedures required to contour critical structures. Therefore, this plan will have the contours already drawn. This exercise gives you the opportunity to practice with the fusion tools, review the general process of planning a 3D prostate patient in Monaco, as well as create a bias dose plan. There are many ways to complete a plan in Monaco. This is just one suggested method of treatment planning. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1.This exercise includes these tasks: Task 1. Select Patient and Open CT and MRI Studysets Task 2. Fuse Studysets Task 3. Import Treatment Couch Task 4. Create Shift Origin Task 5. Start a 3D Plan Task 6. Add Beams Task 7. Create DRRs Task 8. Enter Prescription Task 9. Calculate plan Task 10. Save a Template Task 11. Evaluate Dose Task 12. Edit Beam Weights Task 13. Save Plan Task 14. Print the Plan Task 15. Export the Plan

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 1. Select Patient and Open Studysets This task walks you through the steps to select a patient and open a studyset. 1.

Open the Monaco software to automatically show the Open Patient Selection dialog box.

2.

Select the patient Fusion Prostate using one of these methods: Double-click on the patient name. OR Click the name once. Click the OK button. The system loads the patient information into the Patient Workspace Control.

3.

Select the CT studyset CT1. Use one of these methods: Double-click on the studyset name. OR Click the studyset name once, and then select the Load button at the bottom of the Workspace.

4.

Click the MRI studyset MR1 once, and then right-click to select the Load / Set As Secondary button. The patient appears in the Planning activity.

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 2. (Optional) Fuse Studysets This task lets you practice with the fusion tools available in Monaco. 1. Select the Image Fusion

Workspace.

2. Create a registration manually. Use the translate (move) tools to adjust the position of the secondary studyset.

and rotate

3. Click the Save button on the toolbar to save the registration.

Monaco

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 3. (Optional) Import Treatment Couch 1.

Select the Planning Workspace.

2.

Click the Plan Options tab.

3.

Click the Import Positioning Device

4.

Highlight a Sample Couch to import into your plan as an example.

5.

Click the OK button.

6.

Adjust the Treatment Couch Position, you can pan or move the couch position with your mouse or edit the shifts in the Treatment Couch Position dialog box (Figure 5-1).

button.

Figure 5-1: Treatment Couch Position dialog box 7.

5-4

Click Done on the Treatment Couch Position dialog box.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 4. Define the Scan Reference Point You can use the Scan and Setup Reference tool to replace the original patient origin with a new (0,0,0) location. Monaco calculates the offset shift between the setup reference point and the scan reference point. 1.

Click the Plan Options ribbon.

2.

Click the Scan and Setup Reference dialog box opens (Figure 5-2).

button. The Setup Reference

Figure 5-2: Setup Reference dialog box 3.

Monaco

Designate the Scan Reference point’s position with either of these methods.

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise Task 4. Define the Scan Reference Point (cont.) 4.

Type the X, Y, and Z values in the Setup Reference dialog box. OR Use the mouse to reposition the cross hairs in the transverse view.

5-6

5.

Select the Patient orientation when scanned: Head-in/Supine.

6.

Select the Setup Reference Point location, Center of GTV.

7.

Check the Lock Shift option in the Setup Reference dialog box. With the shift locked, no further interaction with the point is allowed unless you explicitly unlock it.

8.

Close the Setup Reference dialog box.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 5. Create a New Monaco Plan from Template This task walks you through the steps to select a template to import. 1.

Click the Planning tab.

2.

Click the drop-down arrow next to the New Plan button and select New Monaco Plan in the drop-down list. This opens the New Monaco Plan dialog box (Figure-2).

3.

Type in a Plan Name and Description.

4.

Select 3D for the Delivery.

5.

Select All for the Anatomical Site.

6.

Place a checkmark by the template named DEFAULT3D1beam (Rx Site , Rx Dose: 2.0Gy , Total Beams: 1).

7.

Select Head First for the Treatment Orientation.

8.

Select a treatment unit used in your clinic, labeled as Demo.

9.

Select the Collapsed Cone Algorithm.

10.

Select the Photon Energy to be used in the plan.

11.

Select the Isocenter Location: Center of GTV.

Monaco

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise Task 5. Create a New Monaco Plan from Template (cont.) 12.

Select OK to load the template and open the patient in Planning Control.

Figure 5-3: New Monaco Plan dialog box

Task 6. Edit DRR

5-8

1.

Right-click in the DRR window, select Maximize from the menu.

2.

Right-click in the DRR window, toggle Show MLC to turn the MLC display on the DRR on and off.

3.

Right-click in the DRR window, click Filters from the menu.

4.

Select Sim Film from the DRR filters menu.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 7. Create Anterior Port 1.

Select the Create and Edit Ports

2.

In the Create/Edit Ports dialog box, select MLC as the Port.

3.

Click to place a check mark in the Snap Jaws to Port box.

4.

Use the mouse cursor Superior: Inferior: Lateral:

button.

to draw a whole pelvis port.

SI Joint Ischial tuberosities 2 cm lateral to the pelvic rim

5.

Close the Create/Edit Ports dialog box.

6.

Right-click in the DRR window, toggle Show MLC to turn the MLC display on the DRR on and off.

Figure 5-4: AP DRR and Port

Monaco

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3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 8. Duplicate and Oppose Anterior Beam 1.

Click the New Beam

drop-down menu.

2.

Create a posterior beam Select the Duplicate and Oppose button.

Task 9. Edit Beams in Planning Activity This task is only required when you need to add beams to or modify beam arrangements from a template. This task should be less frequently used once you create and save your own clinical templates.

5-10

1.

In the Planning Control spreadsheet, click the Beams tab.

2.

Select the General tab to modify Treatment Unit, energy, Isocenter location.

3.

Select the Geometry tab to edit the Jaw parameters.

4.

Label the Field ID for the applicable beam(s). Refer to the Planning Tools section of this training guide for additional information.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 10. Add Right Lateral Beam 1.

In the Planning Control spreadsheet, click the Beams tab.

2.

Select the option. OR Select the New Beam

button.

3.

Click the Geometry tab in the Planning Control spreadsheet.

4.

Edit the Gantry angle to that of a Right Lateral.

5.

Edit additional beam information. Use the steps in task 9.

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3D Prostate Case Practice Exercise (cont.) Task 11. Create Right Lateral Port 1.

Select the Create and Edit Ports

2.

In the Create/Edit Ports dialog box, select MLC as the Port.

3.

Click to place a check mark in the Snap Jaws to Port box.

4.

Use the mouse cursor Superior: Inferior: Posterior: Anterior:

button.

to draw a whole pelvis port.

SI Joint Ischial tuberosities S3 Pubic symphysis

5.

Close the Create/Edit Ports dialog box.

6.

Right-click in the DRR window, toggle Show MLC to turn the MLC display on the DRR on and off.

Figure 5-5: Right Lateral DRR and Port

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3D Prostate Case Practice Exercise (cont.) Task 12. Duplicate and Oppose Right Lateral Beam 1.

Click the New Beam

drop-down menu.

2.

Create a posterior beam Select the Duplicate and Oppose button.

3.

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Edit beam information. Use the steps in task 9.

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3D Prostate Case Practice Exercise (cont.) Task 13. (Optional) Edit a Port The port editing tools enables you to reshape the MLCs of a port or to replace the port. Follow these instructions if you want to manually make edits to your port. Verify the active port before editing. Click the Create and Edit Ports

2.

Click the Replace editing tool radio button on the Create and Edit Ports dialog box.

3.

Left-click on the area of the port you want to edit. Hold and drag your mouse to draw the new portal segment. The mouse cursor for editing a port is a

.

4.

Click and drag the yellow edit box around the port to resize the port shape.

5.

Click the Reshape editing tool radio button on the Create and Edit Ports dialog box.

6.

The selected MLC for editing is shown in red. The mouse cursor you use to edit a port is

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button.

1.

. Click and drag a MLC leaf to the new location.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 14. Enter the Prescription This task is only required when you need to edit the prescription from a template. This task should be less frequently used once you create and save your own clinical templates. 1.

Select the Prescription tab on the Planning Control (Figure -3).

2.

Type Whole Pelvis for RX Site.

3.

Select Plan Isocenter in the Prescribe to Column.

4.

Type 45 in the Rx Dose (Gy) column.

5.

Type 25 in the Number of Fractions column. The Fractional Dose (Gy) column automatically updates with 1.8 as the value.

6.

Click Equal Weights equally.

to distribute the weight of the beams

Figure 5-6: Prescription Control

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3D Prostate Case Practice Exercise (cont.) Task 15. Force Electron Density This task is only required if there is an object in the treatment that needs to maintain a constant mass density. In this studyset, the bladder structure contains contrast. 1.

Click the Structures tab on the Planning Control.

2.

Check the Force ED box on the Bladder row of the spreadsheet.

3.

The Relative ED for the bladder is now 1.0.

Task 16. Calculate Dose 1.

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Select the Calculate

button, on the planning ribbon.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 17. Evaluate Isodoses and DVH 1.

Open the Isodoses Control (Figure 5-7).

Figure 5-7: Isodoses 2.

Adjust the Isodose display for your plan.

3.

Review the isodoses on T/S/C and 3D views.

4.

Right-click on the DVH window and select Statistics from the menu.

5.

Review your plan. Use the DVH and DVH Statistics.

Task 18. Edit Beam Weights 1.

Select the Prescription tab on the Planning Control.

2.

Use the slider bar the beam weight in percentage.

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or numerical entry box to adjust

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3D Prostate Case Practice Exercise (cont.) Task 19. (Optional) Rescale Dose If your plan already has calculated dose, you can adjust the dose from within the Planning activity. 1.

Select the Prescription tab on the Planning Control.

2.

Use the Rescale Dose dialog box drop down menus to rescale the dose. Table 5-1: Rescale Dose Name

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Description

to cover

% and Structure field appears

to min dose of structure

Structure field appears

to mean dose of structure

Structure field appears

to max dose of structure

Structure field appears

to dose at point

All available points appear

to relative isoline

You can type a value for the % isoline in the number field that appears

to absolute isoline

You can type a value for the cGy or Gy isoline in the number field that appears

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 20. Save the Plan 1.

Click the Save

button.

OR Type (Ctrl + S) on your keyboard.

Task 21. Create 6 Field Boost Plan 1.

Click on the drop-down arrow next to the New Plan New Monaco Plan in the drop-down list.

2.

Type in a Plan Name and Description.

3.

Select 3D for the Delivery.

4.

Select All for the Anatomical Site.

5.

Place a checkmark by the template named DEFAULT3D1beam (Rx Site , Rx Dose: 2.0Gy , Total Beams: 1).

6.

Select Head First for the Treatment Orientation.

7.

Select a treatment unit used in your clinic, labeled as Demo.

8.

Select the Collapsed Cone Algorithm.

9.

Select the Photon Energy to be used in the plan.

10.

Select the Isocenter Location: Center of GTV.

11.

Click OK to load the template and open the patient in Planning Control.

Monaco

button and select

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3D Prostate Case Practice Exercise (cont.) Task 22. Add/Edit Additional Beams 1.

Click the Beams tab in the planning control.

2.

Click to create five additional beams.

3.

On the Geometry tab, edit Gantry angles to generate a 6 field beam arrangement.

4.

On the General tab, edit the Beam Description and Field ID.

Task 23. Create Ports

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1.

Select the Create and Edit Ports

button.

2.

In the Create/Edit Ports dialog box, select MLC as the Port.

3.

Auto Conform to Structure: PTV.

4.

Type 1.0 (cm) for the Auto Conform Margin.

5.

Click to place a check mark in the Snap Jaws to Port box.

6.

Activate each beam and create a por. Use these steps.

7.

Close the Create / Edit Ports dialog box.

3D Prostate Case Volume II of IV Monaco Training Guide

3D Prostate Case Practice Exercise (cont.) Task 24. Enter the Prescription 1.

Select the Prescription tab on the Planning Control.

2.

Type Prostate Boost for RX Site.

3.

Select Plan Isocenter in the Prescribe to Column.

4.

Type 21.6 in the Rx Dose (Gy) column.

5.

Type 12 in the Number of Fractions column. The Fractional Dose (Gy) column automatically updates with 1.8 as the value.

Task 25. Edit Beam Weights 1. Use the slider bar adjust the beam weight in percentage.

or numerical entry box to

Task 26. Force Electron Density 1.

Click the Structures tab on the Planning Control.

2.

Check the Force ED box on the Bladder row of the spreadsheet.

3.

The Relative ED for the bladder is now 1.0.

Task 27. Calculate Dose

1. Select the Calculate

Monaco

button, on the planning ribbon.

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3D Prostate Case Practice Exercise (cont.) Task 28. Evaluate Isodoses and DVH 1.

Open the Isodoses Control.

2.

Adjust the Isodose display for your plan.

3.

Review the isodoses on T/S/C and 3D views.

4.

Right-click on the DVH window and select Statistics from the menu.

5.

Review your plan. Use the DVH and DVH Statistics to evaluate whether 95% of the PTV receives the prescribed dose and the example constraints shown below: Table 5-2: Planning Score Criteria example

Bladder

Rectum

Less Than …

Receives…

40%

66.6 Gy or higher

60%

50.0 Gy or higher

25%

66.6 Gy or higher

50%

50.0 Gy or higher

Task 29. (Optional) Rescale Dose 1. Select the Prescription tab on the Planning Control. 2. Use the Rescale Dose dialog box drop down menus to rescale the dose.

Task 30. Save the Plan 1. Click the Save

button.

OR Type (Ctrl + S) on your keyboard.

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3D Prostate Case Practice Exercise (cont.) Task 31. Create Plan Summation Monaco enables you to combine plans regardless of dose calculation matrix variations. Monaco creates a new, independent dose matrix for plan summation. 1.

In the workspace control, left-click to highlight the first plan you created.

2.

Hold down the Control key and left-click on the second plan you created.

3.

Right-click and select Sum Plans from the menu.

Task 32. Plan Summation Review 1.

Use the Multiplan Navigation control and the slice mode indicator to reveal the area of interest.

2.

Adjust the color ranges in the isodose control.

3.

Review the DVH, the summed plans adopt Absolute normalization mode. Percent normalization is not available for summation plans.

Task 33. Save the Plan Summation 1. Click the Save

button.

OR Type (Ctrl + S) on your keyboard.

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IMRT Tools Volume II of IV Monaco Training Guide

IMRT Tools Overview This section of the training guide specifically outlines the buttons and tools available in the Monaco Planning workspace. Within this activity, you can optimize and evaluate your Monaco IMRT plans. You can also print Monaco plan reports. When you complete this section, please go to Practice Exercise 3. IMRT and QA in the Practice Exercises section of this guide.

Planning Control When you create a New Monaco Plan, this launches the Planning Control window (Figure 6-1). It is an interactive window where you can make edits to the prescription, beam properties, and IMRT constraints. You can edit some properties during optimization. Below is an example of the tabulated contents located in the Planning Control Window (Figure 6-1).

Figure 6-1: IMRT Planning Control Window

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IMRT Tools Structures You can edit the structure’s properties when you double-click on the structure name or edit the cells in the columns. From the Structures tab, you can check the Force ED box to maintain a constant electron density for a structure (Figure 6-2).

Figure 6-2: Planning Control | Structure Tab

Prescription Prior to optimizing, select the Prescription tab to define all prescription relevant information in one place. From this tab you can make a Physician’s intent, manage beam weights, and rescale normalization details. (Figure 6-3). See the Plan Review Activity and 3D Planning sections of this guide for more information on the tools you can use on the Prescription tab.

Figure 6-3: Planning Control | Prescription Tab

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IMRT Tools Beams You can use the Beams tab in the Planning Control to add new beams or to edit the configuration of beams already in your plan. You can also edit treatment aids such as bolus, and manage setup beams (Figure 6-4). NOTES:

If the plan contains split beams, you cannot make changes to the child beams. Setup beams that you create in Planning on the Setup Beam tab are not included in the dose calculation for the given plan. Monaco does not account for dose accumulation for setup beams. The system exports any assigned monitor units for use during filming.

Figure 6-4: Planning Control | Beams Tab

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IMRT Tools IMRT Constraints Use the IMRT Constraints tab to define the IMRT target objectives and organ at risk constraints. You have the option to choose the Pareto Mode on the IMRT constraints. Normally, Monaco sets constraints on healthy tissue while it administers dose to target volumes. In Pareto mode, Monaco relaxes constraints on healthy tissue while prioritizing target underdoses on tumor volumes. During optimization phase two, you can select the Sensitivities tab to show the sensitivities of each constraint in relationship to each target. From this tab, you receive indications of which structures are impeding you meeting the prescription. Use this information to make informed decisions as to what trade-offs to make to improve your plan. (Figure 6-5)

Figure 6-5: Planning Control | IMRT Constraints Tab

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IMRT Tools Dose Reference Points The treatment planning system computes the Dose Reference Points (DRPs) that represent point doses to user-defined locations on a per-beam basis. You can report or export the information represented in dose reference points to external systems for the purpose of independent MU calculation checks or dose tracking in a record and verify system. You can view the dose reference point dialog box in Planning and Plan Review activities. But, you can only edit dose reference points in Planning activity. NOTE:

DRPs are saved with the plan. But, if the plan is saved as a template, DRPs are reset to the isocenter of the first beam for the new plan where the template is applied.

Figure 6- 6: Dose Reference Point Window You can edit the description of each Dose Reference Point. Type a new description in the dialog box (Figure 6-6). You can also edit the position of the dose reference points. Simply type X, Y, and Z values in the Dose Reference Point window or use the mouse.

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IMRT Tools Dose Reference Points (cont.) Use the mouse to move a Dose Reference Point 1.

Click the Dose Reference Points tab in Planning Control window to show the Dose Reference Point dialog box.

2.

You can edit all DRPs at once or edit individual DRPs. Toggle the Location button to link

(edit all DRPs) or unlink

(edit individual DRP).

3.

Click Show/Edit DRPs shown in orange.

4.

In any Transverse, Sagittal, Coronal or Fluence view, place your mouse over the selected Dose Reference point. The mouse pointer visually changes to look like this

5.

. The active Show/Edit DRPs button is

.

Hold down your left mouse button and drag the point to a new location. NOTE:

DRPs default to the isocenter of each beam/sequence.

Update DRP with Prescribe to Point To move the dose reference point to the Prescribed to point on the Prescription tab, click Update DRP with Prescribe to Point. NOTE:

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The Prescribed To and DRP locations are linked by default for 3D plans. For IMRT plans where the Prescribed To point is a volume, the button disables.

IMRT Tools Volume II of IV Monaco Training Guide

IMRT Tools Dose Reference Points (cont.) Reset All Dose Reference Points to Isocenter If you have moved your Dose Reference Points and now want to reset them back to the isocenter of the plan, click the Reset All to Isocenter Dose Reference Point window.

button on the

Planning Tab The panels below are available in the Planning tab of the Planning workspace. You can locate several tools for IMRT planning within these panels (Figure 6-7).

Figure 6-7: IMRT Planning tab Panels NOTE:

Monaco

You can find a more detailed discussion of the tools launched from this toolbar in the Monaco Planning and Workflow section of this guide.

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IMRT Tools Planning Tab (cont.) Planning Tab | Calculation Panel Table 6-1: Planning tab – Calculation panel buttons, tools, and descriptions Buttons and Tools

Description This button launches the Calculation Properties dialog box. It shows editable calculation and global parameters related to your plan and structures in the prescription. This button launches the Sequencing Parameters dialog box. These editable parameters relate to fluence, segmentation, and monitor unit properties of optimized segments. The Start Optimization button starts the optimization for stage one or stage two. The subscript number indicates which stage will start when the button is clicked. The Batch Optimization button lets you perform stage one and stage-two optimization without pausing in between. The Skip Forward button lets you manually stop an optimization by “skipping forward” to the next converged state. Note that when you skip forward, you prematurely end the optimization, which could lead to an unacceptable result. The Skip Back button has different functionalities and depends on which stage you are in. When clicked once, it lets you manually skip back to the last idle state. If you are in stage one, you can click the Skip Back button twice to reset to the initial (preoptimized) fluence. In stage two, you can click the Skip Back button twice to reset the optimized segments back to optimized fluence. You can also use Skip Back to “PAUSE” optimization. You can make prescription edits and then press the “start” button again. The Reset Calculation Engine button lets you remove fluence, segments, and dose.

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IMRT Tools Planning Tab (cont.) Planning Tab | Fluence Panel for IMRT Plans The tools below are available on the fluence panel when you plan IMRT, dMLC and Conformal RT plans (Figure 6-8).

Figure 6-8: Fluence Panel – IMRT, dMLC and Conformal RT Plans Table 6-2: Planning tab – Fluence panel buttons, tools, and descriptions Buttons and Tools

Description Click the up and down arrows to select the beam you want to show in the Fluence View, or click the dropdown arrow to the right of the field and select a specific beam to show. Gantry Angle is a non-editable field that shows the angle of the gantry of the active beam. Use the Segment Selector to movie through the segments in the Fluence View. When the field is highlighted, you can use the scroll wheel to movie through the segments quickly. The monitor units shown are the monitor units for the segment currently shown in the fluence view. The MU Cursor works like the volume cursor tool. But, it shows monitor units at a selected point on the BEV instead of dose. Click the MU Cursor button. Then, hold down your left mouse button over the intensity map. Monaco shows a MU value associated with the intensity at that point.

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IMRT Tools Planning Tab Planning Tab | Fluence Panel for IMRT Plans (cont.) Table 6-2: Planning tab – Fluence panel buttons, tools, and descriptions (cont.) Buttons and Tools

Description The range of monitor unit values for all fluence profiles in the plan appears on the hot/cold indicator in grayscale or color. Click the fluence color button between the two numbers to toggle the intensity map in the BEV from color to grayscale.

NOTE:

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To turn off the intensity map and monitor unit fluence, right-click in the BEV and select the Show MU/Fluence option to remove the checkmark.

IMRT Tools Volume II of IV Monaco Training Guide

IMRT Tools Planning Tab (cont.) Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans The tools below are available on the Fluence panel when you plan VMAT and Dynamic Conformal Arc plans (Figure 6-9).

Figure 6-9: Fluence Panel – VMAT and Dynamic Conformal Arc Plans Table 6-3: Planning tab – Fluence panel buttons, tools, and descriptions Buttons and Tools

Description Click the up and down arrows to select the sequence you want to show in the Fluence View, or click the drop-down arrow to the right of the field and select a specific sequence to show. When the Gantry button is selected (orange), all the gantry angles for the sequence appear in the drop-down list. Only the segments for the selected gantry angle are available in the Segment dropdown list. When the Segment button is selected (orange), all the segments for the entire sequence appear in the drop-down list. Only the starting and ending gantry angles for the selected segment are available in the Gantry drop-down list. Most segments have two control points, so you can choose to show the starting position or ending position for that segment. Select Start or End. If the segment is static, Static appears in this field.

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IMRT Tools Planning Tab Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans (cont.) Table 6-3: Planning tab – Fluence panel buttons, tools, and descriptions (cont.) Buttons and Tools

Description The monitor units that appear are the total monitor units for the segment that currently appears in the fluence view. The MU Cursor works like the volume cursor tool. But, it shows monitor units at a selected point on the BEV instead of dose. Click the MU Cursor button Hold down your left mouse button over the intensity map. Monaco shows a MU value associated with the intensity at that point. This option is grayed out for Dynamic Conformal since the MU is constant for each segment. (VMAT Only) The range of monitor unit values for all fluence profiles in the plan appears on the hot/cold indicator in grayscale or color. Click the fluence color button between the two numbers to toggle the intensity map in the BEV from color to grayscale.

NOTE:

To turn off the intensity map and monitor unit fluence, right-click in the BEV and select the Show MU/Fluence option to remove the checkmark.

This option is grayed out for Dynamic Conformal since the MU is constant for each segment.

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IMRT Tools Planning Tab Fluence Analysis and Visualization Tools The fluence analysis and visualization tools below are available in the Planning tab from the Fluence Panel. To show the fluence image view, turn on a BEV View Type. When you have this option selected, you can right-click in the BEV window to show these display options. All options are accessed when you right-click in the BEV window and select them. Show MLC – Toggle the segment display on or off. Show MLC Edges –Toggle the segment edges on or off. Segment edges appear in light green. Show Leaf Outlines – Toggle the display of the leaf outlines on or off. The color of the leaf outline changes where the leaf is blocked. Show Leaf Interiors – Toggle the display of the leaf shading on or off. The color of the shading changes where the leaf is blocked. Clip Leaves at Jaw Edges – Toggle the display of the full extent of the leaves on or off. This option limits the MLC leaf display to the jaw extents. Jaw extents appear in dark blue. Show Maximum Segment Extents – Toggle the segment display between showing the segment extents of the selected segment to showing the maximum extent of all segments. Enable DRR/MIP – Toggle the display of the DRR image on or off. Show MU/Fluence – Toggle the display of the Fluence on or off.

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IMRT Tools Planning Tab (cont.) Planning Tab | Grid Volume Panel The Grid Volume panel has different functionality based on which activity you are in. The functionality below is available in the Planning workspace. (Figure 6-10)

Figure 6-10: Grid Volume Panel Volume Cursor

The Volume Cursor is a mouse tool on the Grid Volume Panel that shows you: • • • •

NOTE:

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Volume information, such as Hounsfield units or PET units Pixel and voxel electron density Relative electron density of secondary image sets Point dose information regarding the image or plan selected

Hounsfield Units and Electron Density values for all image sets are based on pixel resolution. All other values that appear when you use the volume cursor are based on dose grid resolution.

IMRT Tools Volume II of IV Monaco Training Guide

IMRT Tools Planning Tab Planning Tab | Grid Volume Panel (cont) Studyset and Grid Slider Bar The Studyset and Grid Slider Bar lets you fade the display between the primary studyset and any grid volume option selected.

You can choose the Grid Type from the drop down menu. This lets you set which visualization tool you want to use. For example, the Cost Function Occupancy (available only in the Planning Workspace) shows cost function occupancy per voxel. When you choose certain Grid Types, you can also choose to view a Structure. The drop-down menu enables you to select a structure when VOI Occupancy, CF Occupancy, Variation, or when you select Relax Response as the Grid Type. The Units button enables you to view the lowest and highest level of monitor units within the segment. You can find more information on use of the volume toolbar in the Monaco Planning and Workflow section of this guide.

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IMRT Tools Plan Options Tab Optional Panel The Optional Panel contains controls you can use for IMRT and VMAT planning. (Figure 6-11)

Figure 6-11: Options Tab Panels Fluence Statistics

The Fluence Statistics dialog box shows fluence data for each beam along with the total and mean monitor units for entire plan. The fluence statistics (Figure 6-12) give you information based on beam fluence generated in stage-one and stage-two optimization. You can select Print to print fluence statistics report.

Figure 6-12: Fluence Statistics dialog box

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IMRT Tools Plan Options Tab Optional Panel (cont.) Show Dose Extents

If you want to see a graphical representation of the calculation volume on the transverse, sagittal and coronal views, select Show Dose Extents. This control is available for Monaco plans.

DVH Panel You can evaluate the Optimized or Total Dose dose-volume histograms after stage one or stage two of the optimization when you use the tools on the DVH panel (Figure 6-13).

Figure 6-13: DVH Panel There are two main types of dose-volume histograms you can view in IMRT Activity. Toggle between the two DVH types. Right-click in the DVH window and select Total Volume DVH (total volumes) or Optimized DVH (volumes used by optimizer). The DVH Properties sets the Dose Maximum, Grid Style, Grid Line Style, Volume Display, Volume Maximum, Line Thickness, and Resolution and Bin width. You can combine structures when you use the set operations union, intersection, and difference. You can view the combined structure in the DVH structure report, DVH graph, and in the structure control.

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IMRT Tools Plan Options Tab DVH Panel (cont.) You can control the background color of the dose – volume histogram graph when you select DVH color setup. You can view a summary of minimum, maximum, and mean dose when you select the DVH Statistics button. For more detailed information on how to use the DVH tools and set the properties, see the Plan Review Activity section of this training guide.

Dose Normalization Panel When you use the Dose Normalization panel (Figure 6-14), you can choose to normalize your plan in Absolute doses or Percent doses. You can also choose to show the doses in Gy or cGy.

Figure 6-14: Normalization Toolbar NOTE:

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For more information on using the normalization tools, see the Plan Review Activity section of this training guide.

IMRT Tools Volume II of IV Monaco Training Guide

IMRT Tools Tools Tab

Figure 6-15: Tools Tab

Click the Interest Points and Markers button, located in the Tools tab. Or, right-click in the transverse view to show the shortcut menu, then click Interest Points & Markers. The treatment planning system computes the Interest Points and Markers that represent point doses to user-defined locations. You can report or export the information represented in dose reference points to external systems for the purpose of independent MU calculation checks or dose tracking in a record and verify system. You can view the Interest Point & Markers dialog box in Planning and Plan Review activities. But, you cannot use the right-click shortcut key in Plan Review.

Interest Points and Markers Editing Interest Points and Markers

Figure 6-16: Interest Point and Markers dialog box You can edit the Description of each Interest Point when you type a new description in the dialog box (Figure 6-16). You can also edit the position of the points when you type X, Y, and Z values in the Interest Point and Markers dialog box or use the mouse. NOTE:

Monaco

The interest point or marker’s new location may re order the list if the Y value is lesser than the interest points and markers that are already made.

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IMRT Tools Tools Tab Interest Points and Markers (cont.) Additional Interest Point and Marker Functionality In the Planning, Plan Review and QA activities, there is expanded functionality and information that you can access from the Interest Point and Marker dialog box. For example, there is a column that shows Total Dose to the interest point or marker. You can also sample a user-defined volume instead of a point. This is useful to evaluate Monte Carlo doses that have inherent statistical uncertainty. To sample a volume (sphere) around interest points and markers, type a value for the Radius of the sampling sphere. The Volume in cm3 and number of Points in the volume sample are automatically generated and appear just below the Radius field. Next to each interest point or marker, fields such as the Mean Dose, Min Dose, Max Dose, Standard Deviation and # of Grid Points (dose calc grid) appear in reference to the sample volume.

Measure Tool The Measure Tool is available in all activities. See the Planning Tools section for basic use of these tools.

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IMRT Tools Additional IMRT Tools Progress Meter

Figure 6-17: Progress Meter The progress meter (Figure 6-17) consists of three real-time graphs, designated by the colors blue, red and green that update with each iteration during both stages of optimization. The red graph shows the convergence of the target objectives Target EUD(s) and the overall target coverage of the prescribed dose. When the dotted line converges to 1.0, all objectives applied to the targets are met during optimization. The blue graph shows the current status of all constraints, essentially the Constraint Violation. During constrained optimization, this graph should converge to 0.0, meaning that all applied constraints are being met. The green graph shows the Modulation Degree. This indicates the current total relative degree of modulation of all beams or sequences.

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IMRT Tools Additional IMRT Tools (cont.) Beam Visibility Control In IMRT activity, you can toggle individual beams or sequences and their doses on or off from the Beam Visibility Control. The system highlights the active beam/sequence in red. It highlights all other beams in blue.

Figure 6-18: Beam Visibility Control

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•

Click on an individual beam/sequence name to turn the selected beam/sequence on or off.

•

Click on the heading Plan/Rx/Beam to toggle all beams/sequences on or off.

•

Check or uncheck the box under Dose for each beam or Rx to toggle dose on or off.

•

Click on the heading Dose to toggle all beams/sequences on or off.

•

Click the Current button to turn off the visibility of all beams except the current beam (in red).

•

If you plan with Bias Dose, the base plan name appears on the Beam Visibility Control so you can toggle the dose on or off.

•

With multiple Rx(s), you can toggle each Rx(s) beams on and off if you select a specific Rx (example Rx A).

•

With multiple Rx(s), you can toggle each Rx(s) dose on and off when you check the Dose check box next to the specific Rx.

Planning and Workflow: Calculation Parameters and IMRT Constraints Volume II of IV Monaco Training Guide

Planning and Workflow: Calculation Parameters and IMRT Constraints Calculation Properties You can edit specific Calculation Parameters from the Calculation Properties dialog box (Figure 7-1).

Figure 7-1: Calculation Properties dialog box – Monte Carlo

Figure 7-2: Calculation Properties dialog box – Electron Monte Carlo

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Planning and Workflow: Calculation Parameters and IMRT Constraints Volume II of IV Monaco Training Guide

Planning and Workflow: Calculation Parameters and IMRT Constraints Calculation Properties (cont.)

Figure 7-3: Calculation Properties dialog box-Collapsed Cone

Calculation Parameters Calculation Parameters are those parameters that can affect optimization, dose calculation, or both. The Grid Settings parameters are applied to all prescriptions. The Algorithm Settings parameters are specific per prescription. Algorithm This is a non-editable field in this dialog box. You can select the algorithm you want to use in the Beam tab on the Planning Control. Monaco updates the information in the Algorithm field on the Calculation Parameters information. Grid Spacing This value refers to the uniform spacing of the calculation points on a threedimensional grid. Keep in mind that the calculation grid is defined by and encompasses all contoured structures and cannot be resized. If you have small structures such as in a head and neck case, you may want to use a grid spacing of 2mm. Understand that smaller grid spacing significantly increases calculation time. Plans with larger structures could be set to a larger grid spacing (such as 3mm) to increase the calculation speed. Keep in mind, when you use too large of a grid spacing, it can lead to a poorer resolution of the optimization problem and, in addition, to a less accurate monitor unit calculation.

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Planning and Workflow: Calculation Parameters and IMRT Constraints Calculation Properties Calculation Parameters (cont.) Calculate Dose Deposition to: You have the option to calculate dose to Medium or dose to Water. The default value is Calculate dose to Medium. To be consistent, select the same option in QA Activity for your QA plan that you selected here. NOTE:

For more detailed information on this topic, see the Report of the AAPM Task Group No. 105: Issues associated with clinical implementation of Monte Carlo-based photon and electron external beam treatment planning.

Statistical Uncertainty (%) The system only uses this value during the final dose calculation when you select the Monte Carlo Algorithm as the Secondary Algorithm. There are two options to choose from, Per Control Point and Per Calculation. Statistical Uncertainty Per Control Point is the percent (%) statistical uncertainty per voxel, on a per-segment basis, that you are willing to accept for the final dose calculation. So, the mean, per-voxel, uncertainty in a central region of the dose of a segment is equal to the user-specified statistical uncertainty at the end of the dose calculation. The uncertainty is not the same in all voxels. For example, the low dose voxels in the peripheral regions of the patient has a higher uncertainty of dose than the voxels in the region of maximum dose (target). The relative uncertainty of the total treatment plan is inversely proportional to the square root of the number of histories. Dose uncertainty in the target volume for the final plan is calculated and appears in the console after stage-two dose calculation (Figure 7-4). The uncertainty of the entire plan is always less than the uncertainty value you typed in the Statistical Uncertainty field since that value is per segment.

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Planning and Workflow: Calculation Parameters and IMRT Constraints Calculation Properties Calculation Parameters Statistical Uncertainty (%) (cont.)

Figure 7-4: Console Entry for Dose Uncertainty Statistical Uncertainty Per Control Point (CP) The range for this field is 0.1-10.00%. The smaller the statistical uncertainty (SU), the longer the dose calculation. Suggested values are as follows: # of CP 100 150 200

Planning SU 3% 4% 5%

QA SU 2% 2.50% 3%

When you use these values, the result should be a final dose uncertainty of approximately 1% for the plan in the central region of the target volume. We suggest smaller statistical uncertainty values for QA, since QA devices have a limited number of detectors to match computed dose to measured dose.

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Planning and Workflow: Calculation Parameters and IMRT Constraints Calculation Properties Calculation Parameters Statistical Uncertainty Per Calculation The percent (%) statistical uncertainty per calculation that you are willing to accept for the final dose calculation. The range for this field is 0.1-5.00% (per calculation). Suggested value is 1.0% per calculation. Calculation time is faster for this options versus the per Control Point option since the dose calculation is based on a smaller number of histories. NOTE:

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When you have structures in the prescription with small volumes, (for example, lens) we do not recommend that you use a Statistical Uncertainty higher than 1.5 % per calculation or 5 % per control point. If you use a higher value, it causes the system to underestimate the cost function value assigned to that structure. Refer to the Monaco Technical Reference: PostModeling Adjustment of MLC Parameters in Support Plus for additional information.

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Planning and Workflow: Calculation Parameters and IMRT Constraints Planning Control – Structures You can set the display properties of the structures on the Structures tab. You can override the electron densities of structures when you use the Force ED and Fill ED options. Click the Force ED option if there is an object in the treatment that needs to maintain a constant mass density. Click the column header to toggle the force density feature on or off for all of the structures.

Figure 7-5: Structures Click the Fill ED option to fill a structure with a minimum electron density. The Relative Electron Density Field is empty until you mark either the Force ED or Fill ED fields. It then shows the default electron density for the structure. You can type in a new value. Relative Electron Density values can be:

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Electron Monte Carlo from 0.01 to 2.456

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Collapsed Cone from 0.01 to 2.456

Planning and Workflow: Calculation Parameters and IMRT Constraints Volume II of IV Monaco Training Guide

Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Introduction The key to IMRT Treatment planning is to enter a carefully planned prescription. It is important to use a logical thought process and the tools to make a great treatment plan. Monaco makes it easy. It has a user-friendly prescription panel (Figure 7-6). Click on the IMRT Constraints tab on the Planning Control to see the IMRT Constraints dialog box. The Constraints tab is where you type in your prescription.

Right-click on any Cost Function on the IMRT Constraints page to get this menu.

Right-click on any Structure on the IMRT Constraints page to get these menus. Figure 7-6: IMRT Constraints dialog box and Right Mouse Click Options

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Introduction (cont.) You may find it useful to view the IMRT Constraints dialog box on the Planning Control during optimization to view the Isoeffect and Relative Impact updating during optimization and to make edits to the interactive fields, if necessary. You can change some of the IMRT Constraints dialog box fields during optimization. You can only change others when the system is idle (not optimizing or calculating) or converged. During the optimization, you can change the Enabled and Multicriterial status and the Isoconstraint values.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure (cont.) Structure This column lists all the structures that are in the optimization. The assigned color of each structure appears to the left of each structure name. The system lets you plan with up to 31 structures. You should list the structures (layer them) in order of their importance so that voxels are prioritized and defined appropriately when structure overlaps exist. You can also assign unique structure properties to individual structures. You can read more details about structure layering and structure properties and their global parameters in the sub-sections.

Structure Mismatch Since you use templates to start planning, occasionally you might have a structure mismatch. This means that the structure name in the template does not exist in the currently loaded patient’s structure set. A structure mismatch is easy to recognize since the structure name appears in red on the IMRT Constraints dialog box and say ‘Mismatch in structure names’ at the bottom. It is also easy to resolve when you select another structure name from the drop-down list, or delete the structure altogether. Figure 7-6 shows an example where the structure PTV and SKIN do not have a match in the current studyset.

Structure Layering The layering order determines how the optimizer treats the voxels in the volume where the structures overlap. It does not imply that one structure’s objectives or constraints are more or less important. The structure that is listed higher in the layering order ‘owns’ the voxels in an area of overlap with another structure even if there is no cost function assigned to it in the prescription. You can also assign voxels of overlapping regions completely to one structure when you use the structure properties. To edit the structure layering on the IMRT Constraints dialog box, left-click a or down structure name to highlight. Click the up that structure up or down in the layering order.

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arrow buttons to move

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Layering (cont.) The images below illustrate examples of layering order applied to two overlapping structures. These voxel priorities represent the default behavior, but can be overridden by individual cost functions with an additional parameter. Figure 7-7 PTV

PTV higher in layering order than Rectum

In this example, the PTV 'owns' the voxels in the overlap region. The cost function(s) assigned to the rectum is only applied to the volume in blue.

Rectum higher in layering order than PTV

PTV

Rectum Figure 7-8

In this example, the Rectum 'owns' the voxels in the overlap region. The cost function(s) assigned to the PTV is only applied to the volume in yellow.

Figure 7-9

PTV2 higher in PTV2

PTV1

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Rectum

layering order than PTV1

In this example, you need to list the PTV2 higher in the layering order than PTV1. If not, its cost functions will be overridden by the cost functions of PTV1 since PTV1 totally encompasses PTV2.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure (cont.) Structure Optimization Properties and IMRT Prescription Parameters Monaco has powerful structure definition tools that let you define voxel priorities and physical properties for each structure in the prescription. In other words, you can determine which voxels a cost function will be applied to within a selected structure. NOTE:

Prescription Parameters are applied across all structures where the associated structure property is assigned. For example: When you set the Minimum CT Number, that value is applied to all structures where Clear is applied. If the value is changed, it is changed for all structures.

You can designate very specific properties for each individual structure. You can use these properties alone or in combination with each other. Instead of creating additional contouring to alter how the cost function is applied to those structures, you could simply apply a specific structure optimization property to accomplish the same goal. The uses and limitations of these properties are defined here. To view the structure optimization properties (Figure 7-10) for a specific structure, right-click on the structure name in the IMRT Constraints dialog box and select the Properties option. To edit the Prescription parameters (Figure 7-11), click on IMRT Parameters on the IMRT Constraints tab. These parameters are specific per prescription.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters (cont.)

Figure 7-10: Structure Optimization Properties

Figure 7-11: IMRT Prescription Parameters

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters (cont.) Clear all Voxels below the Minimum CT number Apply this property when you want to identify and exclude all voxels in a structure whose values fall below a user-defined Hounsfield number during the optimization. Type the minimum Hounsfield value in the Minimum CT Number in the IMRT Prescription Parameter dialog box. You typically use the Clear property for targets containing air voxels. This property is sometimes used in combination with the Fill property. Fill is always done before Clear, when used in combination. Fill is applied to set a minimum electron density for all voxels that belong to the structure. Then, the Clear property removes all the voxels in the structure below the selected Hounsfield number entered. The voxels where “Clear” is applied are not taken into account during the optimization, but those voxels are accounted for during the final dose calculation. This field is ignored if you are planning on an MR studyset. Clear and Fill Example: It is practical to remove air density voxels from structures so the optimization algorithm does not artificially inflate the dose to the structure when it tries to deliver dose into an area of very low density. This could lead to hot spots elsewhere. You may also want to set a minimum density for that structure used in the dose calculation.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters Clear all Voxels below the Minimum CT number (cont.) In this head and neck case, the contoured target volume includes air voxels. If the structure is divided into voxels based on the selected grid spacing and electron density, this slice may look like the image in (Figure 7-12). The purple voxels represent CT values in the range of air (0.1). The yellow voxels represent ED values in the range of 0.4, since they border air voxels. The blue voxels represent voxels with an ED of 1.0 or greater. Use Fill to apply a minimum density 0.5 (-500 HU) to all of the voxels with a density below 0.5. See (Figure 7-13) where it changes the purple and yellow voxels to green. When Clear (-200 HU) is applied to the filled voxels, you get an altered structure volume represented in (Figure 7-14). NOTE:

Clear is applied to total voxels. See Figure 7-14.

Figure 7-12: Voxelized Structure NOTE:

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Figure 7-13: Application of Fill

Figure 7-14: Application of Clear

This is an artistic rendering of the application of Fill and Clear. These color maps do not appear on your screen.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters (cont.) Display Total Volume DVH Apply this property when you want to designate that the volume shown in the DVH during optimization (for the selected structure). This always pertains to the entire volume of the structure, regardless of any overlap with higher priority structures. It is not necessary to select this property for the first item in the Structure Layering list since the volume of the DVH always pertains to the total volume. When you select this property, it has no bearing on voxel sharing only the optimized DVH display. Auto Flash Typically, when a target is superficial or lies in the build-up region just beneath the patient surface (like a breast or neck), it is difficult to sufficiently cover the target with the prescribed dose due to the rapid fall off of dose at the surface. In some cases, the target volume could move outside of the treatment field due to breathing. Select the Auto Flash option to create a flash margin of voxels that extends beyond the target volume, with the specified margin, in the direction of the skin surface (Figures 7-15 and 7-16). Monaco automatically opens the jaws, when needed, to cover the “virtual target” when it is near the surface of the patient so that the prescribed dose is better achieved to superficial targets. Users can type a specific margin value (0.0-2.5 cm) in the Auto Flash Margin in the IMRT Prescription Parameter dialog box.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters Auto Flash (cont.)

Figure 7-15: Coronal View of Breast Tangent Fluence without Auto Flash

Figure 7-16: Coronal View of Breast Tangent Fluence with 1.0 cm Auto Flash

Do Not Store Dose This option is only available when a cost function is not assigned to the selected structure and Display Total Volume DVH is not checked. When selected, dose is attenuated through the structure and does not store dose for this structure in memory. This option might be useful once you contour the table or an immobilization device and want to account for attenuation through it, but do not need to track the dose delivered there.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters (cont.) Avoidance This option only applies to organs at risk. You control it with the IMRT Prescription Parameter| Avoidance Margin option. Check this box if you want to apply an avoidance margin to your organ at risk. See the section on Avoidance Margin-IMRT Prescription Parameter for more information. Surface Margin – IMRT Prescription Parameter You can apply Surface Margin to a structure’s cost functions to limit the cost function’s effect in the build-up region at the patient surface. The range for the surface margin value is 0.00 to 1.00. NOTE:

See the section Understanding the Cost Function Parameters for more information on how to use Surface Margin.

Beamlet Width – IMRT Prescription Parameter You use the beamlet width during stage one and stage-two optimization. In stage-one, you use it to define the resolution of the fluence map. In stage-two, you use it during segment shape optimization to fine tune the segment shapes in step and shoot IMRT. In general, the smaller the beamlet width, the finer the fluence grid. This fine fluence grid is an advantage since this lets the optimizer define sharper gradients where necessary. The recommended beamlet width is 2mm. Beamlet length is automatically determined by the MLC leaf width.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Structure Structure Optimization Properties and IMRT Prescription Parameters (cont.) Target Margin – IMRT Prescription Parameter You can alter the fluence profiles created for target structure(s) when you change the target margin. A target margin is always applied when you create fluence profiles. The default value is Normal. But, you can tighten or widen the margin when you select a different option. Avoidance Margin – IMRT Prescription Parameter You can alter the fluence profiles created for an OAR structure(s) when you change the avoidance margin. Avoidance margins are optional, mainly for use with the Dynamic Conformal Arcs delivery mode. It is only applied when you turn it on in the Structure Optimization Properties for an OAR. The default value is Normal (8 mm). But, you can tighten or widen the margin when you select a different option. Avoidance margins are hard constraints for dynamic conformal arcs. The system assigns voxels to avoid during the rotational delivery by the value of the margin assigned. See the section on Structure Optimization Properties for more information.

Figure 7-17: Avoidance Margin: Dynamic Conformal Arc

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Cost Function Overview In general, all IMRT optimizers seek to minimize a composite cost-function, comprised of the sum of the cost functions that may be objectives or constraints. This column lists all the cost functions applied to each structure in the prescription. A cost function relates an inhomogeneous dose distribution to a single value. You can use this value to define a penalty for violating an objective or constraint. The system evaluates this penalty - value during optimization. In constrained optimization, the only contribution to the objective function is given by the objectives. Therefore, the value of the composite cost function in Monaco is a measure of the violation of the target prescription.

Objective Objectives are anatomy-specific functions that establish dose and/or biological response goals. When used in combination with constraints, the objective is always limited so that constraints are met. You must loosen constraints in order to improve objectives.

Constraint Constraints are anatomy-specific functions that must be met. They are often referred to as hard constraints. When used in combination with objective functions, constraints are met regardless of the effect on the objectives and may limit the dose to the target volume (objectives).

EUD (Equivalent Uniform Dose) EUD is a homogeneous dose that, when applied to an organ, has the same clinical effect as any given, inhomogeneous dose distribution. The concept of EUD assumes that any two dose-distributions are assumed equivalent if they cause the same radiobiological effect.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions (cont.) Application of Objectives and Constraints Monaco gives you a set of biological and DVH based cost functions to use during optimization. Most are considered constraints. For constrained optimization, constraints must be met for the optimization to converge. The cost function primarily used to designate targets is considered an objective. An objective is treated like a goal and may not be met during optimization if the constraints are too restrictive. When you apply the Pareto optimization mode, you place priority on underdose constraints to targets over constraints you apply to organs at risk. When you use biological cost functions, this takes advantage of the biological volume effect of structures. The biological volume effect indicates that higher doses may be tolerated when the irradiated volume is reduced. When you use a biological cost function as opposed to a physical (dose-based) cost function, each structure is equipped with its particular volume effect, as opposed to the optimizer treating all structures as if they had the same dose response mechanism. To view the Properties dialog box for each cost function, right-click on any cost function and select Properties.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions (cont.) Required Cost Function Parameters Target Penalty This physical cost function is the ‘objective’ version of the Quadratic Underdose constraint for targets (Figure 7-18). The isoeffect is a DVH based physical parameter. The Target Penalty is a quadratic penalty which starts at the threshold dose. You can configure the dose and reference volume. You must use at least one of the two target objectives (Target EUD or Target Penalty) in your prescription. This is a non-EUD based objective. It does not add hot spots to the target to compensate for cold spots. As a result, it produces steeper dose gradients after target threshold doses are met. Monaco does not show sensitivity values for the Target penalty because there is no direct relationship between iso-effect and objective function value. A change to the objective function may not change the reported iso-effect. Therefore, Monaco cannot report sensitivity, which is a change to the iso-effect.

Figure 7-18: Required parameters for the Target Penalty constraint

Figure 7-19: Target Penalty a Prescription of 72 Gy.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Target EUD This biological cost function is an objective (not a constraint) and is the primary cost function for targets. This cost function defines a structure as a target volume. It expresses the probability that a target cell survives a given dose. The field size for each beam or sequence is automatically designed to encompass the target volume.

Figure 7-20: Required Parameters for Target EUD This cost function requires that you to type in a Prescription, which is an EUD (Equivalent Uniform Dose) prescription. If the dose distribution in the structure is homogeneous, the EUD is close to the mean dose, which, in the case of a target, also represents the desired prescribed dose. If severe cold spots exist, it is close to the minimum dose and depends on cell sensitivity. Type the actual prescribed dose for the structure. This value is the desirable effective dose for this structure. This cost function also requires you to type in the Cell Sensitivity for the target structure. When you increase the cell sensitivity, you increase the penalty paid for cold spots within the selected structure. Figure 7-21 graphs the changes in the penalty for low doses when the cell sensitivity is altered. In difficult cases, higher values of the cell sensitivity effectively increases the pressure to deliver dose to cold spots. Cell sensitivity and tumor cell density may become more important in future planning when functional imaging is available for treatment planning. Until then, it is reasonable to use the default cell sensitivity value of 0.50 for most cases.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Target EUD (cont.) Target EUD Increasing Penalty for Cold Spots

25 20 15 Cell Sen. =0.1

10

Cell Sen. =0.25

5

Cell Sen. =0.5

0 65

67

69

71

73

75

77

79

Dose (cGy)

Figure 7-21: Changing Cell Sensitivity

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Serial This biological cost function is the preferred constraint for serial OARs. For some organs, high doses are harmful even if they are limited to small volumes. These organs are considered serial structures. Examples of serial structures are spinal cord and bowel. It implements the critical volume model of normal tissue complications where it sees the organ as a chain. It breaks when one link breaks. Consequentially, it applies large penalties for hot spots even if they are small in volume. The serial cost function is the biological equivalent of a maximum dose penalty.

Figure 7-22: Required Parameters for Serial The isoconstraint is the Equivalent Uniform Dose (EUD), where value is similar to an acceptable maximum dose when the k value is large (ex. 12) and is equivalent to the mean dose when the k value is equal to 1. The EUD is the dose that causes the same damage if applied uniformly to the entire volume of the organ. The isoconstraint is the value you should change during optimization if you when you meet your desired prescription goal for the selected OAR. This cost function requires one value that is the Power Law Exponent (k) volumeeffect parameter. In general, when you use a small k value, a large volume-effect is assumed. This means that low dose volumes and high dose volumes are approximately equally weighted. When you use a large k value, there is less tolerance for excessive damage to small volumes of the assigned structure. In this case, low dose volumes receive a very small weight relative to high dose volumes. Figure 7-23 graphs the changes in the weight (penalty) of a dose in the overall EUD calculation when the k value is altered. k values are typically set once and not changed during optimization. When you select a particular k value, you essentially select a complication model based on the desired outcome for the selected structure.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Serial (cont.) NOTE:

It may be helpful for you to learn how Monaco re-samples the patient to create voxelized structures for optimization. This effects how cost functions, in particular, the Power Law Exponent for the Serial are applied to the structures. For detailed information, see the Monaco Patient Model section of this guide.

Figure 7-23: Effect of Various Power Law Exponents

Figure 7-24: Comparison of Three Serial DVH Curves

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Serial (cont.) Figure 7-25 demonstrates a comparison of three serial DVH curves for the structure rectum. A k-value of 12 gives you the best curve for the rectum without significantly softening the shoulder on the PTV. As a rule of thumb, you can derive a clinically significant power law exponent for serial structures when you use this equation: k = 0.15 x D 50 The D 50 value is the dose that causes a complication in 50 percent of all patients. Unfortunately, this is not a well-established clinical quantity. In general, it is better to overestimate k as this prevents potentially perilous hot spots. The table below gives examples of common k values used to return clinically acceptable results. Results may vary based on the contour and location of the structure. Serial OAR

Common k Value

Rectum Bladder Spinal Cord Brainstem Optic Nerve, Chiasm Heart Eye Inner Ear Mandible, Mouth, Larynx Parotid Gland Brain Plexus

12 8 12-14 12-14 12 -16 6 2 12 8 1 1 5

Common Isoconstraint Values (Gy) 64 60 29-36 36-40 32-48 21-24 25 38 40-46 22 12 55

Figure 7-25: Examples of common k values for delivery of 2 Gy/fraction

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Serial (cont.) NOTE:

It is important that you research the effect of the Power Law Exponent to determine the k value and isoconstraint that is most effective for use in your clinic.

The length of the weight arrows corresponds to where and how hard the Serial cost function is working to meet the constraints of the OAR.

Figure 7-26: How the serial cost function controls the DVH curve Figure 7-26 demonstrates the effect of the Serial cost function on a DVH curve. Notice that the cost function does not affect only one point along the curve. It actually affects the entire curve in varying degrees and particularly works on the tail to decrease hot spots.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Parallel This biological cost function is the preferred constraint for parallel OARs. It is the biological equivalent of the DVH constraint. Some organs tolerate very high dose values in small sub-volumes, if the rest of the organ is spared. Consider these organs parallel structures. Examples of parallel structures are lungs, parotids, kidneys and liver. This model implements the critical volume model of normal tissue complications where it sees the organ as a rope: it breaks when a certain number of strands break.

Figure 7-27: Required parameters for the Parallel Cost Function This cost function requires that you assign three parameters. The first parameter is the Reference Dose (EUD) whose value is analogous to the dose that is only just acceptable for the majority of the structure, and at which a clear dose response begins to show. For lung, this would be around 20 Gy. If the organ were to be irradiated homogenously with the reference dose, 50% of the organ would be lost. The second parameter is the isoconstraint, which is the Mean Organ Damage to the structure in %. The Mean Organ Damage is the biological equivalent to the fraction of the volume of the structure that can be sacrificed. You can divide the function of any organ into a large number of sub-volumes (aka functional sub-units, tissue-repairunits) that all work in parallel (Figure 7-28).The effect of radiation is assumed to knock out sub-volumes, and thereby reduce the function of the organ. Consequentially, the function is degraded on a continuous scale.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Parallel (cont.) Because each subvolume has a continuous dose-response (that is, each sub-volume can lose function on a continuous scale), 50% of the organ function can be lost in two extreme ways. Either by irradiating 50% of the organ volume to a dose that obliterates function, or by irradiating the entire organ to a dose that obliterates 50% of the function of each sub-volume. The total damage to the organ is therefore the mean of the functional losses of all sub-volumes. The isoconstraint is the value you should change during optimization if your desired prescription goal for the selected OAR is not being met. The third parameter is the Power Law Exponent (k). This value changes the shape of the dose response curve and determines how responsive the structure is to the Reference Dose and Mean Organ Damage values entered. A higher k value translates to a steep dose response that often translates into a pronounced kink in the DVH. k values are typically set once and not changed during optimization. When you select a particular k value, you are essentially selecting a complication model based on the desired outcome for the selected structure.

Figure 7-28: Functional Units (voxels)

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Parallel (cont.) Figure 7-29 demonstrates the shape of the cost function curve when you alter the k value. Figure 7-30 demonstrates the effect on the parotid when you alter the k value. Note that there are no significant differences between the plans for the target structures. The difference between the global max doses for all three plans was negligible.

Increasing Complication Probability

Parallel Cost Function Dref =20

k=2 k=3 k=4 Inflection point 0

20

40

60

Reference Dose

Figure 7-29: Effect of Various Power Law Exponents on one functional unit (voxel)

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Parallel (cont.)

Figure 7-30: Comparison of Parallel DVH Curves

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Parallel (cont.) Based on historical data, you can derive a clinically significant power law exponent for parallel structures when you use this equation: k = 0.15 x D ref Below are examples of common k values used to return clinically acceptable results. Parallel OAR

Ref Dose (Gy)

Common k Value

Mean Organ Damage (%)

Lung

20

3

20

Parotid

26

3.9

40

Kidney

14

2.1

20

Liver

30

4.0

33

NOTE:

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It is important that you research the effect of the Power Law Exponent to determine the k value and isoconstraint that are most effective for use in your clinic.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameter Parallel (cont.) The length of the weight arrows corresponds to where and how hard the Parallel cost function is working to meet the constraint of the OAR.

Figure 7-31: How a parallel cost function controls the DVH curve Figure 7-31 demonstrates the effect of the Parallel cost function on a DVH curve. Notice that the cost function does not affect only one point along the curve, it actually affects the entire curve in varying degrees and particularly works on the middle of the DVH curve.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Conformality This physical cost function is a constraint that you can only use with OARs. The purpose of the Conformality cost function is to shape the high dose volume tightly around one or several target volumes. The farther away from the target a voxel is located, the higher the cost function penalizes high doses. You can use this instead of the Quadratic Overdose cost function. The rationale that you use this cost function is that it is more acceptable to have a higher dose closer to the target than it is to have high doses distant from the target. The Conformality cost function does not restrict the optimum dose. The Conformality cost function uses local importance weights that depend on the distance of a voxel to the nearest target volume and the dose prescribed to this voxel to modify the local effectiveness of the cost function.

F=

1 N

V

 D(i ) 

i =1



∑ f  D (i)  0



Where D 0 (i) is an estimate of the desired dose at point i. D 0 (i) depends on the distance of point i from the nearest target volume voxel, and the prescription dose to that voxel. f is a local penalty function N is the normalization factor Using a decay function of

g ( Ri ) =

1 4 R i

Where R i is the distance of point i from the edge of the target volume, gives a final cost function of:

1 F= N

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 4 Ri D(i )    ∑   i =1  D p ( ji )  V

k

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Conformality (cont.) D p (j i ) is the dose in the current dose distribution. You only have to define one parameter, k. The Conformality cost function does not require you to define an absolute isoconstraint for the prescription, which would be difficult to determine. Instead, it estimates a feasible measure of dose conformality for each case, and then requires you to prescribe how much more or less conformal the dose distribution should be than this estimate. Hence, the cost function only requires you to define a relative isoconstraint (Figure 7-32 Conformality dialog box).

Figure 7-32: Conformality dialog box The Relative Isoconstraint ranges from 0.01 to 1.00. Values less than 0.5 can start to restrict target coverage. Monaco applies a stronger penalty to voxels when you use a lower value for the Relative Isoconstraint. The default distance Monaco applies the Conformality Cost function is 4cm from the edge of the target. When you select Optimize over all voxels in volume , Monaco applies the cost function up to 8.0 cm from the edge of the target. You can also select Multicriterial to make this a secondary objective.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Quadratic Overdose This physical cost function is a constraint you can use with either targets or OARs to limit high doses in the structure to which it is applied. It is most often used in conjunction with the Target EUD objective to limit hot spots in the target. The rationale that you use this cost function is that sometimes a maximum dose limitation should not be enforced strictly while a small, yet controlled hot spot is permissible. In general, penalizing hot spots in IMRT may cause problems with associated cold spots in a target volume, so that a certain violation of the maximum dose limitation appears acceptable.

Figure 7-33: Required Parameters for Quadratic Overdose This cost function requires you to assign a parameter that is the Maximum Dose beyond which a penalty is incurred. Figure 7-34 graphs the shape of the Quadratic Overdose cost function curve. The isoconstraint is the (Root Mean Square) RMS Dose Excess the amount of violation of the prescription you are willing to accept. This value is comparable with the positive dose-variance above the reference dose you are willing to accept.

Figure 7-34: Quadratic Overdose Constraint

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Quadratic Overdose (cont.) This cost function plays an essential role for targets. Without a dose-limiting cost function, the Target EUD objective is bound to push the dose up to values higher than the prescription. A quadratic overdose cost function is ideal to prevent this (that is, if the Maximum Dose is set to the prescription dose in the target volume, and the RMS Dose Excess to a moderate value to control target hot spots). For example, 70 Gy/ 1 Gy is a commonly used practical value. The root mean square of a set of values is determined when you use this equation:

∑ D( x)

2

n D represents the voxel dose in excess of the Maximum Dose and n represents the total number of voxels. Only dose values above the Maximum Dose are considered.

Calculating a Root Mean Square for Dose Excess Consider a simple structure divided into four voxels. The Maximum Dose prescription is 70 Gy and the RMS Dose Excess is 2 Gy. The dose above 70 Gy appears in each voxel. If the root mean square of the Maximum Dose, plus the dose excess is greater than 72 Gy, the constraint is not met and the optimizer must try harder to reduce the dose excess.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Quadratic Overdose (cont.)

= 2.65 Gy 2.65 Gy is greater than the RMS Dose Excess of 2 Gy (or 72.65 Gy is greater than 72 Gy), so the optimizer has to keep working to lower the excess to 2 Gy. NOTE:

For further application of quadratic overdose, refer to the Planning Suggestions section under the Prescription heading.

Quadratic Underdose This physical cost function is a constraint that implements a quadratic penalty for underdose. Therefore, it implies that its structure is a target volume. You should handle this constraint with caution. It may result in an infeasible configuration of the optimization problem. Use this in conjunction with Pareto Mode to shift priority from OAR constraints to Target objectives.

Figure 7-35: Required Parameters for Quadratic Underdose

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Quadratic Underdose (cont.) This cost function requires a parameter that is the Minimum Dose allowable in a target. The isoconstraint is the RMS (Root Mean Square) Dose Deficit the amount of violation of the prescription you are willing to accept. It is analogously applied as the RMS Dose excess. Figure 7-36 graphs the shape of the Quadratic Underdose cost function curve. This isoconstraint works like an objective, may not be met when you apply contradictory constraints. The root mean square of a set of values is determined when you use this equation:

∑ D( x)

2

D represents the voxel dose below the Minimum Dose. n represents the n total number of voxels. Only dose values below the Minimum Dose are considered. NOTE:

Monaco®

The same concept as RMS dose excess applies to RMS dose deficit. See the Quadratic Overdose section for an example of how a root mean square is calculated.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Quadratic Underdose (cont.) Quadratic Underdose Minimum Dose = 70 Gy 400 350 300 Penalty

250 200 150 100 50 0 -50 50

55

60

65

70

75

Minimum Dose

Figure 7-36: Quadratic Underdose Constraint

7-40

80

85

90

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Maximum Dose This physical cost function is a constraint you can use with either targets or OARs. It is effectively a hard barrier. This penalty kicks in “all at once” whenever voxels cross the maximum dose threshold, so it can be troublesome. It may be preferable to use the Quadratic Overdose constraint with a small RMS Dose Excess (0.1 Gy) in most cases.

Figure 7-37: Required Parameters for Maximum Dose The isoconstraint is the maximum tolerated dose, Maximum Dose, which is not exceeded anywhere (any voxel) within the structure. Figure 7-38 graphs the shape of the Maximum Dose cost function curve.

Figure 7-38: Maximum Dose Constraint

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Overdose DVH This physical cost function is the equivalent of a DVH constraint for an OAR. When you add more than one DVH constraint to a structure, the values for dose and percent (%) volume (Figure 7-39) must be consecutive so that they create a single continuous curve.

Figure 7-39: Required Parameters for Overdose DVH Constraint This constraint requires two parameters: the Objective Dose and the Isoconstraint Maximum Volume. When you apply this cost function, it keeps the volume that receives more than the objective dose below the isoconstraint, which is given as a percentage of the total volume. For example, use this constraint if you want no more than 50% of a structure to receive a dose in excess of 60 Gy.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters Overdose DVH (cont.)

The constraint controls only a single point.

Figure 7-40: How an Overdose DVH Constraint Controls the DVH Curve – both DVH curves are effectively equivalent for this DVH constraint.

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Planning and Workflow: Calculation Parameters and IMRT Constraints Volume II of IV Monaco Training Guide

Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Required Cost Function Parameters (cont.) Underdose DVH This physical cost function is the equivalent of a DVH constraint for targets. If you add more than one DVH constraint to a structure, the values for dose and % volume (Figure 7-41) must be consecutive so that they create a single continuous curve. You should handle this constraint with caution. It may result in an infeasible configuration of the optimization problem if used together with dose limiting constraints.

Figure 7-41: Required Parameters for Underdose DVH Constraint It requires two parameters, the Objective Dose and the isoconstraint Minimum Volume. When you apply this cost function, it keeps the volume that receives less than the objective dose above the isoconstraint, which is given as a percentage of the total volume. For example, use this constraint if you want at least 80% of a structure to receive a dose of at least 50 Gy.

Figure 7-42: How an Underdose DVH Constraint Controls the DVH Curve

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions (cont.) Optional Parameters Each cost function has its own set of optional parameters. Not all optional parameters are available for each cost function. You do not have to use the optional parameters to optimize a plan. However, when used appropriately, they could increase your chances of creating a better plan.

Figure 7-43: All Optional Parameters Shrink Margin When you apply IMRT Constraints to structures close to the target volume, this may cause an underdose of the target because the dose gradient gets pushed in. Therefore, it is often desired to limit the effect of the constraint on the target. For example, you could apply a Quadratic Overdose to the unspecified normal tissue to ensure conformality. You can specify this shrunken margin for any structure (OARs or other competing targets) to avoid the application of IMRT Constraints to the voxels near the compromised (objective) target. Essentially, the application of a shrink margin moves the dose gradient out of the target and into the OAR or competing target. You can apply this optional parameter to all cost functions, except Target EUD, Target Penalty, Quadratic Underdose, Underdose DVH, and Conformality. Use shrink margin when you have competing cost functions that are immediately adjacent to each other or overlapping. Competing cost functions could be a target and an OAR (constraint), or a target and the dose limiting constraint of a second target. The shrink margin values are based on the fact that Monaco determines the shrink margin size based on multiples of the grid spacing. Example: If you have 0.3 cm grid spacing and select a 0.5 cm shrink margin, Monaco uses a 0.6 cm shrink margin because it rounds up to the closest multiple of the 0.3 cm grid spacing.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Shrink Margin (cont.) Figure 7-44 shows a head and neck case where a 0.6 cm shrink margin was applied to the quadratic overdose cost function of the unspecified tissue defined by the patient external contour. The purpose of this is to enable the voxels near the targets and other OARs to have a “transition zone” between competing cost functions. The cost function for the unspecified tissue is only applied to the area shaded in red during optimization. Notice that the applied margin only shrinks away from target structures.

Figure 7-44: Application of Shrink Margin/OAR Structure

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Shrink Margin (cont.) Figure 7-45 shows a head and neck case where GTV is inside CTV. It depicts applying a shrink margin to a Quadratic Overdose cost function of the CTV to create a dose gradient between CTV and GTV. The Quadratic Overdose cost function for CTV will be applied to the area shaded in red only. The area between the two structures that is not shaded in red has no penalty (not used by the constraint) applied to it, so it should provide better coverage to GTV.

Figure 7-45: Application of Shrink Margin/Target Structure NOTE:

Monaco®

For further application of shrink margins, refer to the Planning Suggestions section under the Prescription heading.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters (cont.) Surface Margin This optional parameter applies to the Target EUD, Underdose DVH, and Quadratic Underdose cost functions. Each of the cost functions that Surface Margin applies to penalizes for underdoses. Its application lets the cost function essentially ignore the low dose in a structure where it intersects the buildup region. When you select this option, Monaco applies the Surface Margin in the IMRT Prescription Parameter dialog box to the selected cost function. You should use Surface margin on superficial targets. When you select a surface margin for a particular cost function, that cost function only applies to voxels inside the structure (with the exception of the voxels that lie within the surface margin distance). The Surface Margin distance value range is 0.00 to 1.00 cm from the patient surface.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Surface Margin (cont.) The example in Figures 7-46 and 7-47 shows the cost function occupancy where a 0.5 cm surface margin was applied and the same cost function occupancy without surface margin. Only the voxels shaded in red are optimized.

Figure 7-46: Surface Margin of 0.5 cm Applied to Target EUD Cost Function

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Figure 7-47: No Surface Margin Applied

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Surface Margin (cont.) The effects of Surface Margin are shown in Figure 7-48. Two plans that show a comparison of the dose distribution to a superficial brain target: NoSurfMargin - No Surface Margin was applied SurfMargin - Surface Margin was applied NoSurfMargin-SurfMargin – Shows the dose difference between the two plan

Figure 7-48: Application of Surface Margin

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Surface Margin (cont.) The DVH in Figure 7-48 shows that for this case: The target coverage does not vary much from plan to plan (see NOTE below). The dose to the patient (unspecified tissue) structure increases significantly for the plan that does not use surface margin. This also shows well in the subtracted plan. NOTE:

If the target contour is drawn out to the patient’s surface and surface margin is applied, the dose that intersects the target and the buildup region may have a significantly lower dose when surface margin is applied. You must consider this when you determine the acceptable percent coverage to the target.

The benefits when you use Surface Margin (Figure 7-48) are: •

Decreased MU/fx for fields that flash over the surface of the patient

•

Decreased Total MU/fx for the entire plan

•

Decreased Global Max dose for the entire plan

When you draw a target in the buildup region and you do not apply Surface Margin, fields that flash over the patient surface attempt to compensate for the low dose in the buildup while trying to bring the target dose closer to the prescription. This can be a problem as demonstrated in Figure 7-49. Notice the difference in the Relative MU value for the same voxel in the two images.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Surface Margin (cont.)

Figure 7-49: Comparison of BEV With and Without Using Surface Margin

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters (cont.) Optimize Over All Voxels in Volume You can apply this optional parameter to any cost function. It is recommended that you apply this option to a Serial cost function. Due to the volume-effect of the serial cost function, you will typically want to apply the constraint to the entire volume of the structure. When you select the option to “Optimize over all voxels in volume” on the prescription panel for a specific cost function and a specific structure, you are making the decision that the cost function applies to the total volume of the structure, regardless of the structure layering. If there is overlap with another structure, the cost functions for both structures are applied to the overlapped voxels. When you use Optimize over all voxels on a parallel cost function where the structure overlaps or is very close to a target, often gives little improvement to your plan since the parallel cost function does not “work hard” on limiting hot spots. Figure 7-50 and 7-51 shows a head and neck where the GTV, CTV and PTV overlap the Parotid. Figure 7-50 shows the cost function occupancy of the Parallel cost function on the parotid when Optimize Over all Voxels is applied. In this case, in the area where the targets and parotid overlap, both the target cost functions and the parotid cost function are applied. Figure 7-51 shows the cost function occupancy of the Parallel cost function on the parotid when Optimize Over all Voxels is not used. In this case, the Parallel cost function on the parotid is only applied to the voxels shaded in red.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Cost Functions Optional Parameters Optimize Over All Voxels in Volume (cont.)

Figure 7-50: Parallel Cost Function Occupancy with Optimize Over all Voxels

Figure 7-51: Parallel Cost Function Occupancy without Optimize Over all Voxels

Multicriterial This optional parameter applies to Parallel, Serial, and DVH cost functions. When applied, the cost function becomes a secondary objective. It actually tries to achieve an even lower dose (tighten the constraint) to the selected OAR as long as it can still meet the target objective. NOTE:

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See the Monaco Planning and Workflow section for a more detailed explanation of multicriterial. Also, see the Planning Suggestions section under Optimization for further application of multicriterial.

Planning and Workflow: Calculation Parameters and IMRT Constraints Monaco Training Guide

Monaco Cost Functions Quick Reference

Cost Function Target Penalty

Type

Applied To

Objective Target

Target EUD Objective Target

Optimize Reference Total Shrink Isoconstraint Dose Multicriterial Volume Margin Dose at a specified reference volume Prescription YES Rx Dose (EUD)

YES

Surface Margin

YES YES

Notes This is the objective version of the Quadratic Underdose constraint. Biological Cost Function. Cost function for Targets. No Penalty for hot spots. Biological Equivalent of Overdose DVH Constraint.

Parallel

Serial

Constraint or Secondary Objective Constraint or Secondary Objective

OAR

OAR

Quadratic Overdose Constraint Target OAR Quadratic Underdose Constraint Target Constraint or Secondary Conformality Objective OAR

Mean Organ Damage (%)

Reference Dose (EUD)

EUD Equivalent Uniform Dose RMS Root Mean Square Maximum Dose Excess Dose RMS Root Mean Square Minimum Dose Deficit Dose

Dose Decay

YES

YES

YES

YES

YES

YES

YES

YES

Reference Dose is the dose that when applied uniformly to an organ, 50% of that organ will be damaged (TD 50 ).

YES

Biological Cost Function. This applies large penalties for hot spots.

YES

You most often use this with Target EUD to reduce hotspots in the target.

YES

YES

When you use this cost function, it could cause the plan to be infeasible due to the powerful nature of the constraint. You use this to shape the high dose volume tightly around a target volume without being too restrictive to the optimum dose. 55

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Cost Function

Type

Applied To

Optimize Reference Total Shrink Isoconstraint Dose Multicriterial Volume Margin

Maximum Dose Constraint Target OAR Constraint or Overdose Secondary DVH Objective OAR

Maximum Dose Maximum Volume

Threshold Dose

Underdose DVH Constraint Target

Minimum Volume

Threshold Dose

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YES

Surface Margin

YES

Notes This acts as a hard barrier on each voxel of the applied structure. Quadratic Overdose preferred over this constraint. Physical DVH Constraint for OAR

YES

YES YES

YES YES

Physical DVH Constraint for Targets

Planning and Workflow: Calculation Parameters and IMRT Constraints Monaco Training Guide

Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other Rescale Dose You can rescale dose on the Prescription tab on the Planning Control. You have seven options to choose from in the Rescale Dose drop-down menu (Figure 7-52). This option is not available during optimization.

Figure: 7-52: Rescale Dose Drop-Down Menu

Name

Monaco®

Description

to cover

% and Structure field appears

to min dose of structure

Structure field appears

to mean dose of structure

Structure field appears

to max dose of structure

Structure field appears

to dose at point

All available points appear

to relative isoline

You can type a value for the % isoline in the number field that appears

to absolute isoline

You can type a value for the cGy or Gy isoline in the number field that appears

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other Rescale Dose (cont.) 1.

Type a value in the box next to Gy.

2.

Click the drop-down arrow to the right of the to… field.

3.

Select a rescale option from the drop-down menu.

4.

Select and/or type values associated with the rescale option.

Enabled This field lets you manually turn cost functions off or on during the optimization when you place or remove the checkmark in the box. If the optimization is close to completion, it is possible that it will finish before the change takes place. The Status field indicates whether the cost function was on or off during the optimization.

Bias Dose (only shows for Bias Dose Plans) To make a Bias Dose Plan, you can right-click on the plan and select New Bias Dose Plan. Then select the CT set it is based off of. (Figure 7-53)

Figure 7-53: New Bias Dose Plan

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other Bias Dose (only shows for Bias Dose Plans) (cont.) If you have multiple prescriptions, you can use the Bias Dose option in the IMRT Prescription Parameters dialog box. Figure 7-54)

Figure 7-54: Bias Dose Plan option for Multiple Prescriptions

Then you can enable or disable the Bias Dose option on the IMRT Constraints options. This field lets you select which cost functions you want to apply to Bias Dose during the optimization of the composite plan. Typically, you leave Bias Dose for the target cost functions unchecked. In addition, you type the prescription for the current plan for the target(s) and the prescription for the composite plan for the organs at risk. This lets the system create well-defined target dose(s) for the current plan and take into account the total dose limitations of the organs at risk. (Figure 7-55)

Figure 7-55: Enable and Disable Bias Dose on IMRT Constraints

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other (cont.) Status This field shows the status of the cost function in the optimization. The status levels are: On — the optimizer is using the cost function. Off — you manually turned the cost function off so it is not used during the optimization, or the optimizer turns the cost function off since the constraints were not affecting the objective cost function. The latter usually occurs when the constraint prescriptions are considerably higher than the current dose distributions. Offending — the constraint value is unreasonably high and causes numerical problems. Verify that the prescribed constraint is what you intended, or relax the prescription. Infeasible —the values you typed in for the cost function are not reasonable. The optimizer may attempt to change the value of the isoconstraint for a few iterations, but it stops trying if the solution does not get closer to feasible. Make reasonable changes to the prescription or isoconstraint and optimize again, if necessary.

Manual Weighting The Manual field lets you select which cost functions you want to manually weight. The Weight column shows the actual weights used by the optimizer during constrained optimization. You can check manual weighting for a cost function while the others are still controlled by the optimizer. You can also click on the Manual heading to turn on all cost functions for manual weighting. Typically, you leave the manual weighting unchecked during optimization. You can turn on manual weighting for all cost functions for the final calculation in order to fine tune constraints based on the DVH results.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other (cont.) Isoeffect The isoeffect is defined as the equivalent effect of a given dose distribution for each individual complication or cost function. In some cases, the isoeffect is an equivalent uniform dose (EUD). This volumetric dose represents the homogeneous dose to some reference volume that causes the same effect as the given dose distribution. In other cases, the isoeffect is the percentage of maximum damage or destroyed fraction of the organ volume. Monaco calculates the isoeffect for each cost function for you and continuously updates them on the IMRT Constraints dialog box during optimization.

Isoconstraint The definition of the isoconstraint is the maximum permissible total effect for each individual complication or objective. The isoconstraint value you type in may be a dose or percent volume. This depends on the cost function selected. The isoconstraint is the accepted upper limit of the isoeffect for any cost function treated as a constraint. For objectives, the isoconstraint is interpreted as a desired value, but may not be reachable. Typically, the isoconstraint is a value typed in by you. However, there are two cases when Monaco may change the isoconstraint value. One case occurs when multicriterial is turned on. Monaco lowers the isoconstraint, if possible, to achieve a secondary objective. Another case may occur when a cost function is infeasible. Monaco may try to change the isoconstraint of the offending cost function in an attempt to gain feasibility.

Reference Dose This value may be a Minimum or Maximum Dose of a physical constraint. It designates the dose value at which the physical penalty becomes active (relevant for Quadratic Overdose/Underdose and DVH constraints).

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other (cont.) Multicriterial You can treat constraints such as Serial, Parallel, and Overdose DVH cost functions as secondary objectives when you select the multicriterial option. This action changes the constraint to a secondary objective that improves only after the “primary” target objective(s) is/are met. If the optimizer can still reach the target objective without being compromised by prescribed constraints, it begins to tighten the value of the isoconstraint for the Serial, Parallel or Overdose DVH constraint. This means that Monaco attempts to get the OAR dose as low as possible. This option does not take any effect if the target objectives cannot be met, that is, because some constraints are dose limiting. The example in Figure 7-56 shows the difference in dose to the rectum if you use dose points (solid green line), Serial (dotted green line) or Serial with Multicriterial (dashed green line). Notice that the dose to the target for each plan is not compromised for better rectum avoidance.

Figure 7-56: Comparison of methods to limit dose to Rectum NOTE:

For further application of multicriterial, refer to these sections:  Cost Functions, under the Optional Parameters heading  Planning Suggestions, under the Optimization heading

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other (cont.) Relative Impact The relative impact is an indicator that shows how hard the optimizer is working on a particular constraint at any given time during the optimization. The indicators are: Blank- Cost function is an objective or is not being used (inactive) by the optimizer. Relative impact is 0. +

Relative impact of the cost function on the optimizer is greater than 0 but less than 0.25.

++

Relative impact is greater than 0.25 but less than 0.5.

+++

Relative impact is greater than 0.5 but less than 0.75.

++++ Relative impact is greater than 0.75 but less than 1.0. This always represents the most dose limiting constraints.

Optimization Modes The system offers two optimization modes: Constrained (Normal Tissue Priority) and Pareto (Target Volume Priority). Constrained Optimization Mode Constrained mode lets you place priority on normal tissue constraints. All normal tissue constraints are met at the risk of not meeting the target objective. Example of Constrained Optimization: If you use an underdose volume constraint on a target and a constraint on an OAR is not being met because of it, the underdose volume constraint on the target will be relaxed first so the OAR constraint may be met.

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Planning and Workflow: Calculation Parameters and IMRT Constraints IMRT Constraints: Other Optimization Modes (cont.) Pareto Optimization Mode Pareto mode lets you place priority on constraints used to set minimum doses on targets, for example, Quadratic Underdose, or Underdose DVH. Target doses are met at the risk of not meeting the normal tissue constraints. Example of Pareto Optimization: If you use an underdose volume constraint on a target and a constraint on an OAR is not being met because of it, the constraint on the OAR will be relaxed first so the underdose volume constraint on the target may be met. NOTE:

When you use Pareto Mode, it may cause the prescription for conflicting OARs to become infeasible.

Exercises Go to the Practice Exercise section of the Training Guide to complete the following exercises:

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•

Editing IMRT Constraints

•

Adjustment to Serial Power Law (k)

•

Adjustment to Parallel Power Law (k)

Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization This section discusses the optimization of Monaco plans. In Dose Based Optimization, beamlet intensities are weighted to achieve a desired dose distribution. In Evidence Based Biological Optimization, beamlet intensities are weighted via biological models such that the calculated dose distribution yields a known tissue response1. Monaco uses both dose based and biological cost functions. After you type the prescription information into the system, it is time to begin the optimization process. Monaco uses a two-stage process of optimizing dose distributions. Generally, in stage one, the “ideal fluence” distribution of beams is optimized to meet a user-defined prescription for a single set of beams. In stage two, the ideal fluence distribution is translated into a set of segments where the shapes and weights are optimized based on the same prescription. Because Monaco uses a combination of objectives and constraints to calculate the objective function during optimization, all targets and organs at risk should appear on the IMRT Constraints page when you optimize. NOTES:

You must have at least one objective and one constraint defined in your prescription before you can begin optimization. You must apply some cost function to the “patient contour” structure and, in most cases, list it as the last structure in the layering order.

It may be useful for you to understand how Monaco re-samples the patient to create voxelized structures for optimization. This effects how cost functions are applied to the structures. For detailed information, see the Monaco Patient Model section of this guide. On occasion, you may want to batch the optimization process such that both stage one and stage two are performed to completion without a pause in between. You can do batch optimization when you click the Batch Optimization button instead of the Start Optimization button. NOTE:

Monaco®

If you skip forward or skip back during a batch optimization, you may have to skip forward or backward twice. This depends on the phase of the batched optimization when you selected the skip option.

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Planning and Workflow: Optimization and Sequence Parameters Optimization (cont.) Step and Shoot IMRT Delivery Mode Stage One – Fluence Optimization Stage one of the optimization process works as follows:

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1.

When you start the Initialization process, the system creates the dose calculation cube around all defined structures and calculates the structure volumes using cubic voxels.

2.

The system projects the union of all target volumes, plus defines the margin as the Target Margin on the IMRT Calculation Properties dialog box, in a BEV.

3.

Beamlets for each beam are created. Beamlet width is user defined. The beamlet length is the length of the individual MLC leaves.

4.

Monaco uses an enhanced pencil beam algorithm to calculate the open field dose. Then, the fluence optimization begins in which the weights (fluence) of all individual pencil beams are varied simultaneously.

5.

The system then solves an unconstrained problem using a conjugate gradient algorithm.

Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization (cont.) Step and Shoot IMRT Delivery Mode Stage One – Fluence Optimization (cont.) 6.

After the unconstrained optimization finishes, if necessary, Monaco changes each cost function’s relative weight to make the optimizer meet the isoconstraints and restarts the unconstrained optimization problem.

7.

Stage 1 optimization continues until all the constraints are met or the weighting hits a pre-determined threshold, at which time the constraint is identified as infeasible.

When Monaco evaluates the effects of individual constraints on prescribed objectives, it gives you information on the potential to improve the plan by relaxing specific constraints. In other words, after the optimization, Monaco gives feedback for each target volume and defines which constraint should be relaxed in order to improve target coverage. This feedback appears on the Sensitivities tab of the IMRT Constraints dialog box. Constraints which limit the dose to targets have high values in sensitivity, as opposed to constraints that are inactive or do not limit the dose to the target which show low values. Serial, Parallel, and DVH Constraints can also be set as “multicriterial” or in other words, set as secondary objectives. These constraints are subsequently tightened throughout the optimization process as long as they are not the limiting constraints to the objective. NOTE:

See the Plan Analysis Tools section for information on the tools available during and after stage one optimization.

Stage Two – Aperture Optimization and Dose Calculation After you complete the fluence optimization, you can do any of these tasks:

Monaco®

•

Review the optimized results

•

Make edits to the prescription

•

Re-optimize stage one

•

Directly launch into the second stage of optimization where you optimize the apertures (segment weights and shapes)

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Planning and Workflow: Optimization and Sequence Parameters Optimization Step and Shoot IMRT Delivery Mode Stage Two – Aperture Optimization and Dose Calculation (cont.) You can only select Pencil Beam for stage 1 of optimization. You must use Monte Carlo dose algorithm for stage 2. Segmentation of IMRT plans often introduces an unwelcome reduction in the quality of dose distributions. When you apply fluence smoothing constraints, and include the technical limitations of the MLC in the optimization problem, Monaco can overcome this limitation and deliver efficient step-and-shoot beams with fewer segments and MUs – directly translating to faster QA and less time required for patients on the treatment couch.

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Planning and Workflow: Optimization and Sequence Parameters Optimization Step and Shoot IMRT Delivery Mode Stage Two – Aperture Optimization and Dose Calculation (cont.) Stage two of the optimization works as follows: 1.

Monaco extracts and loads the Fluence weight profiles into a static sequencer where segments are extracted and refined.

2.

Monaco optimizes the beamlet and segment weights and uses the constrained optimization where the Minimum MU/Segment is evaluated and segments are refined.

3.

When the problem is solved to the best of its ability, the optimizer converges if Segment Shape optimization is not checked. If it is checked, the optimizer determines if another round of refinement and optimization is allowed or needed. This is called Smart Sequencing. If the optimizer decided another round could be useful, it will send the problem back to the static sequencer mentioned in step 1 and continues through step 4. The secondary algorithm is used during the final iteration.

4.

The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot Beamlets to guide the segment shape changes made during Segment Shape Optimization. Monaco creates a large number of Pilot Beamlets if you use large highly modulated treatment fields, multiple VMAT arcs and a small arc increment. When a large number of Pilot Beamlets, which are stored in memory, are created they can use all the RAM the system has. This slows the process exponentially. Disabling this option removes the creation of pilot beamlets from the SSO process. Pilot beamlets do not affect performance for the majority of treatment plans. You should only disable them if the plan takes a long time to converge. NOTE:

Monaco®

Use the Windows Task Manager to check the RAM utilization of your system if you suspect the plan is taking too long to converge.

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Planning and Workflow: Optimization and Sequence Parameters Optimization (cont.) Conformal RT Delivery Mode Stage One – Optimization Stage one of the optimization process works as follows: 1.

While in the Initialization Process, the system creates the dose calculation cube around all defined structures and calculates structure volumes using cubic voxels.

2.

The system projects the union of all target volumes, plus the margin defined as the Target Margin on the IMRT Calculation Properties dialog box in a BEV.

3.

The system uses an enhanced pencil beam algorithm to calculate the open field dose.

4.

The system then solves an unconstrained problem using a conjugate gradient algorithm.

5.

After the unconstrained optimization is done, if necessary, Monaco changes each cost function’s relative weight to make the optimizer meet the isoconstraints and restarts the unconstrained optimization problem.

6.

Stage 1 optimization continues until all the constraints are met or the weighting hits a pre-determined threshold, at which time the constraint is identified as infeasible.

When you evaluate the effects of individual constraints on prescribed objectives, Monaco gives information on the potential to improve the plan by relaxing specific constraints. In other words, after the optimization, Monaco gives feedback for each target volume and defines which constraint should be relaxed in order to improve target coverage. This feedback appears on the Sensitivities tab of the IMRT Constraints dialog box. Constraints which limit the dose to targets have high values of sensitivity, as opposed to constraints that are inactive or do not limit the dose to the target which shows low values.

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Planning and Workflow: Optimization and Sequence Parameters Optimization Conformal RT Delivery Mode Stage One – Optimization (cont.) You can also set Serial, Parallel, and DVH Constraints as “multicriterial,” or in other words, set as secondary objectives. These constraints are subsequently tightened throughout the optimization process as long as they do not limit constraints to the objective. NOTE:

See the Plan Analysis Tools section for information on the tools available during and after stage one optimization.

After you complete stage one optimization, you can do any of these tasks:

Monaco®

•

Review the optimized results

•

Make edits to the prescription and re-optimize stage one

•

Directly launch into the second stage of optimization where you calculate the final dose with the Monte Carlo algorithm

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Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization (cont.) dMLC Delivery Mode Stage One – Fluence Optimization Stage one of the optimization process works as follows: 1.

While in the Initialization Process, the system creates the dose calculation cube around all defined structures and calculates the structure volumes with cubic voxels.

2.

The system projects the union of all target volumes, plus the margin defined as the Target Margin on the IMRT Calculation Properties dialog box in a BEV.

3.

The system creates beamlets for each beam. Beamlet width is user-defined and the beamlet length is the length of the individual MLC leaves.

4.

The system uses an enhanced pencil beam algorithm to calculate the open field dose. Then, the fluence optimization begins in which the weight’s (fluence) of all individual pencil beams is varied simultaneously.

5.

The system then solves an unconstrained problem with a conjugate gradient algorithm.

6.

After the unconstrained optimization is done, if necessary, Monaco changes each cost function’s relative weight to make the optimizer meet the isoconstraints and restarts the unconstrained optimization problem.

7.

Stage 1 optimization continues until all the constraints are met or the weighting hits a pre-determined threshold, at which time the constraint is identified as infeasible.

When you evaluate the effects of individual constraints on prescribed objectives, Monaco can give information on the potential to improve the plan by relaxing specific constraints. In other words, after the optimization, Monaco gives feedback for each target volume and defines which constraint should be relaxed in order to improve target coverage. This feedback appears on the Sensitivities tab of the IMRT Constraints dialog box. Constraints which limit the dose to targets have high values of sensitivity, as opposed to constraints that are inactive or do not limit the dose to the target which show low values.

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Planning and Workflow: Optimization and Sequence Parameters Optimization dMLC Delivery Mode Stage One – Fluence Optimization (cont.) You can also set Serial, Parallel, and DVH Constraints as “multicriterial,” or in other words, set as secondary objectives. These constraints are subsequently tightened throughout the optimization process as long as they are not the limiting constraints to the objective. The optimizer works to maintain the target dose coverage at the same time. NOTE:

Monaco®

See the Plan Analysis Tools section for information on the tools available during and after stage one optimization.

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Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization dMLC Delivery Mode (cont.) Stage Two – Aperture Optimization and Dose Calculation The sequencing algorithm used for dMLC is called the Sweep Sequencer, and is the same as used for the basis of VMAT sequencing. It is similar in nature to sliding window sequencers, but different in that it has significant improvements to improve delivery efficiency and minimize loss of dose quality. The basic paradigm of the Sweep Sequencer is that the leaves move from their start to their end position in a continuous, unidirectional manner. When you move the leaves across the field from one side to the other, vary the leaf speeds and thereby the gaps between opposing leaves, the system modulates the intensity of the delivered fluence. Changing the leaf gap is accomplished by either accelerating the leading leaf (more fluence) or the trailing leaf (less fluence). At least one leaf moves at maximum velocity at any given time to provide for the shortest possible delivery time.

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Starting with the optimized fluence profiles from stage 1, the system converts each profile to a series of leaf trajectories (that is, leaf position as a function of MU). All trajectories are synchronized to arrive at the same MU count for all leaf pairs. Monaco uses the beamlet width to sample these leaf trajectory positions.

2.

You translate the leaf trajectories into piecewise linear movements between control points. You can control the coarseness of this decomposition, or total number of control points when you use the parameter, Max # Control Points / Beam. In general, the system inserts a control point whenever a single leaf changes velocity.

3.

The system does weight optimization on resulting segments and repeats the optimization until it converges.

4.

If you leave SSO checked, segment shape optimization combines segments and re-weights them in order to create better plan quality and more efficient delivery times.

Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization dMLC Delivery Mode Stage Two – Aperture Optimization and Dose Calculation (cont.) 5.

The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot Beamlets to guide the segment shape changes made during Segment Shape Optimization. Monaco creates a large number of Pilot Beamlets if you use large highly modulated treatment fields, multiple VMAT arcs and a small arc increment. When a large number of Pilot Beamlets, which are stored in memory, are created they can use all the RAM the system has. This slows the process exponentially. Disabling this option removes the creation of pilot beamlets from the SSO process. Pilot beamlets do not affect performance for the majority of treatment plans. You should only disable them if the plan takes a long time to converge. NOTE:

Monaco®

Use the Windows Task Manager to check the RAM use of your system if you suspect the plan is taking too long to converge.

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Planning and Workflow: Optimization and Sequence Parameters Optimization (cont.) VMAT Delivery Mode Stage One – Fluence Optimization Stage one of the optimization process works as follows:

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1.

While in the Initialization Process, the system creates the dose calculation cube around all defined structures and calculates structure volumes using cubic voxels.

2.

The system projects the union of all target volumes and defines the margin as the Target Margin on the IMRT Calculation Properties dialog box in a BEV.

3.

The system calculates a number of static sectors that the optimizer uses to create rays based on the Arc and the Increment you selected.

4.

The system creates beamlets for each sector. Beamlet width is user-defined and the beamlet length is the length of the individual MLC leaves.

5.

The system uses an enhanced pencil beam algorithm to calculate the open field dose. Then, the fluence optimization begins in which the weights (fluence) of all individual pencil beams are varied simultaneously.

6.

The system then solves an unconstrained problem. It uses a conjugate gradient algorithm.

7.

After the unconstrained optimization completes, if necessary, the system changes each cost function’s relative weight to make the optimizer meet the isoconstraints and restarts the unconstrained optimization problem.

8.

Stage one optimization continues until all the constraints are met or the weighting hits a pre-determined threshold, at which time, the constraint is identified as infeasible.

Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization VMAT Delivery Mode (cont.) Stage Two – Aperture Optimization and Dose Calculation 1.

Stage two takes each fluence map and sequences it in such a way that it is spread over the original sector that it represents. The system determines leaf trajectories based solely on the Target Dose rate entered. If segment shape optimization (SSO) is checked, the Target Dose Rate option is not available. In this case, the sequencer controls the target dose rate to make sure it is optimally set for the given plan.

2.

The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot Beamlets to guide the segment shape changes made during Segment Shape Optimization. Monaco creates a large number of Pilot Beamlets if you use large highly modulated treatment fields, multiple VMAT arcs and a small arc increment. When a large number of Pilot Beamlets, which are stored in memory, are created they can use all the RAM the system has. This slows the process exponentially. Disabling this option removes the creation of pilot beamlets from the SSO process. Pilot beamlets do not affect performance for the majority of treatment plans. You should only disable them if the plan takes a long time to converge. NOTE:

Use the Windows Task Manager to check the RAM use of your system if you suspect the plan is taking too long to converge.

3.

The system converts optimized fluences into a deliverable arc sequence with multiple control points.

4.

The system optimizes gantry positions. They are not necessarily equally spaced.

5.

Monte Carlo dose calculation takes place.

6.

The system optimizes Segment Weights.

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Planning and Workflow: Optimization and Sequence Parameters Optimization VMAT Delivery Mode (cont.) Stage Two – Aperture Optimization and Dose Calculation (cont.)

7.

If you leave SSO checked, segment shape optimization combines segments and re-weights them in order to create better plan quality and more efficient delivery times. NOTE:

VMAT is available for Apex MLC when used with MCS 3.0. Apex MLC cannot be used with a variable dose rate, so VMAT with Apex is only available with Constant Dose Rate. The Monaco VMAT segmenter is used, but the dose rate is not modulated during Apex VMAT delivery.

Dynamic Conformal Arc Delivery Mode Aperture Optimization and Dose Calculation Dynamic Conformal Arc calculation only has one stage unless you check Segment Shape Optimization (SSO) in the sequencing parameters dialog box. The optimization process works like this: 1.

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Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Optimization Dynamic Conformal Arc Delivery Mode Aperture Optimization and Dose Calculation (cont.) 2.

The system calculates a number of static sectors that the optimizer uses to create rays based on the Arc and the Increment you selected.

3.

Monte Carlo dose calculation takes place.

4.

The system projects the union of all target volumes and defines the margin as the Target Margin. Then, it removes any OARs that are set as Avoidance with the Avoidance Margin specified on the IMRT Calculation Properties dialog box in a BEV.

5.

Arc weight optimization continues until it meets the best solution or the weighting hits a predetermined threshold. At that time, the constraint is identified as infeasible.

6.

The Sequencing Parameters: Dyn. Conformal Arc Delivery dialog box has a Constant Dose Rate check box. By default, Monaco uses a constant Monitor Unit per Degree of gantry rotation. Deselect the Constant Dose Rate check box to vary the Monitor Unit per Degree of gantry rotation. This option is not available (grayed out) for all add-on MLCs (Apex, all micro-MLCs).

7.

When you select Segment Shape Optimization for Dynamic Conformal Arc delivery, you can change the initial segment shapes to better meet the prescription. (Refer to the VMAT SSO and Pilot Beamlet information in this section for detailed information). NOTE:

Monaco®

When you use an Apex treatment unit while planning, if you check SSO for a Dynamic Conformal Arc delivery plan, the resulting plan may be undeliverable because the minimum dose rate is violated.

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters This section introduces the sequencing parameters and how they apply to each delivery mode. Before or after stage-two optimization, you have the opportunity button to edit the sequencing parameters. Click the Sequencing Parameters to view and edit the sequencing parameters for each type of delivery mode (Figures 8-1 through 8-6). Table 8-1 shows which sequencing parameter applies to which delivery mode. If you edit the sequencing parameters after stage two, the system intelligently decides how far back to go in the calculation, which depends on the parameter that was changed.

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters (cont.)

Figure 8-1: Sequencing Parameters for Step and Shoot Figure 8-2: Sequencing Parameters for VMAT

Figure 8-4: Sequencing Parameters for Conformal RT

Figure 8-3: Sequencing Parameters for dMLC

Figure 8-5: Sequencing Parameters for DCA Figure 8-6: Sequencing Parameters for mArc

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters (cont.) Table 8-1: Sequencing Parameters for all Delivery Mode Delivery Mode

Sequencing Parameter Segment Shape Optimization Min. Segment Area Pilot Beamlets Max Number of Segments per Plan Max Number of Arcs (Elekta and Varian) Max # Control Points/Beam Max# Control Points/Arc Target Dose Rate Min Segment Width Fluence Smoothing Min MU/Segment Park Leaf Gap Under Jaw Max Sweep Efficiency Allow Move Only Segments Constant Dose Rate Min. MU per Dynamic CP

Step and Shoot IMRT X X x

dMLC

VMAT

X x

Conformal RT

DCA

mArc

X

X

X

x

x

x

X X

X

X X* X X

X X* X

X

X X X X

X* X X

X X X X

X

* Target Dose Rate for VMAT, dMLC, and VMAT is only available when you uncheck SSO.

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Planning and Workflow: Optimization and Sequence Parameters Volume II of IV Monaco Training Guide

Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters (cont.) Segment Shape Optimization When you check this option, you enable the system to do segment shape optimization before it calculates the final dose. Segment Shape Optimization includes smoothing, sequencing (clustering) and optimization of beam weights and shapes. You can use segment shape optimization to refine the segment shapes and apply it after the initial sequencing of the segments. It works the same for these delivery modes: Step and Shoot IMRT, VMAT, dMLC, DCA, and mArc. It is turned on by default and is highly recommended in order to give better plan quality and decrease delivery times.

Segment Shape Optimization Characteristics Optimization Time

Increases

Plan Quality

Increases

Delivery Time

Decreases

Segment #

Decreases

MU

May Increase

Figure 8-7: Segment Shape Optimization Characteristics

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters (cont.) Min. Segment Area (cm) This value represents the smallest segment field area (cm2) you are willing to accept in your plan. Use the default value of 0.5 for IMRT plans. You need to use 1.0 for VMAT SSO.

Max. # of Segments per Plan Enter the maximum number of segments you want in the plan. If you do not have a value saved in your plan template, this field defaults to 250 segments. This parameter controls the maximum number of segments so that no new calculation yields more segments than the value of this parameter.

Max. Number of Arcs (Elekta and Varian machines) This value is the max number of rotations per arc that you want to use for an Elekta or Varian VMAT plan. The recommended value is 2 for complex plans.

Max. # Control Points/Beam This value represents the maximum number of control points per beam that you are willing to accept for a dMLC plan.

Max. # Control Points/Arc This value represents the maximum number of control points that you are willing to accept for each VMAT arc. VMAT Specific information: When you use Elekta VMAT to plan, you can determine the value for max number of control points per arc based on how complex the plan is. When you use SSO, we recommend a range of 100-150 for highly complex plans. For simple plans, you can use around 75-100 control points per arc. When you use a Varian machine to plan VMAT, you can do simple plans in a single arc rotation. When you have a more complex plan, more rotations are necessary due to the linac limitations.

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters Target Dose Rate This value is the desired dose rate you want to use to deliver a dMLC plan. SSO, which is defaulted to ON, controls the Target Dose Rate for VMAT, dMLC. If the segment shape optimization (SSO) is left on, the Target Dose Rate option is not available. In this case, the sequencer controls the target dose rate to make sure it is optimally set for the given plan. If SSO is turned off, Monaco uses Target Dose Rate for VMAT and dMLC so that it knows the maximum possible distance the gantry can travel between control points based on the machine’s available dose rate. Monaco is sensitive to the Target Dose Rate and control point input you type in. Therefore, we recommend that you keep SSO checked for VMAT, dMLC, and mArc. Recommended Ranges for Non-SSO VMAT: •

Elekta Specific Information: You must use a higher target dose rate for simple plans. For more difficult plans, you must use a lower target dose rate. The recommended range for all plans that use Elekta machines is 120-360.

•

Varian Specific Information: When you use a higher target dose rate, the number of rotations increases. It is possible that the number of rotations can increase up to the defined maximum that you set. For simple plans, we recommend you use a Target Dose Rate at Max (600) which typically causes a total of 2 rotations. For complex plans, we recommend a target dose rate of approximately 400, which typically causes a total of 3 rotations. We highly recommend that you use SSO which controls the dose rate and results in better plan quality.

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters Min. Segment Width (cm) This is the minimum distance between opposing MLC leafs you are willing to accept. The recommended value is 0.5 cm.

Fluence Smoothing The fluence smoothing parameter controls the smoothing of the fluence in stage one of the optimization. Fluence smoothing options are Off, Low, Medium and High. If you select Off or Low, this could cause the generation of too many segments. If you select High, this could cause the fluence to be too smooth which can degrade the final result. Medium is a recommended starting point. Smooth ↑ Plan Quality ↓ Control Points ↓

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters Target Dose Rate (cont.) Min. MU/Segment This is the minimum Monitor Unit value you will accept for any segment the system creates.

Park Closed Leaf Gaps Under Jaw When planning using MLC models that allow interdigitation, the system automatically creates more efficient segments by placing closed leaf gaps inside the fluence map. The system optimizes dose leakage through the gaps and contributes to the total dose delivered by the plan. To override this feature, select the Park Closed Leaf Gaps Under Jaw option. The closed leaves are instead parked under the jaw. This can add additional time to the delivery in particular for beam modulator.

Max Sweep Efficiency When you use Max. Sweep Efficiency, you can improve the MU efficiency during sequencing of dMLC beams without negatively affecting plan quality. It positions some leaf pairs further apart at the start or end of a sweep pattern and thereby minimizes the overall leaf travel. For example, when you use the Max. Sweep Efficiency option on a typical prostate plan, you can reduce the total number of MU by 100 or more, with only a slight reduction in dose quality. The recommended setting for this option is checked (on).

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Planning and Workflow: Optimization and Sequence Parameters Editing the Sequencing Parameters Allow Move Only Segments (dMLC Only): When you check this option, you allow Move Only Segments for Elekta or Varian linacs. Move Only Segments are segments without fluence that move the leaf carriage to the next beam segment. Once the leaf carriage is in the starting position for the next segment, the dose turns back on. When you uncheck this option, the dose remains on during the entire beam delivery. Your plan quality can decrease if you uncheck this option. NOTES:

This option was added in 3.10. Prior to 3.10, Monaco always allowed move only segments. ARIA Customers: If you check this option for dMLC planning (recommended), you must set the machine “Field X” operation limit motion mode to dynamic or multiple static segment in ARIA in order to approve the treatment plan in RT Chart. Failure to do so could potentially cause validation of fields to fail with this message “ERROR: The fields below are large fields, but the defined machine does not support them.”

Constant Dose Rate The Constant Dose Rate option is only available for those Varian machines that support constant dose rate. It is also available for MLCi/MLCI2, and Apex MLC on Agility. When you check the Constant Dose Rate option, the system uses a constant dose rate for your DCA or VMAT plan.

Min. MU per Dynamic CP The Min MU per Dynamic CP is only available for mARC plans. This variable gives you extra control over the plan quality. For simple single arc Prostate or single lesion plans, you can increase this value to 3 or 4 to keep the level of plan modulation down and improve the delivery efficiency. Siemens recommends a minimum of 2.

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Planning and Workflow: Optimization and Sequence Parameters Beam Splitting For machines that are capable of splitting beams, beam splits are listed in Beam Spreadsheet and appear in all T/S/C and BEV views. Monaco simply creates segments with different jaw settings that avoid the carriage restriction. An optional approach is to use the “Fixed Jaw” setting on the beam spreadsheet. You can define the field sizes for each beam that does not violate the carriage restriction. Monaco retains the resulting fluence and segments inside this jaw setting. Generally, this is how Monaco determines when to split beams. 1.

First, it determines a set of potential carriage groups.

2.

Next, it generates all segments that can be delivered without splitting.

3.

It splits up the remaining fluence into segments. It starts from the side where the leaves would appear at the most retracted positions. These segments are split at the carriage group edge. No feathering is applied.

4.

Finally, if carriage groups are present with few segments that could be redistributed to other carriage groups, it deletes these. The jaw positions of the carriage groups are shrunk to fit at the end.

5.

Beam splitting is triggered by the combination of MLC parameters, like maximum protrusion from neighboring leaf, minimum leaf tuck, etc. The split beams are exported as separated beams with different jaw settings. The beam names in the DICOM export appear as B1S1, B1S2, etc.

Exercises Go to the Additional Cases section of the Training Guide to complete the “Optimization and Plan Evaluation” exercise.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools There are many tools available to analyze and modify your plan during and after each optimization stage. You can only use some tools during or after a particular stage. You can use some others at any time. Options that are only available during or after a particular stage are noted in each section.

Showing the Console during Optimization During optimization, you can optionally show internal status messages from the optimizer. You can view the patient name, patient ID, studyset, plan name and server name on the console title bar (Figure 9-1). On the Workspace tab, click on the drop-down arrow below Controls and select Optimization Console. OR Press Alt | C your computer keyboard. When you save a plan, the log file is saved, each information line is time stamped and you can recall it when you re- open the plan. You have the option to: • Save the current file as a plain text file • Print the saved file • Email the file information There are three view options at the top of the Console log: •

Auto Update

•

Auto Scroll

•

Always On Top

When the Auto Update and Auto Scroll boxes are checked, the Console log automatically moves down when a new line is read. When you enable the Always on Top option, the Console log stays on top of all other open windows.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Showing the Console during Optimization (cont.) At the bottom of the Console window in Message Filter, you can type in keywords to filter through the messages in the console log.

Figure 9-1: Optimization Console

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Showing the Console during Optimization (cont.) Console Messages after Stage Two Below are some useful messages that appear at the end of stage-two optimization.

Figure 9-2: Console Messages after Stage Two Number of Segments/CP This is the number of segments generated for a beam plan, or the number of control points generated for a VMAT plan. Number of Monitor Units This is the total number of monitor units generated for this plan.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Showing the Console during Optimization (cont.) Console Messages after Stage Two (cont.) Estimated Total Delivery Time The estimated total delivery time is, as it says, an estimate and does not include the time individual machines need rotate the gantry to a new angle for beam plans or to ramp up and beam on intermittently during a dynamic treatment. So, this estimate may be close to the actual treatment time, or may be off by quite a bit (this depends on the complexity of the treatment that is to be delivered). Regardless, the Estimated Total Delivery Time is always shorter than the actual delivery time. Minimum # of MU for ideal delivery This value is calculated based on the fluence profiles after sequencing and depends only on the degree of modulation of the plan. This value is always lower than the actual number of monitor units that the plan needs to deliver. Monaco uses this value to calculate the estimated total delivery time. You can control this value when you change your prescription and allow more dose to your organ at risk or a less homogenous target dose. Estimated MU efficiency The estimated monitor unit efficiency shows how Monaco compares the efficient the plan’s actual monitor units to the monitor units for the ideal delivery. Therefore, the higher the efficiency the lower the total monitor units for the plan. To increase the MU efficiency of the plan, lower the Minimum Dose Rate Segment Shape Property. Efficiency ↑ Total MU ↓ Min Dose Rate ↓

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Evaluating Sensitivities After each stage of optimization, use the Sensitivities information on the IMRT Constraints dialog box to make informed decisions as to what prescription trades-offs you can make to improve your plan. Guided by the Sensitivities tool, you can easily solve the conflicts between target goals and dose-limiting constraints. After optimization, the Sensitivities tab is available on the IMRT Constraints dialog box.

Figure 9-3: IMRT Constraints dialog box-Sensitivities tab Sensitivity values of constraints appear for each target. When you place your mouse cursor over any sensitivity value, Monaco shows the relationship of the constraint to each objective. Each constraint represents a row, each target objective a column. Along a target’s column, you can find the entry with the highest value, which corresponds to the constraint limiting that target’s coverage the most. Monaco links the changes of a constraint to a potential gain of EUD to a target. Another use for this tool is to assess the low sensitivity values. Very low sensitivity values identify structures do not conflict with the target dose goal. This indicates that changes made to the prescription for these structures will probably have little to no effect on the dose to the target. Once you determine what constraint you need to loosen, edit the Isoconstraint value and re-optimize. NOTE:

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Sensitivities are volume based. Therefore, small local hot or cold spots may not be obvious when you use this table.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Evaluating Sensitivities (cont.) Point Sensitivity You can use the mouse to determine the sensitivity of each constraint at a particular point in the target(s). Higher values on the organs at risk indicate that a change to the isoconstraint for that structure makes the most impact at that point in the target(s). With the sensitivities dialog box in view, click your mouse on any point inside the target(s) on a transverse, sagittal, or coronal view. Point coordinates appear on the bottom-right corner of the IMRT Constraints dialog box.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Using the Progress Meter The progress meter (Figure 9-4) shows the convergence of the target structure(s) objectives (red) and the max of all constraint violations (blue) applied to any structure. It also shows the degree of modulation of all beams and sequences in the plan (green). The graph updates with each iteration during the optimization.

Figure 9-4: Progress Meter Target EUD(s) Target EUD(s) demonstrates the average over all target objectives of the current Target EUD(s). This means 1.0 indicates that on average, 100 percent of the prescribed EUDs are achieved for the target(s). If the Target EUD(s) completed above the 1.0 line, this indicates that the prescription to the target(s) was met, but there may be hot spots. If the Target EUD(s) completed below the 1.0 line, this indicates the prescription to the target(s) was under-achieved. Target EUD(s) is calculated using the equation: Isoeffect/Isoconstraint. If there is more than one target, then the average of all the targets isoeffects and isoconstraints are used in the equation.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Using the Progress Meter (cont.) Constraint Violation Constraint Violation (CV) calculates the maximum of all constraint cost functions. If a constraint cost function equals zero, it is either inactive or the isoconstraint has been reached (the isoeffect is smaller than or equal to the isoconstraint). Therefore, you can use the maximum value of the CV to determine convergence. A high value indicates that either the constraint is violated or its current impact on the result is too large and has to be lowered in order not to excessively reduce the target objectives. In the latter case, the CV may show a large value even if all constraints are satisfied. (A slack constraint is denoted as inactive). You can determine a proper convergence (meeting all constraints) when the objective function has been minimized and the CV equals zero. NOTE:

The range on the vertical axis of each graph changes during optimization.

Modulation Degree The modulation degree indicates the current total relative degree of modulation of all beams and sequences. Monaco calculates this relative value. It divides the total monitor units of all beams or sequences by the sum of [(Segment Area x Segment MU)\Total Beam Area]. In general, more complex plans should have a higher degree of modulation than simpler plans.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Using the Volume Cursor These are the general instructions to view the volume cursor information. 1.

Click the Volume Cursor

2.

Position the cursor over one of the CT or MR images and hold down your left mouse button to show the cursor information (Examples shown below).

button on the Planning tab.

P: Shows Hounsfield Units (CT only) and pixel Electron Density information about the Primary Volume. S: Shows relative pixel ED of the Secondary Image Volume. D: Shows Dose or Raw Dose value at that point. You only see this when you load a secondary image and you select isodose lines as the dose display option. G: Shows Grid Volume information, such as % Voxel Occupancy, Electron Density Variation and Sensitivity values.

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3.

Hold down your left mouse button and drag the mouse. The cursor information updates dynamically at each pixel as the cursor moves over it.

4.

Press the Shift key and simultaneously hold down your left mouse and drag across the image. The coordinates also dynamically update at each pixel as the cursor moves across it.

5.

Click the Volume Cursor button on the Planning tab to turn off the volume cursor.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Grid Volume Toolbar

Figure 9-5: Planning Tab- Grid Volume Group This section discusses the grid type options available in the Planning activity. Use the volume cursor on the Main toolbar to show the information below in a tooltip in any transverse, sagittal, or coronal view. NOTE:

The options below are voxel representations based on the calculation grid resolution.

Dose When you select this option, the calculated dose appears on the image set. You can use the volume cursor to show the dose to a point. The range of dose color values appears on the Grid Volume toolbar. You can edit the dose range and values on the Isodose Control. You can use the Slider Bar to transition the opacity of the dose shown on the primary image set.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Grid Volume Toolbar (cont.) Dose Raw When you select this option, the un-interpolated dose returned from the optimizer appears. Voxel size represents the actual calculation grid resolution. The range of raw dose color values appears on the Grid Volume toolbar. You can edit the dose range and values on the Isodose Control. You can use the Slider Bar to transition the opacity of the dose that appears on the primary image set. NOTE:

You can only see Raw Dose when the dose display option selected is not Isolines.

Electron Density When you select this option, the electron density per voxel appears. The range of electron density color values is editable on the Grid Volume toolbar. You also see any density overrides, if assigned. You can use the Slider Bar to transition the opacity of the electron dose grid that appears on the primary image set. VOI Occupancy When you select this option, the percent of 3D voxel occupancy for the selected Volume of Interest (VOI) appears. Therefore, you must also select a Structure drop-down option. The range of percent VOI occupancy color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the VOI occupancy grid that appears on the primary image set. CF (Cost Function) Occupancy When you select this option, the voxels assigned to a selected cost function appear. Therefore, you must also select a Cost Function drop-down option. This is a particularly useful tool to visualize the voxel occupancy where cost functions compete. The range of percent CF occupancy color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the cost function occupancy grid that appears on the primary image set.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Grid Volume Toolbar (cont.) CF (Cost Function) Variation When you select this option as your secondary volume, along with a particular structure’s cost function, the relative impact of that cost function on a voxel by voxel basis appears for that structure. The cost function variation shows you which voxels are most affected when you change the cost function parameters for a given structure. Consider the examples below. The first is a serial cost function variation on the rectum (Figure 9-6). The higher penalty area appears in orange. The lower penalty area appears in blue. There is essentially no penalty where there are no colored voxels within the structure.

Figure 9-6: Cost Function Variation- Serial

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Grid Volume Toolbar CF (Cost Function) Variation (cont.) The second example is a parallel cost function on a parotid (Figure 9-7). The highest penalty (appears in Red) is being applied to the voxels receiving the Reference Dose entered in the prescription for that structure and cost function. The lower penalty area appears in blue. There is essentially no penalty where there are no colored voxels within the structure.

V O L u m e

Ref

Dose

Figure 9-7: Cost Function Variation- Parallel

The range of variation color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the cost function variation grid as it appears on the primary image set.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Grid Volume Toolbar (cont.) CF (Cost Function) Relax Response When you select this option and an associated Cost Function drop-down option, you see the predicted, incremental change of the dose distribution if a given constraint were to be relaxed by some small amount. Relaxing some constraints can increase dose in some areas, but at the same time, can decrease dose in others. This tool gives a visual representation of this effect. The range of color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the cost function relax response grid as it appears on the primary image set. CF Sensitivities When you select this option and an associated Cost Function drop-down option, the area that is most sensitive to changes made to the selected cost function appear. You can use the volume cursor to show the percent sensitivity the selected cost function has on a voxel (Figure 9-8). The higher the percent value, the more sensitive the voxel is and therefore would be affected more if you made a change to the selected cost function’s prescription. The range of color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the cost function relax response grid as it appears on the primary image set.

Figure 9-8: CF Sensitivities

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools Grid Volume Toolbar (cont.) Dose Uncertainty When you select this option (only available at the end of stage 2 optimization), the dose uncertainty per voxel appears. Dose uncertainty is greater the farther away a voxel is from isocenter. The range of dose uncertainty color values is editable on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity of the dose uncertainty grid as it appears on the primary image set.

Evaluating the Isodoses and Dose-Volume Histograms You can evaluate the fluence-optimized isodoses and dose-volume histograms before you continue with the second stage of optimization. Or, you canreview them after the stage two optimization. You can evaluate the isodoses on the transverse, sagittal, and coronal images or in a 3D view. There are three types of dose-volume histograms you can review. •

Total Volume DVH

•

Optimized DVH

•

Optimized Total DVH.

Right-click in the DVH window to select these options. Total Volume DVH This DVH shows all structures that are turned on in the structure control list. It uses the default grid resolution to calculate the DVH for the graph. The volumes of the structures that appear are total volumes. Structures that overlap belong to both volumes.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Grid Volume Toolbar Total Volume DVH (cont.) When the plan includes Bias dose, you can toggle the Total Volume DVH to show the DVH dose based on the Composite plan or the Current plan when you check/uncheck the Base plan dose on the Beam Visibility Control.

Figure 9-9: Beam Visibility Control Optimized DVH This shows the DVH dose based on the Current plan. This DVH shows only the structures used in the prescription. It uses the dose grid resolution of the optimized plan to calculate the DVH for these structures. The volumes may be compromised based on the assigned structure properties. Optimized Total DVH (Bias Dose Plans only) This shows the DVH dose based on the Composite plan. This DVH shows only the structures used in the prescription. It uses the dose grid resolution of the optimized plan to calculate the DVH for these structures. The volumes may be compromised based on the assigned structure properties. NOTE:

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DVH statistics in the Planning activity always shows the total volume DVH, not the Optimized DVH structure volumes.

Planning and Workflow: Plan Analysis and Evaluation Volume II of IV Monaco Training Guide

Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Evaluating Intensity Maps and Monitor Units To evaluate the intensity map and point MUs, you must first show the fluence view. In Planning and QA activities, you can show the fluence view when you right-click inside the lower left image window and select Show Fluence View. The Planning Activity section also describes other fluence view options. At the end of stage one or two, you can review the intensity map for each beam/sequence.

Review Segments and Monitor Units per Segment Once the constrained aperture optimization is complete, you can review the segments created in a BEV window (Figure 9-10).

Figure 9-10: Example of a Static Segment in a BEV Toggle through the beams or sequences and segments. Use the controls on the Fluence group on the Planning tab. For more information about the Fluence group on the Planning tab, see the IMRT Tools Section of this training guide.

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Planning and Workflow: Plan Analysis and Evaluation Plan Analysis Tools (cont.) Using the Fluence Statistics The fluence statistics gives information regarding monitor units per fraction for each beam/sequence (Figure 9-11). The Area of the fluence appears per beam/sequence. Take the square root of this value to derive the blocked equivalent square of the fluence map. The point-wise Minimum, Maximum and Mean MU for each beam/sequence appear here along with the Standard Deviation. Use these values to determine dose delivery efficiencies. The mean fluence is the sum of the fluences of the segment in MU weighted by their area, divided by the total area covered by all segments of this beam/sequence. Monaco can interpret this as the MU of this segment if it is an un-modulated field. A larger standard deviation typically translates to a more modulated beam/sequence with more monitor units required to deliver the treatment, and therefore a longer beam on time. Total MU per beam/sequence is also shown. The Total number of Monitor Units and Mean Monitor Units for the entire plan also appear at the bottom of this dialog box.

Figure 9-11: Fluence Statistics dialog box

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Monaco Planning Suggestions The planning suggestions reviewed here are general suggestions for planning in Monaco. You can find any VMAT specific planning suggestions in the VMAT Planning section of this guide.

Workflow The instructions below show you the basic workflow to create a plan in Monaco. See the Monaco Planning and Workflow section of this training guide for a flowchart diagram of this process.

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1.

Carefully Contour all required targets and OARs. If multiple targets exist, create a structure around them all to use for isocenter placement.

2.

Add a template to your patient from the Planning Activity. Use one of the default templates to create a new template from scratch. Edit the template properties and save, as necessary.

3.

If you need to make edits to the beam arrangement, add or delete beams or sequences, you can edit them in Planning activity .You can also make edits to the beam plans in Planning activity.

4.

Resolve any structure mismatches and edit the IMRT Constraints, Calculation Properties, IMRT Parameters, and Sequencing Parameters as necessary.

5.

Do the fluence optimization (Stage 1).

6.

Use plan analysis tools to evaluate your plan.

7.

Make adjustments to the parameters and prescription (constraints) as necessary.

8.

Re-optimize the fluence and repeat evaluation until you have an acceptable optimized plan.

9.

Do the segment optimization (Stage 2).

10.

Use the plan analysis tools to evaluate your final plan.

11.

If the plan is not acceptable, make edits to the properties and/or prescription (constraints) as needed.

12.

Once you have an acceptable final plan, save and print any desired images and reports.

13.

Create a QA plan.

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Monaco Planning Suggestions Cap Bolus You can create a “cap” bolus in Monaco. You must have a few slices above the first patient slice of the CT scan in order to create the “cap” structure. NOTE:

You must create a bolus structure type in order to activate the Bolus icon.

1.

Type a name in the Structure field on the Contouring tab.

2.

Click on the Bolus

3.

You can modify the description in the Bolus Description option.

4.

Select a structure in the Base Structure drop-down list.

5.

Type a value in the Thickness (cm). The default value is 1.00.

6.

Type a value for the Relative ED. The default value is 1.00.

7.

You can put the top and bottom points to define the bolus in any of the T/S/C or BEV views.

8.

In the transverse view, put the bolus start and end points at the same location on the base structure (Figure 10-1).

icon to open the Generate Bolus dialog box.

Figure 10-1: Placing Start and End Point in the Same Location

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Monaco Planning Suggestions Cap Bolus (cont.) 9.

In the Bolus dialog box, click Generate to make the bolus. The bolus is formed around the skull to create a “cap” (Figure: 10-2).

Figure 10-2: Cap Bolus 10.

Click Close to close the dialog box.

Templates You can create templates when you save any completed plan. Use the File drop-down menu and select the Save Template As… option. NOTE:

You can save a Sim template with mixed energies. Only the machine for beam 1 shows on the Template dialog box when you apply the template to a new patient. But, mixed energies are applied.

Machine Energy Typically, you use low to medium machine energies for planning (6-10 MV). You can also plan with multiple machine energies. There may be cases when a higher energy is desired or required. Keep in mind that when planning with Monte Carlo, if you use a higher energy, it can increase the calculation time. Higher energy particle showers take more time to calculate than low energy showers.

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Monaco Planning Suggestions Standardize Planning Make use of standard sets of anatomical site names and templates for recurring treatment setups and prescriptions. When you use templates, it is important for contour names to be consistent from patient to patient. Monaco indicates structure name mismatches, so you can correct these before you begin optimization.

Status Messages Status messages appear throughout the planning process at the bottom of the window. These messages are informative, such as Mismatch in structure names when the prescription does not reflect the structures available for the patient. Or, status messages, such as Press start to begin stage 1.

DVH & Statistics Resolution The resolution for the Optimized DVH is based on grid spacing. Optimized DVH also takes into account Structure Optimization Properties such as Total Volume DVH and overlapped volumes. The Total Volume DVH resolution has a default value of 0.2 cm. We suggest that you set the resolution for the Total Volume DVH to be the same as the grid spacing of your plan. You should always base the final plan evaluation on the Total Volume DVH.

Setup Beams for Portal Imaging You can create setup beam plans in Planning independent of your plan. Start a New Simulation Plan centered on the same isocenter as in the plan. You can arrange setup beams and print or export DRRs. You can save these plans as templates for future use.

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Monaco Planning Suggestions Calculation Region Volume The Calculation Region Volume encompasses all structures listed on the IMRT Constraints dialog box. Monaco requires for patient contours to be contiguous. If you desire a smaller calculation region, you can delete contours from the superior and inferior slices. The system generates DRR images for the extent of the CT slices, even if patient contours do not exist.

Applying Structure Optimization Properties to a Non-Optimized Structure Often, you may have a structure that you do not want to optimize (for example, you have contoured the table or an immobilization device and you want to account for the attenuation, but do not want to store the dose to that structure in memory). Add the structure to the prescription and on the structure optimization properties dialog box. Select the option Do Not Store Dose. You do not need to select a cost function for this structure. The optimizer uses the structure for dose attenuation purposes, but does not optimize or store dose for this structure. If the non-optimized structure overlaps an optimized structure, layering order is important. You can use the voxel visualization tools to verify the cost function occupancy of each structure. NOTE:

If you select the structure property, Display Total Volume DVH, the option for Do Not Store Dose is not available for that structure.

Target Coverage If you do not have good target coverage superiorly and inferiorly after optimization, make sure your grid spacing is at least as small as, or slightly smaller than your CT slice spacing. You cannot influence the overall target dose homogeneity by target dose penalties alone. If the target dose is not homogenous enough, either reduce normal tissue sparing, or add more beams or sequences.

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Monaco Planning Suggestions IMRT Beam Arrangement •

For non-concave targets, any standard arrangement that one would use for regular 3D planning should suffice, since the modulation improves on the dose distribution. Five (5) evenly spaced beams is a good place to start.

•

For concave targets, you are more likely to require more beams in order to shape the dose distribution around the target. Seven to nine (7 to 9) beams usually work.

•

At least fifteen (15) degrees of separation between beams is a general rule of thumb for beam independence.

•

Use a BEV to find beam angles that yield the best separation between target and critical structures.

•

In general, the more beams you use, Monaco generates fewer total segments.

Prescription General Suggestions

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•

For best results, add all targets and dose limiting organs at risk to the prescription panel at once and assign cost functions.

•

You must have at least one objective and one constraint in order to optimize.

•

You must use at least one of the two target objectives (Target EUD or Target Penalty) in the prescription.

•

For very small structures (example, optic chiasm, optic nerves), you may want to create a 1-2 mm expansion margin and use this structure in the prescription. While in plan evaluation, you should evaluate the actual structure instead of the expanded structure.

Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Prescription Tips When Creating Target Volume Prescriptions •

Target volumes may extend to the patients surface. Application of the Auto Flash feature with a 5-7 mm margin may improve the coverage.

•

To make sure you have a uniform dose distribution in the target, apply a Quadratic Overdose penalty on the order of 0.8 to 1.1 Gy above the prescribed dose. In general, the smaller the target volume, the smaller the isoconstraint value for the Quadratic Overdose.

•

When you have overlapping or close target volumes with different prescriptions, you can apply a Shrink Margin to the Quadratic Overdose cost function of the target with the lowest dose to achieve a transition dose gradient between the two structures (highlighted in yellow below).

•

Due to the higher dose gradient in the area where higher dose and lower dose targets abut (highlighted in yellow), unacceptable cold spots in the lower dose target could occur in areas further away from the high dose target. When you have overlapping or close target volumes with different prescriptions, consider increasing the isoconstraint of the Target EUD to the lower dose target(s) about 2 Gy to make sure that you received an acceptable dose gradient throughout the lower dose target.

Figure 10-3: Transition Area

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Monaco Planning Suggestions Prescription Tips When Creating Target Volume Prescriptions (cont.) •

When you have overlapping or close target volumes with different prescriptions, it may be useful to apply a second Quadratic Overdose penalty to the target with the lower dose with a 0 cm Shrink Margin. Assign a prescribed dose to the lower dose target that is equivalent to or slightly lower than the prescription of the highest target dose and assign an Isoconstraint value of 0.1 Gy. This enables you to have an appropriate dose gradient inside the lower dose target and keeps the hot spot inside the target with the highest dose.

•

Understand that when you use EUD cost functions, it is possible that resulting cold spots in a target may be compensated by hot spots in another area of the target. This is the nature of EUD usage. Smaller isoconstraint values on the quadratic overdose cost function for the target can help to limit the range of hot to cold voxels. If the target is large, you may want to split the target into two separate structures and use the same prescription for both.

•

To avoid the incidence of EUD generated hot spots in the target, you can use the “Target Penalty” dose objective option. Because it is a non-EUD based physical dose objective, you can achieve lower hot spots.

Tips When Creating Organ at Risk Prescriptions •

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You can add a Serial cost function to a parallel OAR in addition to a Parallel cost function to reduce hot spots in that structure.

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Monaco Planning Suggestions Prescription (cont.) Avoid Hot Spots in Unspecified Tissue Occasionally, hot spots are created near a target volume, but not inside. To avoid any hot spots created near a target, but not inside, try the prescription tip below: Apply a Quadratic Overdose penalty to the structure defined as the patient with a Maximum Dose equal to 2/3 of the highest target volume prescription. Type an Isoconstraint value of ~0.3 Gy above the max dose. Apply a Shrink Margin to this cost function on the order of 1.5 cm to control the dose just beyond the target volume.

Figure 10-4: Target with Margins If you still have a hot spot that is in normal tissue and not in the target, you can apply a second Quadratic Overdose penalty to the patient structure with a Maximum Dose equivalent to the target prescribed dose, a small Prescription. Isoconstraint value, and zero (0) cm Shrink Margin. The first cost function controls the doses 1.5 cm beyond the target. The second cost function works to control any high dose that tries to escape the margins of the target volume. You can use the application of additional Quadratic Overdose penalties on the patient structure to further conform the dose.

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Monaco Planning Suggestions Prescription (cont.) Controlling Mean Dose in OARs If you need to reduce mean dose, you can add an additional Serial Cost Function to the structure with a k value of 1. This serial cost function effectively controls the mean dose in the structure.

Figure 10-5: Serial Cost Function

Controlling Maximum Dose One thing to remember when you use EUD to plan is that when you have a complex prescription, it may be difficult to control the absolute maximum dose to a certain point. So, occasionally, you may need to include a Maximum Dose cost function in your prescription. Normally, a Serial cost function is able to sufficiently control the hot spots in an OAR. Occasionally, the maximum dose you are willing to accept is exceeded. In this case, you could apply a Maximum Dose cost function together with the Serial cost function to limit the dose to the OAR.

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Prescription (cont.) Using Biological Cost Functions to Control Dose You can use a serial cost function with a high Power Law (k to control high doses in an OAR, for example, to prevent a rectal fistula. If the high dose region of an OAR overlaps a target volume, you can use Optimize Over All Voxels so the cost function can work in the high dose region. You can apply an additional Serial cost function(s) with a lower EUD Dose and a shrink margin to help create a steep dose gradient. For structures, such as lung and parotids, you can apply a Serial cost function with a Power Law (k) of 1 to distribute the penalty equally throughout the volume in order to control the mean dose. In this case, you should apply a shrink margin if the OAR overlaps with a Target Volume to avoid cold spots in the Target Volume. Parallel cost functions act similarly to DVH point dose constraints, but with the benefit of working on the OAR volume rather than just a specified point. Use them to prevent side effects associated with lower radiation doses. You can also use the Parallel cost function to prevent such side effects as, for example, Parotid: Salivary Gland function and Rectum: Diarrhea. Monaco does not limit you to use a single dose constraint for OARs. There may be multiple dose ranges to control per OAR. Therefore, it may be useful to apply multiple cost functions, Serial and/or Parallel. You can control the high and low dose regions as well as the mean dose when you use multiple cost functions together. When you use the appropriate Power Law Exponent values and Shrink Margins, they help direct the penalty towards specified doses within OAR volume so you can achieve optimal plan quality.

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Prescription (cont.) Bias Dose

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•

Divide the Base dose prescription by the Total dose prescription to get a multiplier to apply to each OAR prescription for your base plan. When you lower your OAR goals for the base plan, this helps to achieve better coverage and fewer infeasible results when you create the composite plan. Next, increase the OAR prescription values on the Bias Dose plan to 100% of the goal doses. Then, back them off as needed to achieve final dose goals.

•

Multiple Overlapping targets: For improved results, remove any targets from your IMRT Constraints prescription that are entirely encompassed by another target in your prescription when you create the composite plan.

Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Optimization DVH Statistics After you optimize one time, the system activates the DVH Statistics button. For future optimizations, you can keep the DVH Statistics dialog box open. The system updates reference doses when you refresh. The DVH Statistics always shows the Total DVHs, not Optimized DVHs.

Sensitivity Analysis Make use of the sensitivity analysis tool to determine what to change in your prescription when the optimization is not acceptable. You can use this tool after either stage of optimization.

Multicriterial The most effective time to use multicriterial is when you have an isoeffect on the target structure(s) that is higher than the isoconstraint. This typically means your target and OAR are well separated from each other, and the target(s) coverage is not significantly affected by a tighter constraint on the OAR. As you optimize, pay attention to the isoeffect value and the DVH of the target(s). If you apply multicriterial to an OAR and compromise the target coverage more than you are willing to accept, you should turn off multicriterial and set the isoconstraint of the OAR to a value that, when optimized, creates acceptable coverage to the target(s). Consider using the multicriterial option when you plan dose escalation protocols where you want to increase the dose to targets and keep OAR(s) dose at acceptable levels. You can also consider its use when you are re-treating a patient and a physician agrees to accept compromised target coverage as long as the OAR’s dose can be kept at as low a dose as possible.

Monaco®

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Optimization (cont.) Troubleshooting an Optimization Failure

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•

Check the Logfile. Click the Monaco Application button and select the Log Files| Log…. Review the latest entries on the General Logfile for possible clues that show the failure.

•

Check the Optimization Console. Click the Workspace tab and click the Controls drop-down| Optimization Console option. Review the information on the console for possible causes that show a failure.

•

One common problem is incorrect structure layering. Verify that you have the “patient contour” last in the structure layering. Also, verify if you prescribed to a structure that is completely encompassed by another structure (for example, CTV and PTV). Make sure the one with the highest dose prescription is listed above the other in the layering.

•

Another common problem occurs when there is no CT-to-ED file assigned to the patient. If you use a CT studyset, Monaco requires a CT-to-ED file for optimization and dose calculation. If you use an MR studyset, you must manually set electron density values for your structures.

Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Plan Analysis Fluence Statistics Make use of the fluence statistics after either stage of optimization to evaluate plan delivery efficiencies. Consider this example: We created three plans with superficial targets and used the same number of beams and beam arrangements. However, one plan used Auto Flash, another used surface margin, and the third plan used neither. The fluence maps and corresponding fluence statistics for beam one of each plan appear below with comments.

Auto Flash ON Fluence Statistics

A plan using Auto Flash produces reasonable monitor units per fraction and a small standard deviation. The fluence is slightly hotter in the buildup region as shown on the left side of the fluence map. Application of this tool gives a uniform distribution in the buildup region. Figure 10-6: Auto Flash ON

Monaco®

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Plan Analysis (cont.) Surface Margin ON Fluence Statistics

A plan using Surface Margin produces reasonable monitor units per fraction and a small standard deviation. The fluence is fairly homogeneous.

Figure 10-7: Surface Margin On

Neither Margin ON Fluence Statistics

A plan using neither of these tools produces a large number of maximum monitor units and a large standard deviation. The fluence is very hot in the buildup region as shown on the left side of the fluence map. Without the proper application of structure optimization properties or global parameters, you could produce plans that create too many monitor units per fraction and therefore inefficient beam-on times. Figure 10-8: Neither Margin On

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions Performance Grid Spacing Use smaller grid spacing (0.3 cm or less) when the structures are smaller (example, H&N). Use larger grid spacing (0.4 cm) when the structures are larger (example, Prostate). Calculation time increases with smaller grid spacing.

Statistical Uncertainty per Calculation vs. per Control Point If you use Statistical Uncertainty per Calculation, it results in a faster calculation than the per Control Point option. It is possible to decrease calculation times for VMAT plans if you use a higher Statistical Uncertainty per Calculation value for initial planning. For the first iteration of stage 1 and stage 2, the user selects a higher Statistical Uncertainty than what is recommend for clinical use. When the final plan is calculated, the user can change the Statistical Uncertainty per Calculation to a lower, more clinically acceptable value. The segmented plan automatically begins a re-calculation and returns the new results. The user then selects Skip Forward when it becomes available to return the “segmentation complete” message. The recommended values are 2-3% per plan for initial planning followed by 1% for the final calculation. Please note that as a consequence of using a higher statistical uncertainty, the user must review all aspects of the plan which includes dose distribution and DVH to make sure the plan is acceptable. If you use a higher Statistical Uncertainty, dose to small structures can be affected.

Pilot Beamlets The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot Beamlets to guide the segment shape changes made during Segment Shape Optimization. Monaco creates a large number of Pilot Beamlets if you use large highly modulated treatment fields, multiple VMAT arcs and a small arc increment. When a large number of Pilot Beamlets, which are stored in memory, are created they can use all the RAM the system has. This slows the process exponentially. Disabling this option removes the creation of pilot beamlets from the SSO process. Pilot beamlets do not affect performance for the majority of treatment plans. You should only disable them if the plan takes a long time to converge.

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Monaco Planning Suggestions Volume II of IV Monaco Training Guide

Monaco Planning Suggestions QA Plan Multiple QA Plans If multiple QA plans already exist and you want to create a new QA plan, select a new QA Plan ID from the bottom of the drop-down list.

Show Coronal Slice at Measured Depth Use the measure tool on the transverse image to measure the depth from the surface to where you took your actual measurement. Select the plane icon tool and drag it to the end of the measure tool. This creates a coronal image at measured depth that you can export for comparison.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise The exercise in this section reviews the general process of planning a Step and Shoot, dMLC or Conformal RT patient in Monaco. There are many ways to complete an IMRT plan in Monaco. This is just one suggested method of IMRT treatment planning. This exercise does not include contouring. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. This exercise includes these tasks: Task 1. Task 2. Task 3. Task 4. Task 5. Task 6. Task 7. Task 8. Task 9. Task 10. Task 11. Task 12. Task 13. Task 14. Task 15. Task 16. Task 17. Task 18. Task 19. Task 20.

Monaco®

Select Patient and Open Studyset Start an IMRT Plan Add Beams in Planning Activity Enter the Prescription Enter the IMRT Constraints Edit Calculation Parameters Edit Sequencing Parameters Save an IMRT Template Optimize Fluence (Stage 1) Evaluate Optimized Fluence and Dose Re-Optimize and Evaluate (Optional) Optimize Segment Shapes/Calculate Dose (Stage 2) Evaluate Final Plan Save Plan Print the Plan Create/Calculate a QA Plan Edit QA Plan Beam Weights Save the QA Plan Export the Dose Planes Print the QA plan

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 1. Select Patient and Open Studyset This task walks you through the steps to select a patient and open a studyset. 1.

Open the Monaco software to automatically show the Open Patient Selection dialog box.

2.

Select the patient Fusion Prostate. Use one of these methods: Double-click on the patient name. OR Click the name once. Click the OK button. The system loads the patient information into the Patient Workspace Control.

3.

Select the CT studyset CT1. Use one of these methods: Double-click on the studyset name. OR Click the studyset name once, and then click the Load button. The patient shows in the Planning activity.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 2. Start an IMRT Plan This task walks you through the steps to select an IMRT Template. 1.

Click the Planning tab.

2.

button and select New Click on the drop-down arrow next to the New Plan Monaco Plan in the drop-down list. This opens the New Monaco Plan dialog box. (Figure11-1).

Figure 11-1: New Monaco Plan dialog box

Monaco®

3.

Type in a plan name and description.

4.

Select dMLC or Step and Shoot IMRT for the Delivery.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 2. Start an IMRT Plan (cont.)

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5.

Select All for the Anatomical Site.

6.

Place a checkmark by the template named DEFAULTSNS (Rx Site , Rx Dose: Gy , Total Beams: 7).

7.

Select Head First for the Treatment Orientation.

8.

Select TRNElekta80 for the treatment unit or a treatment unit type used in your clinic.

9.

Select 10.0 MV as the energy.

10.

Select the Isocenter Location: Center of PTV.

11.

Select OK to load the template and open the patient in Planning Control.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 3. Add Beams in Planning Activity This task is only required when you need to add beams to or modify beam arrangements from a template. This task should be less frequently used once you create and save your own clinical templates. 1.

In the Planning Control spreadsheet, click the Beams tab.

2.

(Optional) Use the option to add additional beams. Change to the Geometry tab to edit the Gantry, Collimator, and Jaw parameters. Label the applicable beams. Refer to the Planning Tools section of this training guide for more information.

Task 4. Enter the Prescription This task is only required when you need to edit the prescription from a template. This task is less frequently used once you create and save your own clinical templates. 1.

Select the Prescription tab on the Planning Control.

2.

Type Prostate for RX Site.

3.

Select Plan Isocenter in the Prescribe to Column.

4.

Type 73.8 in the Rx Dose (Gy) column.

5.

Type 41 in the Number of Fractions column. The Fractional Dose (Gy) column updates with 1.8 as the value.

Figure 11-2: Prescription Control

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 5. Enter the IMRT Constraints 1.

Click the IMRT Constraints tab on the Planning Control.

2.

Verify there is not a mismatch in structure names. For example, if the external contour is labeled “skin” in the template and the external contour is labeled “patient” in the plan, the mismatched structure name appears red in the IMRT Constraints tab.

3.

Use the provided Plan Scoring Criteria to add and edit cost functions. For this exercise, we provided suggested cost functions and explanations of their use for each structure. Note that the IMRT Constraints used in this exercise are only an example. You can use other combinations of cost functions to produce similar results. NOTE:

If you do not want any planning hints, skip this section and go directly to the Plan Scoring Criteria table.

PTV - For target structures, a Target EUD or Target Penalty is always required. The target cost functions designate the target as an Objective. Neither target cost function penalizes high doses. You need to use the Quadratic Overdose cost function to make sure the global max dose is not exceeded. This also gives you a more homogeneous dose within the target structure. The Isoconstraint value for the Target EUD/Target Penalty cost function is the target prescription 73.80 Gy. •

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If you use the Target EUD you can use 73.80 Gy for the reference dose and 0.5 for the cell sensitivity to meet the prescription criteria. In this exercise, the target volume does not extend to the patient surface. You do not need to select the Optional Physical Parameters, Surface Margin.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 5. Enter the IMRT Constraints (cont.) For the Quadratic Overdose, you can use 75.00 Gy for the maximum dose, and 2.00 for the RMS dose excess to meet the prescription criteria. •

If you use the Target Penalty, you can use 73.80 Gy for the Prescription and 98% for the Minimum Volume. -

NOTE:

For the Quadratic Overdose, you can use 75.00 Gy for the maximum dose and 2.00 for the RMS dose excess to meet the prescription criteria. You use an RMS of 2.0 in this exercise to decrease the calculation time. You should determine what prescription and RMS to use for your clinical plans based on your clinical experience and goals.

RECTUM - For this organ at risk, use of the Serial cost functions is applicable since the rectum is a serial structure. In some cases, like this one, you might need to meet or exceed the prescription criteria for two serial cost functions. For the first serial model, use a power law exponent of 12 with an EUD of 60.00 Gy and check Optimize Over All Voxels in Volume to keep hot spots to a minimum throughout the entire structure. Since the target and rectum volume are so close and even overlap in some areas, we suggest that you add a second serial cost function to this structure. Use a lower EUD and power law exponent, such as 45.00 Gy and 5 and use a Shrink Margin of 0.4 cm. The second serial cost function lets you further reduce the dose in the area of the rectum where the voxel doses do not compete with the target. BLADDER - For this organ at risk, use of the Serial cost function is applicable since the bladder is a serial structure. Use a power law exponent of 8 and EUD of around 55.00 Gy to reasonably meet the prescription criteria. In addition, use a Shrink Margin of 0.4 cm so as not to include the hot voxels that surround the target. Since the bladder is filled with contrast, apply an electron density of 1.0 to the structure. Click the Structures tab. Check Force ED and verify the relative ED is 1.0. When you apply this property to the structure, the density value you use overrides the “false” high density of the contrast in this patient.

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 5. Enter the IMRT Constraints (cont.) Patient - When you plan IMRT, you should take into consideration dose to all unspecified tissue and apply a cost function to keep the dose to a minimum. You apply the Quadratic Overdose cost functions to the patient contour for this purpose. In some cases, you may need more than one quadratic overdose cost function to meet the prescription criteria. For the first quadratic overdose, use a Maximum Dose of 45.00 Gy and an RMS Dose Excess of 0.50 to keep the dose to the unspecified tissue to a reasonable minimum and keep the femur doses low. Since the unspecified tissue of the patient and the targets abut, it is good practice to add a shrink margin to the patient structure so the optimizer does not try to limit dose in the transition area between the target and the unspecified tissue. In this case, consider a Shrink Margin of 1.2 cm. For the second Quadratic Overdose cost function, consider a higher Maximum Dose of approximately 73.80 Gy with a small RMS dose excess like 0.3. Use a Shrink Margin of 0.4 cm on this cost function. The second cost function lets you control the high doses in the unspecified tissue better. The small RMS dose excess value limits the possibility of a prohibitively high dose voxels in the unspecified tissue. Rt and Lt Femur - You could contour and add these structures into the IMRT constraints tab. But, if you look at the dose to the unspecified tissue (patient), which includes the femurs, the % dose of 45.00 Gy is well below 5%. 4.

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Layer the structures appropriately. Highlight the structure you want to move and click the up or down arrow on the IMRT Constraints tab in the planning control window. Targets are typically at the top and the patient skin surface contour at the bottom.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 5. Enter the IMRT Constraints (cont.) 5.

Review the plan scoring criteria. Target Structures PTV

Organs at Risk (OAR) BLADDER

95% is at or above 73.80 Gy and Max dose < or = 81.18 Gy (110%)

no more than 60% > 40 Gy and no more than 40% > 60 Gy

RECTUM

no more than 50% > 40 Gy and no more than 30% > 60 Gy

Rt Femur Lt Femur

no more than 5% > 45 Gy no more than 5% > 45 Gy

Figure 11-3: Planning Score Criteria example

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 6. Edit Calculation Properties This task lets you set up the calculation properties. Grid Settings are global settings and algorithm settings are per prescription. 1.

button on the Click the Calculation Properties Planning tab to open the Calculation Properties dialog box.

2.

For this practice exercise, Monte Carlo Photon populates as the algorithm.

3.

For this practice exercise, use a Grid Spacing of 0.4 cm. The shrink margin values used in the exercises are based on the fact that Monaco determines the shrink margin size based on multiples of the grid spacing.

4.

Select Calculate dose to Medium.

5.

Use a Statistical Uncertainty per Calculation of 2%.

6.

Click OK when you complete your edits. NOTE:

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You use a Statistical Uncertainty of 2.0 in this exercise to decrease the calculation time. You should determine what prescription and Statistical Uncertainty to use for your clinical plans based on your clinical experience and goals.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 7. Edit IMRT Parameters This task lets you set up IMRT Parameters for each prescription (Rx). 1.

Click IMRT Parameters on the IMRT Constraints tab.

Figure 11-4: IMRT Parameters button

Monaco®

2.

Use Minimum CT Number: Use with Clear option of -200.

3.

Leave the default value for Flash Margin because Flash margin is not used for prostates.

4.

Use a Beamlet width of 0.3 cm.

5.

Use the drop down arrow and click Normal (8mm) for Target Margin.

6.

Use the drop down arrow and click Normal (8mm) for Avoidance Margin.

7.

Click OK when you complete your edits.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 8. Edit Sequencing Parameters 1.

You can do this task at any time before stage one or stage two of the optimization.

2.

Click the Sequencing Parameters Planning tab.

3.

Type/Edit properties when necessary. If you have SSO turned on, we recommend you select Pilot Beamlets.

4.

Click OK when you complete your edits, or Cancel if you made no edits.

button on the

Task 9. Save an IMRT Template You can do this task at any time while in the planning process. However, it is highly beneficial for you to create a prescription before you save an IMRT template.

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1.

and select the Save Template As Click the Monaco Application Menu option to show the Save Template As dialog box.

2.

Type the template name and description TrainPro1.

3.

(Optional) Select Pelvis from the Anatomical Site drop-down.

4.

Click Save to save the template.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 10. Optimize Fluence (Stage 1) This task starts the optimization process. The system automatically gives feedback during optimization on the IMRT Constraints dialog box, the console and the progress meter. You can manually update the dose, DVH and fluence during the optimization process. 1.

Show the IMRT Constraints dialog box (if it is not shown).

2.

Show the Console using one of these methods:

Select the Workspace tab. In the Visibility Panel, select the Controls drop-down menu and select the Optimization Console option. OR Press the Alt and C keys on your computer keyboard.

3.

button located on the Planning tab, to start Click the Start Optimization stage one of the optimization processes. NOTE:

Monaco®

After you create the rays (beamlets), you can see the IMRT Constraints and progress meter start to update with each iteration.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 10. Optimize Fluence (Stage 1) (cont.] 4.

(Optional) If you would like to stop the optimization and move to the end of stage one prematurely, click the Skip Forward action does not result in fully optimized fluence.

button. Understand that this

OR (Optional) If you would like to stop the optimization and go back to the start of button. This action removes the current stage one, click the Skip Back display of fluence and lets you start the optimization again at stage one. 5.

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Once stage one of the optimization completes, the system shows a dialog box with the message “Full Fluence Modulation Complete”. Click OK to acknowledge.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 11. Evaluate Optimized Fluence and Dose After stage one, you have many tools available to evaluate the optimized fluence and dose. Among these tools are Sensitivity Analysis, DVH Statistics, Fluence Display Tools, and isodose curves on the SPV and 3D images. This task references the location in the Monaco training guide where detailed information is located about the use or functionality of these tools. You can use any or all for evaluation at this time. 1.

Use the Sensitivities analysis to evaluate this information. The Sensitivities tab is on the IMRT Constraints window. Refer to the Monaco Planning and Workflow section: Plan Analysis Tools for more detailed information.

2.

Click the Plan Options tab and use the DVH tools to evaluate the plan. The DVH panel contains DVH Statistics, DVH Properties, and Structure Combination.

Figure 11-5: DVH Panel OR Right-click in the DVH window to use the DVH tools. Refer to the Plan Review Activity section to change the DVH Display, Properties, and Statistics. 3.

Use the Fluence Statistics to evaluate. Select the Plan Options tab and click the Fluence Statistics section in this guide.

Monaco®

button. For more information, refer to the IMRT Tools

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 11. Evaluate Optimized Fluence and Dose (cont.) 4.

Use the isodose curves on the SPV and 3D images to evaluate. For more information on evaluating isodose curves, refer to the resources below in this guide: • • •

General Operation and Navigation section Image Navigation and View Types Planning and Workflow: Plan Analysis, Evaluation, and Review

Task 12. Re-Optimize and Evaluate (Optional) If you determine that you need to make changes to the prescription to meet prescribed goals, you may have to re-optimize. When you apply the changes, notice if the start to . If so, the changes you made require button on the toolbar changes from re-optimization. Evaluate again. Use the tools described in task 10. You may reoptimize and evaluate several times before you calculate in stage 2.

Task 13. Optimize Segment Shapes/Calculate Dose (Stage 2) Once the optimized plan meets the prescription goals, you must optimize the segment shapes and calculate the final dose. Both of these actions happen in stage 2 of the optimization.

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1.

(Optional) Verify that the Sequencing Parameters that appear are your desired settings. Change them, if necessary. (See Task 7.)

2.

(Optional) Show the IMRT Constraints dialog box and the Console. (See Task 9.)

3.

Click the Start Optimization

button to start stage 2 of the optimization.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 13. Optimize Segment Shapes/Calculate Dose (Stage 2) (cont.) 4.

(Optional) If you would like to stop the optimization and move to the end of stage two prematurely, click the Skip Forward action does not result in a fully optimized plan.

button. Understand that this

OR (Optional) If you would like to pause stage 2 of the optimization, click the Skip button. This action removes the current display of fluence and lets Back you start the optimization again at stage one. 5.

Once stage two of the optimization completes, the system shows a dialog box with the message “Segment Shape Optimization Complete”. Click OK to acknowledge.

Task 14. Evaluate Final Plan Once the system calculates the plan, you can evaluate and use the same tools used to evaluate the optimized plan (see Task 10). If you choose to make changes to the prescription at this time, the system determines if the change necessitates that you start again at stage 1, or start at stage 2, or continue from its current state.

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 15. Save Plan Save the plan when satisfied that it meets the prescribed goals. NOTE: 1.

You can save optimized plans after stage 1, but optimized dose is not preserved.

Save the plan. Use one of these methods: Click the Save

button on your Quick launch Bar.

OR (Ctrl +S) on the keyboard saves the active plan. OR Click the Monaco Application Menu button and select a Save option.

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 16. Print the Plan There are many documents and images that offer support. You can print or export them for patient files. This task references the location in the training guide where detailed information appears about each type of print job. Subtask 1. Print or Export IMRT Reports For more detailed information on how to print, see the section General Operation and Navigation. 1.

Click the Output tab. a. Select an option on the Individual Report panel to print. b. Type a report comment, click OK. c. Click the Print button shown.

on the preview window to print the image

OR a. Select Customized Report to select a set of reports to print. b. Click the Template drop down arrow and select a saved template. c. Select Print.

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 16. Print the Plan (cont.) Subtask 2. Print Single Plane View, 3D Image or DVH Graph You can print or export the DVH graph from the Output tab. For more information, see the General Operation and Navigation section, Printing Options.

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1.

Select the Output tab.

2.

Select Print Views on the Reports panel.

3.

Select the applicable view to print.

4.

Type a report comment.

5.

Click OK.

6.

Click the Print button

on the preview window to print the image shown.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise Task 16. Print the Plan (cont.) Subtask 3. Print DRR/BEV You can print DRR/BEV images to paper or film and scale appropriately when calibrated. For more information, see the General Operation and Navigation section, Printing Options. 1.

Click the Print Views drop down arrow in the Reports panel on the Output tab. a. Select the applicable view to print. b. Type a comment, as needed, in the Report Comment dialog box. c. Click OK. d. Select the Print icon

.

e. Edit and/or verify Print Setup information. f.

Click OK.

OR 2.

Right-click on any DRR/BEV image. a. Select the Print option in the mouse menu to show the DRR Print dialog box. b. Type the applicable information for location and scaling. c. Click OK to print the image.

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 17. Create/Calculate a QA Plan Once you complete an IMRT plan, you can create a QA plan for verification. For more information, see the IMRT QA Activity section.

1.

On the Planning tab, select the New Plan drop-down arrow Plan.

. Select New QA

OR In the Workspace dialog box, click on the prostate IMRT plan ID that you just created and select New QA Plan from the mouse menu.

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2.

Select the TrainingClinic: Prostate: MonacoPhantom study set. This is the studyset to use to create the QA plan.

3.

For this exercise, you want to maintain the original beams angles. Do not Reset Beams to Nominal Angles.

4.

Select Monte Carlo as the Algorithm.

5.

For this practice exercise, type 0.3 cm for the Calc Vol Grid Spacing.

6.

Use a Statistical Uncertainty per Calculation of 1%.

7.

Select Calculate dose to Medium.

8.

Click OK to show the Setup QA Plan dialog box.

9.

Select the isocenter Center of patient.

10.

Click OK to show the phantom in IMRT QA activity.

11.

Click the Start Dose Calculation button. Once the system completes the calculation of the QA plan, the Optimization Console indicates: Dose Calculation Completed.

Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 18. Edit QA Plan Beam Weights (Optional) Beam weights in QA are automatically scaled to one fraction. If necessary, you can edit the beam weights to accommodate your QA process. 1.

Click the Beams tab of the Planning Control.

2.

Edit the Total MU for each beam individually.

Task 19. Save the QA Plan The system saves QA Plans with their associated IMRT patient plans. 1.

Save the QA plan. Use one of these methods: Click the Save

button.

OR Click the Monaco Application drop-down menu and select the Save option.

Task 20. Export the Dose Planes If you use a third party software to compare planned versus measured dose profiles, you can export those planes when you use the Dose Export Tool. Skip this step for the practice exercise. For more information, see the IMRT QA activity section of this training guide.

Monaco®

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Prostate IMRT Case Volume II of IV Monaco Training Guide

Prostate IMRT Case Practice Exercise (cont.) Task 21. Print the QA plan For more detailed information on how to print QA plan information and images, see the section General Operation and Navigation. Subtask 1. Print QA Plan Reports 1.

Click the Output tab and select Individual Reports or Customized Reports to print. OR Right-click on the loaded QA plan in the Patient Workspace Control. Select an Individual Report to print. OR Select Customized Report to select a set of reports to print. NOTE:

You can save Customized Reports as a template. Refer to the General Operation and Navigation section of this guide for more information.

Subtask 2. Print QA Plan Images You can print images with dose on the phantom just as any single plane view image.

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1.

Select the Output tab.

2.

Select Print Views on the Reports panel.

3.

Select the necessary view to print.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise The exercise in this section reviews the general process of planning a VMAT patient in Monaco. There are many ways to complete a VMAT plan in Monaco. This is just one suggested method. This exercise does not include contouring. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. This exercise includes these tasks: Task 1. Task 2. Task 3. Task 4. Task 5. Task 6. Task 7. Task 8. Task 9. Task 10. Task 11. Task 12. Task 13. Task 14. Task 15. Task 16. Task 17. Task 18. Task 19. Task 20.

Monaco®

Select Patient and Open Studyset Start a VMAT Plan using a Template Add VMAT Sequences in Planning Activity Enter the Prescription Enter IMRT Constraints Edit Calculation Parameters Edit Sequencing Parameters Save a VMAT Template Optimize Fluence (Stage 1) Evaluate Optimized Fluence and Dose Re-Optimize and Evaluate (Optional) Optimize Segment Shapes/Calculate Dose (Stage 2) Evaluate Final Plan Save Plan Print the Plan Create/Calculate a QA Plan Edit QA Plan Beam Weights Save the QA Plan Export the Dose Planes Print the QA plan

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 1. Select Patient and Open Studyset This task walks you through the steps to select a patient and open a studyset. 1.

Open the Monaco software to automatically show the Open Patient Workspace.

2.

Select the patient Fusion Prostate. Use one of these methods: Double-click on the patient name. OR Click the name once. Click the OK button. The system loads the patient information into the Patient Workspace Control.

3.

Select the CT studyset CT1 using one of these methods: Double-click on the studyset name. OR Click the studyset name once, and then click the Load button. The patient shows in the Planning activity.

Task 2. Start a VMAT Plan using a Template This task walks you through the steps to select a template.

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button on the

1.

Click on the drop-down arrow next to the New Plan Planning tab to choose a plan type.

2.

Select New Monaco Plan in the drop-down list. This opens the New Monaco Plan dialog box.

3.

Type in a plan name and description: ProstateVMAT.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 2. Start a VMAT Plan using a Template (cont.) 4.

Select VMAT for the Delivery.

5.

Select All for the Anatomical Site.

6.

Place a checkmark by the template named DEFAULTVMAT (Rx Site:, Rx Dose: Gy, Total Beams:1).

7.

Select Head First as the Treatment Orientation.

8.

Select the Center of PTV for the Isocenter Location.

9.

Select a Treatment Unit associated with a machine type used in your clinic.

10.

Select 6.0MV as the Energy.

11.

Click OK to load the template and patient into the planning activity.

Task 3. Add VMAT Sequences in Planning Activity You can only add VMAT sequences in IMRT activity. Once you create and save your own clinical VMAT templates, you use this task less frequently. 1.

Click on the Beams tab in the Planning Control.

2.

Verify this beam information in the Geometry tab: Description: Couch: Collimator: Gantry Start: Arc: Increment: NOTE:

Monaco®

Seq1 0 0 180 360 30

For more information on Arc and Increment definition and use, see the section Arc Planning Terminology in this guide.

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 4. Enter the Prescription You only use this task when you need to edit the prescription from a template. Once you create and save your own clinical templates, you use this task less frequently. 1.

Select the Prescription tab on the Planning Control.

2.

Type Prostate for Rx Site.

3.

Select Plan Isocenter in the Prescribe to Column.

4.

Type 73.8 in the Rx Dose (Gy) column.

5.

Type 41 in the Number of Fractions column. The Fractional Dose (Gy) column updates with 1.8 Gy as the value.

Task 5. Enter the IMRT Constraints 1.

Click the IMRT Constraints tab on the Planning Control. NOTE:

2.

Use the Plan Scoring Criteria to add/edit cost functions we gave you. For this exercise, we gave you suggested cost functions and explanations of their use for each structure. Note that the IMRT Constraint values used in the exercise are only examples. You can use other combinations of cost functions to produce similar results. NOTE:

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Verify there is not a mismatch in structure names. If the structure names do not match, the mismatched name is red in the Structures column on the IMRT Constraints tab.

If you do not want any planning hints, skip this section and go directly to the Plan Scoring Criteria table.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 5. Enter the IMRT Constraints (cont.) PTV - For target structures, a Target EUD or Target Penalty is always required. The target cost functions designate the target as an Objective. Neither target cost function penalizes high doses. You need to use the Quadratic Overdose cost function to make sure you do not exceed the global max dose. This also gives you a more homogeneous dose within the target structure. The Isoconstraint value for the Target EUD/Target Penalty cost function is the target prescription 73.80 Gy. •

If you use the Target EUD, you can use 73.80 Gy for the reference dose and 0.5 for the Cell Sensitivity to meet the prescription criteria. -

•

If you use the Target Penalty, you can use 73.80 Gy for the Prescription and 95% for the Minimum Volume. -

NOTE:

For the Quadratic Overdose, you can use 75.00 Gy for the maximum dose and 2.00 for the RMS dose excess to meet the prescription criteria.

For the Quadratic Overdose, use 75.00 Gy for the maximum dose and 2.00 for the RMS dose excess to meet the prescription criteria. You use an RMS of 2.0 in this exercise to decrease the calculation time. You should determine what prescription and RMS to use for your clinical plans based on your clinical experience and goals.

RECTUM - For this organ at risk, a Serial cost function would be appropriate since the rectum is a serial structure. In some cases, like this one, you may need two serial models to meet or exceed the prescription criteria. For the first serial model, a power law exponent of 12 with an EUD of 62.00 Gy keeps hot spots to a minimum throughout the entire structure. Since the target and rectum volume are so close and even overlap in some areas, we suggest that you add a second serial cost function to this structure. Use a lower EUD and power law exponent, such as 46.00 Gy and 5 and use a Shrink Margin of 0.4 cm. The second serial cost function lets you further reduce the dose in the area of the rectum where the voxel doses do not compete with the target.

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 5. Enter IMRT Constraints (cont.) BLADDER - For this organ at risk, a Serial cost function would be appropriate since the bladder is a serial structure. A power law exponent of 8 and EUD of around 55.00 Gy would be reasonable to meet the prescription criteria. In addition, use a Shrink Margin of 0.4 cm so as not to include the hot voxels that surround the target. Since the bladder is filled with contrast, apply the structure property Uniform Density, with a density of 1.0. Click on the Structures tab. Check Force ED and verify the relative ED is 1.0. When you apply this property to the structure, the density value you use overrides the “false” high density of the contrast in this patient. Patient - When you plan, you should take into consideration dose to all unspecified tissue and apply cost function(s) to keep the dose to a minimum. The Conformality cost function works well here. Use the Conformality cost function with a Relative Isoconstraint of 0.7. Select Optimize over All voxels in volume to apply the cost function up to 8 cm from the edge of the PTV. Rt and Lt Femur - You could contour and add these structures to the prescription. However, after dose calculation, if you look at the dose to the unspecified tissue (patient), which includes the femurs, the % dose of 45.00 Gy is well below 5%. 3.

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Layer the structures appropriately. Highlight the structure you want to move and click the up or down arrow on the IMRT Constraints dialog box. Targets are typically at the top and patient skin surface contour at the bottom.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 5. Enter IMRT Constraints (cont.) 4.

Once you assign all the structures, doses, and isoconstraints in the IMRT Constraints dialog box, the system recognizes the updates and leaves the dialog box open. Target Structures PTV

Organs at Risk (OAR) BLADDER

95% is at or above 73.80 Gy and Max dose < or = 81.18 Gy (110%)

no more than 60% > 40 Gy and no more than 40% > 60 Gy

RECTUM

no more than 50% > 40 Gy and no more than 30% > 60 Gy

Rt Femur Lt Femur

no more than 5% > 45 Gy no more than 5% > 45 Gy

Figure 12-1: Planning Score Criteria example

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 6. Edit Calculation Parameters This task lets you set up the calculation parameters for the current plan. NOTE:

The values used in the training class for this exercise may not represent actual clinical values. The Calculation Properties (Grid Spacing, Statistical Uncertainty) are chosen to decrease the time it takes to run the plan to give you more time to run more iterations (if needed) in the training class. Use a smaller Grid Spacing and Statistical Uncertainty if you are calculate the plan overnight.

1.

Click the Calculation Properties to open the Calculation Properties dialog box.

2.

For this practice exercise, use a Grid Spacing of 0.4 cm.

3.

Select Calculate dose to Medium.

4.

Use a Statistical Uncertainty Per Calculation of 4%. NOTE:

button on the Planning tab

It is possible to decrease calculation times for VMAT plans if you use a higher Statistical Uncertainty per Calculation value for initial planning. For the first iteration of stage 1 and stage 2, the user selects a higher Statistical Uncertainty than what is recommend for clinical use. When the final plan is calculated, the user can change the Statistical Uncertainty per Calculation to a lower, more clinically acceptable value. The segmented plan automatically begins a recalculation and returns the new results. The user then selects Skip Forward when it becomes available to return the “segmentation complete” message. The recommended values are 2-3% per plan for initial planning followed by 1% for the final calculation. Please note that as a consequence of using a higher statistical uncertainty, the user must review all aspects of the plan which includes dose distribution and DVH to make sure the plan is acceptable. If you use a higher Statistical Uncertainty, dose to small structures can be affected.

5.

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Click OK once you complete your edits.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 7. Edit Sequencing Parameters 1.

You can do this task at any time before Stage 2 of the optimization.

2.

Click the Sequencing Parameters

3.

Make sure that you define these sequencing parameters: Segment Shape Optimization Pilot Beamlets Max Number of Arcs:

Checked Checked 1

Max. # of Control Points/Arc: Min. Segment Width: Fluence Smoothing:

120 1.0 Medium

NOTE:

4.

button.

(Use 1 for only Elekta machines. Use 2 for nonElekta machines. Monaco automatically increases this value if it needs more than one arc for non-Elekta machines.)

For more information on Sequencing Parameters definition and use, see the Monaco Planning and Workflow or the Planning Suggestions sections of this training guide.

Click OK once you complete your edits. Click Cancel if no edits were made.

Task 8. Save a VMAT Template You can do this task at any time while in the planning process. However, it is highly beneficial for you to create a prescription before you save the template. 1.

and select the Save Template As Click the Monaco Application Menu option to show the Save Template As dialog box.

2.

Type the template name TrainProVMAT.

3.

Type the template description TrainProVMAT.

4.

(Optional) Select Pelvis from the Anatomical Site drop-down.

5.

Select Save to save the template.

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 9. Optimize Fluence (Stage 1) This task starts the optimization process. The system automatically gives feedback in optimization on the IMRT Constraints dialog box, the console, and the progress meter. You can manually update the dose, DVH, and fluence in the optimization process. 1.

Click the IMRT Constraints tab in the planning control.

2.

Show the Console using one of these methods:

Select the Optimization Console option in the Controls on the Workspace tab.

drop-down menu

OR Press the Alt and C keys on your computer keyboard. 3.

Click the Start Optimization one of the optimization process. NOTE:

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button on the Planning tab, to start stage

After you create the rays (beamlets), you can see the IMRT Constraints dialog box and progress meter start to update with each iteration.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 9. Optimize Fluence (Stage 1) (cont.) 4.

(Optional) If you would like to stop the optimization and move to the end of stage one prematurely, click the Skip Forward action does not result in fully optimized fluence.

button. Understand that this

OR (Optional) If you would like to stop the optimization and go back to the start of button. This action removes the current stage one, click the Skip Back display of fluence and lets you start the optimization again at stage one. 5.

Once stage one of the optimization is complete, the system shows a dialog box with the message “Full Fluence Modulation Complete.”

6.

Click OK to acknowledge.

Task 10. Evaluate Optimized Fluence and Dose After stage one, you have many tools available to evaluate the optimized fluence and dose. Among these tools are Sensitivity Analysis, DVH Statistics, Fluence Toolbar, and isodose curves on the SPV and 3D images. This task references the location in the Monaco training guide where detailed information is located about the use or functionality of these tools. You can use any or all for evaluation at this time. 1.

Monaco®

You can use the Sensitivities information on the IMRT Constraints dialog box to evaluate your plan. Refer to the Monaco Planning and Workflow section: Plan Analysis Tools for more detailed information.

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 10. Evaluate Optimized Fluence and Dose (cont.) 2.

You can also use the DVH tools to evaluate your plan. You can select from any of these DVH tools on the Plan Options tab: DVH Statistics, DVH Properties, and Structure Combination.

Figure 12-2: DVH Panel OR Right-click in the DVH window to use the DVH tools. Refer to the Plan Review Activity section of this training guide to change the DVH Display, Properties, and Statistics. 3.

Use the isodose curves on the SPV and 3D images to evaluate. Refer to these resources: • • •

General Operation and Navigation section Image Navigation and View Types Plan Review Activity section, Dose Toolbar Controls

Task 11. Re-Optimize and Evaluate (Optional) If you determine that you need to make changes to the prescription to meet prescribed goals, you may have to re-optimize. When you apply the changes, notice if the start to . If so, the changes you made button on the Planning tab changes from require re-optimization. Evaluate again. Use the tools described in Task 10. You may re-optimize and evaluate several times before calculating stage 2.

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 12. Optimize Segment Shapes/Calculate Dose (Stage 2) Once the optimized plan meets the prescription goals, you must optimize and calculate the final dose. Both of these actions occur in stage 2 of the optimization. 1.

(Optional) Verify that the Sequencing Parameters that appear are your desired settings. Change them, if necessary. (See Task 7.)

2.

(Optional) Show the IMRT Constraints dialog box and the Console. (See Task 9.)

3.

Click the Start Optimization

4.

(Optional) If you would like to stop the optimization and move to the end of

button to start stage 2 of the optimization.

stage two prematurely, click the Skip Forward action does not result in a fully optimized plan.

button. Understand that this

OR (Optional) If you would like to pause stage 2 of the optimization, click the Skip button. This action removes the current display of fluence and lets Back you start the optimization again at stage one. 5.

Once stage two of the optimization completes, the system shows a dialog box with the message “Segmentation Complete”. Click OK to acknowledge.

Task 13. Evaluate Final Plan Once the system calculates the plan, you can evaluate. Use the same tools you used to evaluate the optimized plan (see Task 9). If you choose to make changes to the prescription at this time, the system determines if the change necessitates that you start again at stage 1, starting at stage 2, or continue from its current state.

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 14. Save Plan Save the plan once you are sure that it has met the prescribed goals. NOTE: 1.

You can save optimized plans after stage 1, but optimized dose is not preserved.

Save the plan using one of these methods: Click the Save

button on your Quicklaunch bar.

OR Click the Monaco Application Menu and select a Save option.

Task 15. Print the Plan There are many documents and images that offer support. You can print them for patient files. This task references the location in the training guide where detailed information appears about each type of print job. Subtask 1. Print or Export IMRT Reports For more detailed information on how to print, see the section General Operation and Navigation. 1.

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Click on the Output tab to select an individual or customized report to select a set of reports to print.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 15. Print the Plan (cont.) Subtask 2. Print Single Plane View, 3D Image or DVH Graph You can print Images from any activity. You can print the DVH graph from Planning or Plan Review activity. Calculated dose only appears on images in Planning and Plan Review Activity. 1.

Select the Output tab.

2.

Select Print Views on the Reports panel.

3.

Select the necessary view to print.

4.

For some reports, the system gives you the option to type a report comment.

5.

Click the Print button on the preview window to print the report shown.

Subtask 3. Print DRR/BEV You can print DRR/BEV images to paper or film and scaled appropriately when calibrated. For more information, see the General Operation and Navigation section, Printing Options. 1.

Click the Print Views drop-down arrow located in the Reports panel on the Output tab. OR Right-click on any DRR/BEV image and select the Print option to show the DRR Print dialog box.

2.

Type the applicable information for location and scaling.

3.

Click OK to print the image.

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 16. Create/Calculate a QA Plan Once you complete an IMRT plan, you can create a QA plan for verification. 1.

In the Workspace window, right click on the plan ID you created in this exercise and select New QA Plan from the mouse menu. OR Click the New Plan button on the Planning tab, and select New QA Plan from the drop-down.

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2.

Select the TrainingClinic: MonacoPhantom studyset. This is the studyset where on which the QA plan will be created.

3.

For this exercise, you want to maintain the original beams angles, so do not select Reset Beams to Nominal Angles.

4.

Select Monte Carlo as the Algorithm.

5.

For this practice exercise, type 0.3 cm for the Calc Vol Grid Spacing.

6.

Use a Monte Carlo Statistical Uncertainty per Plan of 1%.

7.

Select Calculate dose to Medium.

8.

Click OK to show the Setup QA Plan dialog box.

9.

Select the isocenter Center of patient.

10.

Click OK to create the QA plan.

11.

Click the Planning tab.

Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise Task 16. Create/Calculate a QA Plan (cont.) 12.

Click the Start Dose Calculation button. Once the system completes the calculation of the QA plan, it shows a dialog box with the message “QA Calculation Complete.”

13.

Click OK to acknowledge.

NOTE:

You can edit the calculation properties, edit and assign electron densities, and utilize other tools. See the IMRT QA Tools, Planning Tools, and IMRT Tools sections for more detailed information.

Task 17. Edit QA Plan Beam Weights (Optional) Beam weights in QA are automatically scaled to one fraction. If necessary, you can edit the beam weights to accommodate your QA process. 1.

Click the Beam tab in the Planning Control.

2.

Edit the Total MU for the sequence.

Task 18. Save the QA Plan The system saves the QA Plans with their associated patient plans. 1.

Save the QA plan, by either using one of these methods: Click the Save

button on your Quicklaunch Bar.

OR Click the Monaco Application Menu button and select the Save option.

Monaco®

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Prostate VMAT Case Volume II of IV Monaco Training Guide

Prostate VMAT Case Practice Exercise (cont.) Task 19. Export the Dose Planes If you use third party software to compare planned versus measured dose planes, you can export those planes when you use the Dose Plane Export Tool . For ArcCHECK, Delta4 and other 3D devices, DICOM Export the RTPLAN and RTDOSE to third party software for measurement comparisons. Skip this step for the practice exercise. For more information, see the IMRT QA Tools section of this training guide.

Task 20. Print the QA plan For more detailed information on how to print a QA plan information and images, see the section General Operation and Navigation. Subtask 1. Print QA Plan Reports 1.

Right-click on the loaded QA plan in the Patient Workspace Control. Select an Individual Report to print. OR Select Customized Report to select a set of reports to print. OR Click the Output tab. Select an Individual Report OR Customized Report to select a set of reports to print.

Subtask 2. Print QA Plan Images You can print images with dose on the phantom just as any single plane view image.

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Head and Neck Case Volume II of IV Monaco Training Guide

Head and Neck Case Practice Exercise This exercise assumes you are familiar enough with the planning in Monaco that you no longer require specific steps. You can use the steps in the Prostate Plan as a reference if you need it. This exercise includes prescription objectives based on the RTOG 0022 Protocol and contours already drawn for you. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. This stepwise task list helps you in your planning process. You may or may not do all of the tasks on this list to complete your plan.

Monaco®

•

Select Patient HnNPlan and Open Studyset HnNss

•

Start Plan

•

Add Beams or Sequences in Planning Activity

•

Enter/Update the Prescription

•

Edit Calculation Parameters

•

Edit Sequencing Parameters

•

Save a Template

•

Optimize Fluence (Stage 1)

•

Evaluate Optimized Fluence and Dose

•

Re-Optimize and Evaluate (Optional)

•

Optimize/Calculate Dose (Stage 2)

•

Evaluate Final Plan

•

Save Plan

•

Print the Plan

•

Create/Calculate a QA Plan

•

Edit QA Plan Beam Weights

•

Save the QA Plan

•

Export the Dose Profiles

•

Print the QA plan 13-1

Head and Neck Case Volume II of IV Monaco Training Guide

Head and Neck Case Practice Exercise (cont.) General Planning Instructions

Target Structures PTV66 PTV60

PTV54 Organs at Risk (OAR) Brainstem Spinal Cord Unspecified Tissue (patient) Parotids

1.

Place the isocenter at the center of the structure PTV TOTAL.

2.

Select a 6MV treatment machine that best represents a machine that you use clinically (Varian, Siemens, or Elekta).

3.

Create a plan and use seven beams spaced evenly around the patient, or create a sequence for VMAT.

4.

Use a Grid Spacing of 0.4 cm.

95% of PTV66 is at or above 66Gy 30 fx 95% of PTV60 is at or above 60Gy 30 fx 95% of PTV54 is at or above 54Gy 30 fx and no more than 20% of any PTV receives >110% of prescribed dose no more than 1% of any PTV receives 110% of 66Gy Mean dose to either parotid 35 Gy Max 54 Gy no more than 5% > 5 Gy no more than 5% > 5 Gy Max 50 Gy Max 50 Gy

For DCAT, the OARs in the prescription are only used to show that avoidance is applied to the apertures. Therefore, you can leave the isconstraints blank in order to avoid conflict, unless you have Segment Shape Optimization checked. To make an OAR an avoidance, check the Avoidance option in the structure’s Properties dialog box.

3.

Type 26 for the Number of Fractions.

4.

Type 46.80 Gy for the Prescription.

Brain Case – Two Partial Arcs Volume II of IV Monaco Training Guide

Brain Case – Two Partial Arcs Practice Exercise (cont.) Task 5. Edit Calculation Properties This task lets you set up the calculation properties. NOTE:

The values used in the training class for this exercise may not represent actual clinical values. The intent is to decrease the time it takes to run the plan to give you more time to run more iterations (if needed) in the training class.

1.

Click the Calculation Properties the Calculation Properties dialog box.

button to open

2.

For this practice exercise, use a Grid Spacing of 0.3 cm.

3.

For this practice exercise, select Monte Carlo Photon for the Secondary Algorithm.

4.

Select Calculate dose to Medium.

5.

Use a Statistical Uncertainty per Calculation of 3%.

6.

Click OK when you completer your edits.

Task 6. Edit IMRT Parameters This task lets you set up IMRT Parameters

Monaco®

1.

Click IMRT Parameters on the IMRT Constraints tab.

2.

For Target Margin select Narrow (3-4mm).

3.

For Avoidance Margin, select Tight (2mm).

4.

Click OK when you complete your edits.

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Brain Case – Two Partial Arcs Volume II of IV Monaco Training Guide

Brain Case – Two Partial Arcs Practice Exercise (cont.) Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) Click the Sequencing Parameters sequencing parameters.

button to set the

Use these sequencing parameters for this plan: Segment Shape Optimization: Checked Pilot Beamlets: Checked Max Number of Arcs: 1 Max # of Control Points/Arc: 75 Min. Segment Width (cm): 0.50 Fluence Smoothing: Low Use these sequencing parameters for a DCA plan: Constant Dose Rate: Unchecked Segment Shape Optimization: Checked

Task 8. Optimize Fluence and Calculate Dose This task starts the optimization process. The system automatically gives feedback during optimization on the IMRT Constraints dialog box, the console, and the progress meter. You can manually update the dose, DVH and fluence during the optimization process. 1.

Press the Alt and C keys on your keyboard to show the Console.

2.

Click the Optimize NOTE:

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button to start the optimization process.

After you create the rays (beamlets), you can see the IMRT Constraints dialog box and progress meter start to update with each iteration.

Brain Case – Two Partial Arcs Volume II of IV Monaco Training Guide

Brain Case – Two Partial Arcs Practice Exercise (cont.) Task 8. Optimize Fluence and Calculate Dose (cont.) 3.

(Optional) If you want to stop the optimization and move to the end of the button. Understand optimization prematurely, click the Skip Forward that this action does not result in fully optimized fluence. OR (Optional) If you want to stop the optimization and go back to the start, button. This action removes the current display of click the Skip Back fluence and lets you start the optimization again.

4.

Once the optimization completes, the system shows a dialog box with the message “Final Dose Calculation Complete.”

Task 9. Evaluate Plan You have many tools available to evaluate your plan. Among these tools are: •

Sensitivity Analysis

•

DVH Statistics

•

Fluence Display Tools

•

Isodose curves on the SPV

•

3D images

This task references the location in the Monaco training guide and shows the location of detailed information about the use or functionality of these tools. You can use any or all for evaluation at this time. 1.

Monaco®

Use the Sensitivity Analysis information to evaluate. The Sensitivities button is in the upper-right corner of the IMRT Constraints tab. Refer to the Monaco Planning and Workflow section Plan Analysis Tools for more detailed information.

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Brain Case – Two Partial Arcs Volume II of IV Monaco Training Guide

Brain Case – Two Partial Arcs Practice Exercise (cont.) Task 9. Evaluate Plan (cont.) 2.

Use DVH Statistics to evaluate. Refer to the Plan Review section to show a DVH and review the DHV Statistics on the Plan Options tab.

3.

Use Fluence Tools on the Planning tab to evaluate. Refer to the IMRT Tools section Fluence Toolbar.

4.

Use isodose curves on the SPV and 3D images to evaluate. Refer to these resources: • • •

General Operation and Navigation section Image Navigation and View Types Plan Review Activity section, Dose Toolbar Controls

Task 10. Re-Optimize and Evaluate (Optional) If you determine that you need to make changes to the prescription to meet prescribed goals, you may have to re-optimize and evaluate again. Use the tools described in Task 8. You can re-optimize and evaluate several times before you accept the final plan. For DCAT plans, the tools available to improve plan quality are limited to Target and OAR avoidance margins. You can also change the beam position to improve the plan quality.

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Brain Case – Two Partial Arcs Volume II of IV Monaco Training Guide

Brain Case – Two Partial Arcs Practice Exercise (cont.) Task 11. Save Plan Save the plan when once you decide that it meets the prescribed goals. 1.

Open the Save as Plan dialog box. Use one of these methods: Click the Save

button on your toolbar.

OR Click the Monaco Application the menu.

Monaco®

2.

Type the plan name ArcPlan.

3.

Click Save to save the plan

button and select Save Plan As from

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise This exercise reviews the general process of planning a brain patient in Monaco when you use the Siemens mARC Delivery. There are many ways to complete a plan in Monaco. This is one suggested method of treatment planning. This exercise does not include contouring. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. This exercise includes these tasks: Task 1. Task 2. Task 3. Task 4. Task 5. Task 6. Task 7. Task 8. Task 9. Task 10.

Monaco®

Select Patient and Open Studyset Start an mARC Plan Add Beams in Planning Activity Enter/Update the Prescription Edit Calculation Parameters/Global Parameters Enter/Edit Sequencing Parameters (VMAT Plans only) Optimize Fluence and Calculate Dose Evaluate Plan Re-Optimize and Evaluate (Optional) Save Plan

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 1. Select Patient and Open Studyset This task walks you through the steps to select a patient and open a studyset. 1.

Open the Monaco software to automatically show the Open Patient Workspace.

2.

Select the patient ID DynamicConformal. Use one of these methods: Double-click on the patient name. OR Click the name once. Click the OK button. The system loads the patient information into the Patient Workspace Control.

3.

Click the studyset name once, and select New Monaco Plan from the mouse menu. The patient information loads and the New Monaco Plan dialog box appears.

Task 2. Start an mARC Plan This task walks you through the steps to select a default template and start a new plan.

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1.

Click the Template: DEFAULT VMAT option. There is no default template for an mARC plan. Modify the VMAT template once you are in Planning mode.

2.

In the spreadsheet, select any valid Treatment Unit. If necessary, select the Energy.

3.

Click OK.

4.

Click the Beams tab on the Planning Control spreadsheet.

5.

Use the drop-down menu to change the Delivery to mARC.

6.

Use the drop-down menu to change the Treatment Unit to Siemens160IMRT.

7.

Use the drop-down menu to change the Isocenter Location to Center of Target.

mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 3. Add Beams in Planning Activity You only complete this task when you need to add beams to or modify beam arrangements from a template. You use this task less frequently once you create and save your own clinical templates. 1.

button Add two new mARC beams to the plan. Click the New Beam on the Beams tab of the Planning Control spreadsheet twice to add the beams.

2.

Click the Geometry button in the upper-right corner of the Beams tab. You edit the Collimator, Couch, and Gantry information here. Beam 1

Monaco®

Beam 2

Beam 3

Couch

0.0

Couch

45.0

Couch

270.0

Collimator

0.0

Collimator

0.0

Collimator

0.0

Gantry Start

40.0

Gantry Start

50.0

Gantry Start

50.0

Arc

140.0

Arc

130.0

Arc

130.0

Increment

20.0

Increment

20.0

Increment

20.0

Isocenter

Center of Target

Isocenter

Center of Target

Isocenter

Center of Target

Direction

CW

Direction

CW

Direction

CW

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 4. Enter/Update the Prescription You only complete this task when you need to edit the prescription from a template. You use this task less frequently once you create and save your own clinical templates. 1.

Click the IMRT Constraints tab on the Planning Control dialog box spreadsheet.

2.

You need to edit the existing constraints. The structures saved with this patient are not valid. You also need to add constraints so the plan meets the Plan Scoring Criteria. Edit the existing structure prescriptions. Add structures and prescriptions to create an initial prescription for this patient. Target Structures Target

95% is at or above 46.80 Gy

Organs at Risk (OAR) Brain Stem Chiasm Rt Eye

Lt Eye Rt Optic Nerve Lt Optic Nerve

3.

Once you assign all the structures, doses, and isoconstraints, click the Prescription tab on the Planning Control Spreadsheet.

4.

Type 26 for the Number of Fractions.

5.

Type 46.80 Gy for the Rx Dose.

NOTE:

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Max 45 Gy no more than 50% > 35 Gy Max 54 Gy no more than 5% > 5 Gy no more than 5% > 5 Gy Max 50 Gy Max 50 Gy

If necessary, click the Plan Options tab at the top of the screen. Change the units to Gy. Click the Planning tab to continue with the plan.

mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 5. Edit Calculation Properties This task lets you set up the calculation properties. Grid Settings are global settings and algorithm settings are per prescription. NOTE:

The values used in the training class for this exercise may not represent actual clinical values. Our intent is to decrease the time it takes to run the plan to give you more time to run more iterations (if needed) in the training class.

1.

Click the Calculation Properties Calculation Properties dialog box.

2.

For this practice exercise, use a Grid Spacing of 0.3 cm.

3.

Use Monte Carlo Photon for the Secondary Algorithm.

4.

Select Calculate dose to Medium.

5.

Use a Statistical Uncertainty Per Calculation of 3%.

button to open the

Task 6. Edit IMRT Parameters This task lets you set up IMRT Parameters for each prescription.

Monaco®

1.

Click IMRT Parameters on the IMRT Constraints tab.

2.

For Target Margin, select Narrow (3-4mm).

3.

For Avoidance Margin, select Tight (2mm).

4.

Click OK when you complete your edits.

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) This task lets you set up the sequencing parameters for the current plan. 1.

Select the Sequencing Parameters

2.

Use these sequencing parameter for this plan:

button.

Segment Shape Optimization: Checked Pilot Beamlets: Checked Max Number of Arcs: 1 Max # of Control Points/Arc: 75 Min MU Per Dynamic CP: 2 Min. Segment Width (cm): 0.50 Fluence Smoothing: Low 3.

Click OK. NOTE:

Segment Shape Optimization works the same for all delivery modes (VMAT, SnS, dMLC, DCAT, mArc). We recommend you use SSO in order to create better plan quality and delivery times. When you enable SSO, the sequencer controls the target dose rate to make sure it is optimally set for the given plan. Therefore you do not enter a Target Dose Rate. The Min MU per Dynamic CP is only available for mARC plans. This variable gives you extra control over the plan quality. For simple single arc Prostate or single lesion plans, you can increase this value to 3 or 4 to keep the level of plan modulation down and improve the delivery efficiency.

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 8. Optimize Fluence and Calculate Dose This task starts the optimization process. The system automatically gives feedback during optimization on the prescription dialog box, the console, and the progress meter. You can manually update the dose, DVH, and fluence during the optimization process. 1.

Click the IMRT Constraints tab on the Planning Control spreadsheet.

2.

Show the Console. Use one of these methods: Click the Workspace tab and select the Controls | Optimization Console option. OR Press the Alt and C keys on your computer keyboard.

3.

(If necessary) Click the Planning tab.

4.

Click the Optimize NOTE:

Monaco®

button to start the optimization process.

After you create the rays (beamlets), you can see the prescription dialog box and progress meter start to update with each iteration.

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise Task 8. Optimize Fluence and Calculate Dose (cont.) 5.

(Optional) If you want to stop the optimization and move to the end of the button. Understand optimization prematurely, click the Skip Forward that this action does not result in fully optimized fluence. OR (Optional) If you want to stop the optimization and go back to the start, button. This action removes the current display of click the Skip Back fluence and lets you start the optimization again.

6.

Once optimization completes, the system shows a dialog box with the message “Full Fluence Modulation Complete. Press Start to Begin Segmentation”. Click OK to acknowledge.

7.

Click the Optimize

8.

Once optimization completes, the system shows a dialog box with the message ‘Segmentation Complete’. Click OK to acknowledge.

button to do stage 2 of the optimization.

Task 9. Evaluate Plan You have many tools available to evaluate your plan. Among these tools are:

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•

Sensitivity Analysis

•

DVH Statistics

•

Fluence Display Tools

•

Isodose curves on the SPV

•

3D images

mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise Task 9. Evaluate Plan (cont.) This task references the location in the Monaco training guide and shows the location of detailed information about the use or functionality of these tools. You can use any or all for evaluation at this time. 1.

Use the Sensitivity Analysis information to evaluate. Sensitivities tab is located on the IMRT Constraints tab of the Planning Control spreadsheet. Refer to the Monaco Planning and Workflow section Plan Analysis Tools for more detailed information.

2.

to evaluate. Refer to the Plan Review Use DVH Statistics Activity section to change the DVH Display Properties and DVH Statistics.

3.

Use Fluence Statistics Fluence Toolbar.

4.

Use isodose curves on the SPV and 3D images to evaluate. Refer to these resources: • • •

to evaluate. Refer to the IMRT Tools section

General Operation and Navigation section Image Navigation and View Types Plan Review Activity section, Dose Toolbar Controls

Task 10. Re-Optimize and Evaluate (Optional) Should you determine you need to make changes to the prescription to meet prescribed goals, you may have to re-optimize and evaluate again. You can reoptimize and evaluate several times before you accept the final plan. You can also change the beam position to improve the plan quality.

Monaco®

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mARC Brain Case Volume II of IV Monaco Training Guide

mARC Brain Case Practice Exercise (cont.) Task 11. Save Plan Save the plan when you are sure that it has met the prescribed goals.

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1.

Click the Monaco Application button and select the Save Plan As option.

2.

Type the plan name ArcPlan.

3.

Click Save to save the plan.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning You can use two tangential open fields with segments to create a Forward radiation therapy plan. The MLC segments are constructed based on BEV projections, conforming MLCs to isodose surfaces. This exercise shows you how to apply the Forward planning technique for breast with Monaco. This exercise contains all necessary steps to create two tangential beams with multiple segments. It is assumed that you are already familiar with breast planning. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section1. Once you complete this exercise, you should understand these concepts and be able to execute the various tasks without additional supervision. • • • • • • • • • • • • • •

Monaco

Select a patient and open a studyset Contour Structures Manage Structure Display Manage Templates Edit beam Isocenter Create a new beam Create and edit photon and SCV ports Create Interest Points Manage Prescription Properties Display and Evaluate isodoses Create Segments Edit Beam Weighting Manage MU/Fluence Display Save a plan

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 1. Open the Patient 1.

Click the Monaco Applications menu

button.

2.

Select Open Patient

3.

Select the patient BreastTRN. Use one of these methods:

.

Double-click on the patient name. OR Click the name once and click OK. 4.

The system loads the patient information into the Patient Workspace Control.

5.

Select the CT studyset CT1. Use one of these methods: Double–click on the studyset name. OR Click the studyset name once, and then click the Load button. The patient data appears in the Planning activity.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 2. Create Contours Contour the following structures. • Patient (external) • Right lung • Left lung • Spinal cord • Heart • Lumpectomy_PTV You may choose from any of the contouring methods outlined in the Contouring Tools section of this training guide. Refer to those procedures as needed.

Task 3. Use Auto Margin to Expand the Target Volume Use the Auto Margin tool if you would like to combine structures to create a new structure or create positive, negative, or variable margins on structures. Refer to the Contouring Tools section of this training guide for more information on creating 3D auto margins. button on the Contouring ribbon.

1.

Click the Auto Margins

2.

Type the structure name: Lumpectomy_PTV in the Structure field.

3.

View the Source Selection List By Study.

4.

Select Tumor (GTV) in the Structure Selection List.

5.

Click the Add button.

6.

Make sure Uniform Margin is checked.

7.

Type the value 1.0 cm next to Superior.

8.

Click the Create button.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 4. New Plan from Template 1.

Click the drop-down arrow next to New Plan

2.

Select New Monaco Plan in the drop-down list. •

.

This opens the New Monaco Plan dialog box (Figure 17–1).

Figure 17-1: New Monaco Plan dialog box

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3.

Type a plan name and description: ForwardBreast.

4.

Select 3D Delivery.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning Task 4. New Plan from Template (cont.) 5.

Select All for Anatomical Site.

6.

Select the Template: DEFAULT3D1beam (Rx Site , Rx Dose: 2.000 Gy, Total Beams: 1).

7.

The Treatment Orientation for this plan is Head First. The Scan Orientation is indicated as Head First Supine.

8.

Select the Treatment Unit labeled Demo Synergy – 6MV. NOTE:

The Treatment Units in the training data are associated to specific energies.

9.

Select the Algorithm Collapsed Cone.

10.

Select 6.0 MV for the beam energy.

11.

Select any option in the Isocenter Location column. This exercise guides you to change the location of the isocenter in Task 5.

12.

Click OK to load the template and open the patient in Planning Control. The Patient orientation icon shows the head pointing toward the top of the screen.

Figure 17-2: Head First Patient Orientation Icon

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 5. Edit Beam Isocenter 1.

Click the Planning Ribbon tab.

2.

Click Edit Beam

3.

Position the mouse cursor over the central crossmark on the isocentric plan. The

.

mouse pointer looks like this:

(Figure 17-3).

Figure 17-3: Mouse Cursor to Move Isocenter

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning Task 5. Edit Beam Isocenter (cont.) 4.

Click and drag the crossmark to a new isocenter location close to the chest wall (Figure 17-4).

Figure 17-4: Isocenter Location NOTE:

Monaco

You can also change the isocenter when you type the X, Y, and Z coordinates for the new isocenter location on the beam tab in the Planning Control. Select Beams on the Planning Control Bar | General.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 6. Edit Gantry Angle 1.

Your Edit Beam

button should still be selected.

2.

Position the mouse cursor over the active beam’s central ray. The mouse pointer (Figure 17-5). looks like this:

3.

Left-click and move the mouse in a circular motion until you achieve your desired medial tangent gantry angle.

Figure 17-5: Mouse Cursor to Rotate Gantry NOTE:

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You can also change the Gantry, Collimator, and Couch angles by navigating to the Planning Control. Select Beams on the Planning Control Bar| Geometry.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 7. Manage Structure Display 1.

Open the Structure Visibility Control. In the default location, the control appears on the right side of your screen.

2.

(Optional) If you cannot find the Structures Control, reset your controls.

3.

Click the Column Header: Structure to turn all structures off. When all structures are off, the Structure Visibility window is gray.

4.

Click Breast_PTV_EVAL to show your target volume. NOTE:

Monaco

You can also manage structure’s visibility on the Structures tab on the Planning Control Bar. Select and unselect the Visible box.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 8. Edit Field Size 1.

Left-click in the Beam’s Eye View (BEV) to activate window.

2.

Right-click and select Maximize.

3.

Toggle the MLC display off. Right-click in the BEV, unselect Show MLC. Your Edit Beam button should still be selected.

4.

Position your mouse pointer over the collimator jaw position lines so that the mouse pointer looks like this:

5.

(Figure 17-6).

Increase the field length so that the field covers the whole target. Move the mouse while you hold down the left-mouse button to adjust the collimator jaw position line to the desired position.

Figure 17-6: Mouse Cursor to Edit Field Size NOTE:

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You can also change the Field Size in the Planning Control when you select Beams on the Planning Control Bar | Geometry.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 9. Create and Edit Port 1.

Turn on your MLC display. Right-click in the BEV window and select Show when the MLCs MLC. Monaco places a checkmark in the menu appear.

2.

Select Create and Edit Ports

3.

In the Create/Edit Ports dialog box, select MLC as the Port.

4.

Use the mouse cursor

5.

(Optional) Edit individual MLC leafs. When you hover your mouse over the MLCs, the selected MLC for editing appears in red. The mouse cursor for editing . Click and drag a MLC leaf to the new location. a MLC is a

.

to draw a Medial Tangent port.

OR Select Show Leaf Table in the Create and Edit Ports dialog box. a. A MLC leaf table is seen which is editable (Figure 7-17).

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 9. Create and Edit Port

Figure 17-7: Show Leaf Table 7.

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Close the Create and Edit Ports dialog box when the previous step is complete.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 10. Duplicate and Oppose Beam to Create Lateral Tangent 1.

Click the New Beam

2.

Select Duplicate and Oppose

drop-down. .

Task 11. Edit Beam Descriptions in the Beam Control 1.

Open the Beams tab on the Planning Control, located on the bottom of your screen above Slice Mode. NOTE:

2.

You can Reset the location of the Planning Control by selecting Workspace | Reset Controls. If the Beams tab is not visible select Workspace| Controls | Beams. The Beams tab should then become visible on the Planning Control Bar.

On the General tab of the Beam Control, edit the Beam Descriptions and Field IDs (Figure 17-8).

Figure 17-8: Field ID and Description

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 12. Line up Superior Edge of the Fields There are different techniques on how to line up the Superior field edge to get rid of divergence. This is just one way to demonstrate this. 1.

While looking at the 3D View change the Couch angle on the Beams tab| Geometry to line up the superior edge of the field. The couch angle moves the superior edge of the field superior to inferior.

2.

While looking at the 3D View change the collimator angle on the Beams tab| Geometry. The collimator angle tilts the beam edge left to right. NOTE:

You may line up the superior edge if you are going to treat a half beam block supra clavicular field.

Zero Couch Rotation Figure 17-9: Zero Rotation

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Zero Collimator Rotation

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 12. Line up Superior Edge of the Fields (cont)

Figure 17-10: Couch and Collimator Rotations

Figure 17-11: Bean data for couch and collimator rotations Couch and Collimator rotations to get rid of superior edge divergence.

Task 13. Re-evaluate the Ports 1.

Since the Couch and Collimator have moved you want to re-evaluate your ports to make sure they are covering everything.

2.

If changes need to be made select Create and Edit Ports and make the edits.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 14. Add an Interest Point In the Tools ribbon, you can place interest points or markers. This task explains how to create interest points in Monaco. For more information on how to place interest points or markers, refer to the Planning Tools section in this training guide. 1.

button on the Tools tab. Monaco shows Click the Interest Points/Markers the Interest Points& Markers dialog box (Figure 17-12).

Figure 17-12: Interest Points & Markers dialog box 2.

To place an Interest Point, select New Interest Point •

An interest point appears on the studyset (Figure 17-13).

Figure 17-13: Interest Point

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.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 14. Add an Interest Point (cont.) 3.

Type a Description for the Interest Point next to its coordinates.

4.

Move the point on a transverse, sagittal, or coronal image. To do this, place the mouse pointer over the point or marker. (The mouse pointer visually .) Hold down your left mouse button and drag changes to look like this the point to a new location. OR Type new coordinates for the point or marker in the dialog box.

5.

Click Done when complete. NOTE:

Try to keep the interest point 2cm away from the field edge if you are using it as a weight point. This will keep it out of the penumbra region. You can use the Measure tool on the Tools tab if you need to measure the distance (Figure 17-14).

Figure 17-14: Measure Distance for Interest Points

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 15. Enter Prescription 1.

Click the Prescription tab on the Planning Control.

2.

Type LtBREAST as the Rx Site. Monaco asks if you want to add the LtBREAST site to the list of Rx Sites.

Figure 17-15: Add to the List of Rx Sites dialog box 3.

Click Yes.

4.

Select the Prescribe To point. This could be the Interest Point you just created.

5.

Type an Rx Dose (Gy) of 48.6.

6.

Type 27 Number of Fractions. The Fractional Dose updates to 1.8 Gy.

7.

Equally Weight the Prescription dose between the Medial Tangent and Lateral Tangent, Beam 1 and 2 in the example below (Figure 17-16).

Figure 17-16: Beam Weights

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 16. Calculate Dose 1.

Click the Planning ribbon.

2.

Click the Calculate

button.

Task 17. Evaluate Dose/Isodose Templates 1.

Open Isodoses Control. The default location for this control is on the left side of your screen (Figure 17-17).

Figure 17-17: Isodoses Control 2.

(Optional) To Locate your Isodoses Control:

3.

Click Workspace | Reset Controls. OR Click Workspace | Controls| Isodoses.

4.

Monaco

Adjust Isodose levels as needed.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 17. Evaluate Dose/Isodose Templates (cont.) 5.

You can also select an isodose template from the drop-down.

Figure 17-18: Isodoses Template drop-down 6.

If you want to create an Isodose template: a. Type in the isodose line values. b. Select if you want the isodose line value on or off for 2D and 3D. c. Select Save As. d. Type in the Template Name or select a template from the drop-down you want to re save it as. e. Select Save.

7.

17-20

Review the 100% isodose line to make sure it adequately covers the breast and does not intrude into the lung. If it does not adequately cover the breast, return to Task 2 and increase the field sizes and/or rotate the gantry until you are satisfied with the coverage. You may also need to scale your Prescription.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 18. Edit Beam Weighting 1.

Click the Prescription tab in the Planning Control.

2.

(Optional) Adjust the beam weighting for the Tangent fields 1and 2 to achieve the best isodose display.

Figure 17-19: Beam Weighting Dose

Task 19. Display 3D Isodose for Forward Planning 1.

Open the Isodoses Control (see task 17).

2.

Pin the Isodose Control. To do this, click the thumb tack

3.

In the first Isodose value box, type the first overdose value you want to remove.

4.

Click the 3D drop- down arrow for the first isodose value box (Figure 17-20).

5.

Select an option.

button.

Figure 17-20: Isodoses Control

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 20. Manage MU/Fluence Display 1.

Right-click in the BEV. Select Maximize from the submenu.

2.

Right-click in the BEV. Select Show MU / Fluence from the submenu. You should now only see the 3D dose display and MLCs on the BEV (Figure 17-21).

Figure 17-21: BEV 3D Dose Display The above window shows the 118% hotspot in the BEV of your medial tangent. You use this to create the first segment.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 21. Create Second Medial Segment 1.

Open and pin the Prescription tab.

2.

Select the Segments tab.

3.

You then want to copy segment 1. Click Copy Segment. NOTE:

If you select Add Segment the jaw settings default to the parent beam’s open field size.

Figure 17-22: Copy Segment 1 4.

Click the Planning ribbon.

5.

Click Create and Edit Ports.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 21. Create Second Medial Segment (cont.) 6.

Edit the MLC’s to block the overdose region displayed as a 3D isodose. You may allow flash around the parts of the breast where you are not doing any modulation. •

As you add segments the system freezes the dose from the previous calculation so the isodose is still visible when you add segments.

Figure 17-23: BEV Blocking Hotspot 7.

17-24

Click Close on the Create and Edit Ports dialog box when the previous step is complete.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 22. Calculate Dose and Adjust Beam Weighting for Second Medial Segment 1.

On the Planning ribbon, click Calculate

.

2.

On the Segments tab you can adjust the weight of the new segment (Figure 17-24).

Figure 17-24: Beam Weight Second Segment 3.

Increase segment 2 weight using the slider bar or by typing a value in the weight field, until the overdose 3D isodose disappears (Figure 17-22).

4.

You must recalculate each time after you adjust the weight.

Figure 17-25: Isodose not seen in BEV

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 23. Create Second Lateral Segment 1.

Edit the 3D isodose display to a value approximately 2-5% less than its current value (Figure 17-26).

Figure 17-26: 2-5% Less Hot Spot Isodose 2.

Click the Beam drop-down and select Beam 2 (Figure 17-27).

Figure 17-27: Beam drop-down on Segments tab 3.

Click Copy Segment (Figure 17-28).

Figure 17-28: New Segment

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 23. Create Second Lateral Segment (cont.) 4.

Click the Planning ribbon.

5.

Click Create and Edit Ports.

6.

Edit the MLC’s to block the overdose region displayed as a 3D isodose (Figure 17-29).

Figure 17-29: New Segment Blocks Hot Spot area 5.

Monaco

Click Close on the Create and Edit Ports dialog box when you are finished editing the block.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 24. Calculate Dose and Adjust Beam Weighting for Second Lateral Segments

1.

On the Planning ribbon, click Calculate

.

2.

On the Segments tab you can adjust the weight of the new segment (Figure 17-30).

Figure 17-30: Beam Weight Second Lateral Segment 3.

Increase segment two’s weight using the slider bar or by typing a value in the weight field, until the overdose 3D isodose disappears (Figure 17-31).

Figure 17-31: Segment covers Hot Spot Isodose

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 25. Calculate Dose and Adjust Beam Weighting for Remaining Segments 1.

Alternating between the Medial and Lateral Tangent fields, repeat the same procedure as previously described above to eliminate other hotspots until you reach your desired isodose distribution. Be aware of the location of your calculation point that it is not being covered by the block.

Task 26. Rescale a Plan 1.

(Optional) You may need to rescale the plan. To do this click the Prescription tab in the Planning Control.

2.

Rescale the Dose: 48.6Gy to Cover 97% of Breast_PTV_EVAL (Figure 17-32). NOTE:

Review the plan after you rescale to make sure the plan has adequate coverage.

Figure 17-32: Rescale Dose

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning Forward Planning (cont.) Task 27. Add Setup Beams

17-30

1.

Open the Beams tab on the Planning Control.

2.

Click the Setup Beams tab.

3.

Click .

4.

Edit the beam Description, ID, and Geometry an Anterior Posterior (AP) setup field.

5.

Click .

6.

Edit the beam Description, ID, and Geometry to create a Left Lateral setup field.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan Task 1. Add another Prescription 1. Select Add RX on the Prescription tab (Figure 17-33).

Figure 17-33: Add Rx 2. The Import Template into Existing Plan opens (Figure 17-34).

Figure 17-34: Import Template into Existing Plan dialog box

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions –- Electron Boost Plan (cont.) Task 1. Add another Prescription (cont.) 3. Select 3D Delivery. 4. Select All for Anatomical Site. 5. Select the Template: DEFAULT3D1beam (3D Number of Beams: 1). 6. The Treatment Orientation is the same as the Initial RX. This option is grayed out and not editable. 7. Select the Treatment Unit labeled DemoSynergyElec. 8. Select Electron as the Modality. 9. Monte Carlo populates in the Algorithm column. 10. Select 12MeV for the beam energy. 11. Select Center of Lumpectomy PTV in the Isocenter Location column. 12. Click OK to load the template and open the patient in Planning Control. 13. The Plan now shows the multiple prescriptions in the Workspace. a. The electron boost is Rx B (Figure 17-35).

Figure 17-35: Multiple Rx in the Workspace

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) Task 2. Fill in the New Prescription Information 1. Select the Prescription tab on the Planning Control Bar opens. 2. Fill in the Prescription information: a. Rx Dose-1200cGy b. Number of Fractions-6 fractions c. Select the Prescribe to Point drop-down i. Select Depth of Beam 3 (Figure 17-36).

Figure 17-36: Depth of Beam 3 ii. Next type in the depth in cm that is clinically relevant for the energy you chose to calculate to. (Figure 17-37) NOTE:

If bolus is assigned to the electron beam the bolus thickness must be taken into account when you choose a depth.

Figure 17-37: Depth in centimeters (cm)

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) 3. Scale the beam to the absolute line of 1080cGy, which is 90%. (Figure 17-38)

Figure 17-38: Rescale the Prescription 4. (Optional) Fill in Beam Information (Figure 17-39). a. Description b. Field ID

Figure 17-39: Beam Information

Task 3. Edit Electron Beam

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1.

Click the Beams tab on the Planning Control.

2.

Type the Beam Description: eBoost.

3.

Type 3A for the Field ID.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) Task 4. Edit Isocenter Location 1. Click the Planning Ribbon tab. 2. Click the Edit Beam

button.

3. Position the mouse cursor over the beam entrance point on the plan. The mouse pointer looks like this:

(Figure 17-40).

Figure 17-40: Edit the Beam 4. Rotate the gantry so the beam is en face to the e- boost/PTV target. 5. You can fine tune the gantry rotation on the Beams tab| Geometry. a. Example-Gantry 54.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) 6. On the Geometry tab you can also make couch rotations if necessary. a. Example-Couch 15 degrees b. On the Sagittal and Coronal view the beam appears more en face to the patient surface. (Figure 17-41)

Figure 17-41: En face beam in sagittal view and coronal view 7. Then go to Beams|General tab and select SSD as the Setup. 8. Type 105 for the Source to Skin Distance, SSD (CM).

Task 5. Add Applicator 1. Click the Treatment Aids tab on the Beam Control. 2. Click the Applicator ID drop-down arrow. 3. Choose an Applicator size to cover your target. a. Example: A 10 x 10

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) Task 6. Create Electron Aperture 1. Click the Create and Edit Ports button on the Planning ribbon. The Create\Edit Ports dialog box appears on your screen (Figure 17-42).

Figure 17-42: Create/Edit Ports dialog box – electron 2. (Optional) check the box Cut Aperture at Applicator Limits to toggle the option on and off. The aperture cannot extend beyond the electron applicator limits. You can use the Cut Aperture at Applicator Limits option to automatically cut the aperture at the edge of the applicator. If you do not use this option, Monaco will not calculate dose if the aperture does not fit within the applicator. NOTE:

Monaco

Electron beams can have only one aperture per beam. You cannot change the material and thickness values defined in beam modeling for the Electron Monte Carlo algorithm.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) Task 6. Create Electron Aperture (cont.) 3. Draw your aperture on the BEV. OR 4. You can create a uniform margin around a structure if you select a structure from the Structure drop-down. a. Example - Lumpectomy PTV 5. Then, type in the margin in the Margin text entry box. 6. Select Apply to Visible Beams. 7. Then, select Close to close the Create/Edit Ports dialog box.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.) Task 7. Calculate Dose 1.

Click the Planning ribbon.

2.

Click Calculate. a. With multiple prescriptions from the calculate drop-down you can select Calculate Active Rx or Calculate All Rx (Figure 17-43).

Figure 17-43: Calculate Rx Options

Task 8. Evaluate Dose 1. Open the Beam Visibility Control. a. Select the Dose check box next to the prescription(s) you want to review. i. This effect the dose seen in the T/S/C views, DVH, and DVH statistics

Figure 17-44: Dose Column Option on Beam Visibility 2. Open the Isodoses Control. b. Review the isodose display and adjust Isodose levels as needed.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Breast Bolus Here are steps on how to generate a bolus structure if a bolus is needed for planning.

Task 1. Generate and Assign Bolus to Beams 1.

Click the Structures tab in the Planning Control.

2.

Click .

3.

Rename the “NewStructure”: 0.5 cm Bolus.

4.

Select Bolus as the “0.5 cm Bolus” structure type. NOTE:

5.

Click the Contouring Ribbon.

6.

Click the Bolus

7.

Type 0.5 cm as the bolus description.

8.

Select Patient as the base structure.

9.

Type 0.5 as the Thickness (cm).

10.

The Relative ED for the exercise stays as 1.0.

11.

In the transverse view, Define Start Point and Define End Point. Click on the base (patient) structure to define the bolus start and end points. For this exercise, the start point is the medial border and the end point is the lateral border. NOTE:

17-40

You must create a bolus structure type in order to activate the Bolus button on the Contouring ribbon.

button. The Generate Bolus dialog box opens.

The System creates bolus clockwise from the start to the end point on plans in the Head First orientation. The System creates bolus counterclockwise from the start to the end point on plans in the Feet First orientation.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescription Breast Planning – Breast Bolus (cont.) Task 1. Generate and Assign Bolus to Beams (cont.) 12.

Click the image where you want to define the top (superior) and bottom (inferior) points of the bolus. You can Define Top Point and Define Bottom Point in any of the T/S/C or BEV views.

13.

(Optional): You can move the mouse over the points and press the Delete key on the keyboard to remove it.

14.

Click the Generate button in the Generate Bolus dialog box.

15.

Click Close to close the dialog box.

16.

Open the Beams tab on the Planning Control.

17.

Click the Treatment Aids tab.

18.

Click the drop down arrow in the Bolus column and select the 0.5 cm bolus that you generated. This assigns the bolus to the beam for calculation. NOTE:

Monaco

The calculation engine does not take into account any bolus outside the patient structure for dose calculation (that is, unless you assign the bolus on the Treatment Aids tab of the Beams Control). For IMRT plans the bolus has to be on all or none of the beams. For 3D plans you can select which beams have bolus assigned to them.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise General Planning Instructions This exercise assumes you know enough about Monaco you do not need detailed steps for everything. Use the patient named ProstateNodes for planning. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. Prescriptions

Prescription A

Prescription B

Prescription C

Target Structures PTV1 4500 -right and left pelvic nodes, 1.0 cm margin PTV2 5580- prostate + sv, 1 cm margin with 0.5 cm margin posterior PTV3 7740 - prostate, 1 cm with 0.5 cm margin posterior

Organs at Risk (OAR) Rectum

Bladder Bowel Femoral Heads

95% of PTV1 4500 is at or above 45.0 Gy 25 fx

95% of PTV2 5580 is at or above 55.80 Gy 6 fx, total 31 fx 1.8 Gy/fx 95% of PTV3 7740 is at or above 77.40 Gy 12 fx, total 43 fx 1.8 Gy/fx

Limit 17% to 65 Gy Limit 35% to 40 Gy 90% isodose line should not cover more than ½ the rectal volume 50% isodose line should not cover the entire rectal volume Avoid hotspots near the anterior rectal wall Limit 25% to 65 Gy Limit 50% to 40 Gy No more than 150cc should exceed 40 Gy Limit 10% to 50 Gy

Figure 17-45: Prostate with Nodes - Plan Scoring Criteria

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1.8 Gy/fx

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise (cont.) Prescription A 1. Open and Load the patient ProstateNodes. 2. Select New Plan | New Monaco Plan. a. Select Step and Shoot for Delivery Type. b. Select All for Anatomical Site. c. Select the 7 field template. d. Select TRNElekta80 as the machine. e. Select Photon. f.

Select Monte Carlo for the algorithm.

g. Select 10MV for energy. h. Select Center of PTV1 4500 for the Isocenter Location. i.

Select OK.

3. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 45.00 Gy for the prescription. d. Type in 25 for the Number of Fractions. 4. Go to the Beams tab on the Planning Control bar a. Type in the Beam Description. b. Type in the Field IMultiple Prescriptions

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise Prescription A (cont.) c. Select the Geometry tab. i. You can use the gantry angles that are listed or use angles that are more clinically relevant to you such as – 180, 231, 282, 333, 24, 75, and 126. 5. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT Constraints so they are clinically relevant to the prescription. i. The PTV1 4500 needs at least 1 target cost function. ii. Put in the OAR Constraints so they are clinically relevant to the prescription. iii. The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function. 6. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary. NOTE:

For faster calculation times, use a higher statistical uncertainty per calculation value for initial planning. When the final plan is calculated, change the statistical uncertainty per calculation to a lower value. For optimized plans a re-calculation automatically begins and returns the updated results. Click skip forward when it becomes available to return segmentation complete message. Recommended values are 3% per calculation for initial planning followed by 1% for the final calculation.

Prescription B 1. Once you complete the plan for prescription A, go to Prescription on the Planning Control bar. 2. Select the Add Rx button. 17-44

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise Prescription B (cont.) 3. The Import Rx into Existing Plan window opens. Select your options. a. Select Step and Shoot for Delivery Type. b. Select All for Anatomical Site. c. Select the 7 field template. d. Select TRNElekta80 as the machine. e. Select Photon. f.

Select Monte Carlo for the algorithm.

g. Select 10MV for energy. h. Select Center of PTV1 4500 for the Isocenter Location. i. Select the isocenter location you chose for the initial unless you are going to do a shift to a new isocenter. i.

Select OK.

4. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 10.80 Gy for the prescription. d. Type in 6 for the Number of Fractions. 5. Go to the Beams tab on the Planning Control bar. a. Type in the Beam Description. b. Type in the Field ID.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise Prescription B (cont.) c. Select the Geometry tab. i. You can use the gantry angles that are listed or use angles that are more clinically relevant to you such as – 230, 295, 0, 65, and130. ii. Delete the last 2 beams. 6. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT Constraints so they are clinically relevant to the prescription. i.

The PTV2 5580 needs at least 1 target cost function.

ii.

Put in the OAR Constraints so they are clinically relevant to the prescription.

iii.

The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function.

7. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary. a. When you evaluate a plan with multiple prescriptions you can choose which prescription doses you evaluate. i. Select Beam Visibility. ii. Check the check box in the Dose column next to the prescription and/or beams you dose to appear in the T/S/C and DVH views.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise (cont.) Prescription C 1. Once you complete the plan for prescription B, go to Prescription on the Planning Control bar. 2. Select the Add Rx button. 3. The Import Rx into Existing Plan window opens. Select your options. a. Select Step and Shoot for Delivery Type. b. Select All for Anatomical Site. c. Select the 7 field template. d. Select TRNElekta80 as the machine. e. Select Photon. f.

Select Monte Carlo for the algorithm.

g. Select 10MV for energy. h. Select Center of PTV1 4500 for the Isocenter Location. i. Select the isocenter location you chose for the initial unless you are going to do a shift to a new isocenter. i.

Monaco

Select OK.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise Prescription C (cont.) 4. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 21.60 Gy for the prescription. d. Type in 12 for the Number of Fractions. 5. Go to the Beams tab on the Planning Control bar a. Type in the Beam Description. b. Type in the Field ID c. Select the Geometry tab. i.

You can use the gantry angles that are listed or use angles that are more clinically relevant to you such as – 230, 295, 0, 65, and130.

ii.

Delete the last 2 beams.

6. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT Constraints so they are clinically relevant to the prescription.

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i.

The PTV3 7740 needs at least 1 target cost function.

ii.

Put in the OAR Constraints so they are clinically relevant to the prescription.

iii.

The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function.

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Prostate Exercise Prostate with Nodes Exercise Prescription C (cont.) 7. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary. a. When you evaluate a plan with multiple prescriptions you can choose which prescription doses you evaluate. i. Select Beam Visibility. ii. Check the check box in the Dose column next to the prescription and/or beams you dose to appear in the T/S/C and DVH views.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan General Planning Instructions This exercise assumes you know enough about Monaco you do not need detailed steps for everything. Use the patient named ProstateNodes for planning. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1.

Prescriptions

Prescription A

Prescription B

Prescription C

Target Structures PTV1 4500 -right and left pelvic nodes, 1.0 cm margin PTV2 5580- prostate + sv, 1 cm margin with 0.5 cm margin posterior PTV3 7740 - prostate, 1 cm with 0.5 cm margin posterior

Organs at Risk (OAR) Rectum

Bladder Bowel Femoral Heads

95% of PTV1 4500 is at or above 45.0 Gy 25 fx

95% of PTV2 5580 is at or above 55.80 Gy 6 fx, total 31 fx 1.8 Gy/fx 95% of PTV3 7740 is at or above 77.40 Gy 12 fx, total 43 fx 1.8 Gy/fx

Limit 17% to 65 Gy Limit 35% to 40 Gy 90% isodose line should not cover more than ½ the rectal volume 50% isodose line should not cover the entire rectal volume Avoid hotspots near the anterior rectal wall Limit 25% to 65 Gy Limit 50% to 40 Gy No more than 150cc should exceed 40 Gy Limit 10% to 50 Gy

Figure 17-46: Prostate with Nodes - Plan Scoring Criteria

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1.8 Gy/fx

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription A 1. Open and Load the patient ProstateNodes. 2. Select New Plan | New Monaco Plan. a.

Select Step and Shoot for Delivery Type.

b. Select All for Anatomical Site. c. Select the 7 field template. d. Select TRNElekta80 as the machine. e. Select Photon. f.

Select Monte Carlo for the algorithm.

g. Select 10MV for energy. h. Select Center of PTV1 4500 for the Isocenter Location. i.

Select OK.

3. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 45.00 Gy for the prescription. d. Type in 25 for the Number of Fractions. 4. Go to the Beams tab on the Planning Control bar. a. Type in the Beam Description. b. Type in the Field Multiple Prescriptions.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Prostate with Nodes Case – Bias Dose Plan Bias Dose Plan (cont.) Prescription A (cont.) c. Select the Geometry tab. i. You can use the gantry angles that are listed or use angles that are more clinically relevant to you such as – 180, 231, 282, 333, 24, 75, and 126. 5. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT Constraints so they are clinically relevant to the prescription. i. The PTV1 4500 needs at least 1 target cost function. ii. Put in the OAR Constraints so they are clinically relevant to the prescription. iii. The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function. 6. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary.

Prescription B 1. Once you complete the plan for prescription A, go to Prescription on the Planning Control bar. 2. Select the Add Rx button.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription B (cont.) 3. The Import Rx into Existing Plan window opens. Select your options. a. Select Step and Shoot for Delivery Type. b. Select All for Anatomical Site. c. Select the 7 field template. d. Select TRNElekta80 as the machine. e. Select Photon. f.

Select Monte Carlo for the algorithm.

g. Select 10MV for energy. h. Select Center of PTV1 4500 for the Isocenter Location. i. i.

Select the isocenter location you chose for the initial unless you are going to do a shift to a new isocenter.

Select OK.

4. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 10.80 Gy for the prescription. d. Type in 6 for the Number of Fractions. 5. Go to the Beams tab on the Planning Control bar a. Type in the Beam Description. b. Type in the Field ID.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription B (cont.) c. Select the Geometry tab. i.

You can use the gantry angles that are listed or use angles that are more clinically relevant to you such as – 230, 295, 0, 65, and130.

ii.

Delete the last 2 beams.

6. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT parameters button. b. The IMRT Parameters dialog box opens. i. Select Rx A to contribute the dose from the plan to create a bias dose plan.

Figure 17-47: IMRT Prescription Parameters dialog box ii. Then select OK.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription B (cont.) c. Select the IMRT Constraints so they are clinically relevant to the prescription. i.

The PTV2 5580 needs at least 1 target cost function. 1. For a more homogeneous result plan to the prescription dose for the PTV. For this example that would 10.80Gy. Make sure the Bias Dose column is not checked.

ii.

Put in the OAR Constraints so they are clinically relevant to the prescription. 2. For a Bias dose plan you want to put in constraints for the OARs that includes the dose from all bias dose contributors. Make sure the Bias Dose column is checked on the IMRT Constraints tab. For this example you would plan for 55.80Gy.

iii.

The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function.

Figure 17-48: IMRT Constraints panel

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription B (cont.) 7. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary. a. When you evaluate a plan with multiple prescriptions you can choose which prescription doses you evaluate. i. Select Beam Visibility. ii. Check the check box in the Dose column next to the prescription and/or beams for the dose you want to appear in the T/S/C and DVH views. 8. Now save prescription B as template to use for prescription C. a. Select Monaco Application button | Save Template As.

Figure 17-49: Save Template As option

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription B (cont.) b. Then, type in the Template Name, Template Description and select an Anatomical Site.

Figure 17-50: Save Template As dialog box c. Select Save.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription C 1. Once you complete the plan for prescription B, go to Prescription on the Planning Control bar. 2. Select the Add Rx button. 3. The Import Rx into Existing Plan window opens. Select your options. a. Select Step and Shoot for Delivery Type. b. Select the anatomical site you saved the Prescription B template as. i. In this example it is under Pelvis.

Figure 17-51: Import Templates into Existing Plan dialog box c. Select the 5FieldIMRT template. i. This populates all the other fields. Check to make sure these are correct. d. Select OK. 17-58

Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription C (cont.) 4. Go to the Prescription tab. a. Select the Rx Site or type it in. b. Select the Prescribe to point if necessary. c. Type in 21.60 Gy for the prescription. d. Type in 12 for the Number of Fractions. 5. Go to the Beams tab on the Planning Control bar. 6. Check the beams are labeled and positioned correctly. 7. Then go to the IMRT Constraints on the Planning Control bar. a. Select the IMRT parameters button.

Monaco

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription C (cont.) b. The IMRT Parameters dialog box opens. i. Select Rx A and Rx B to contribute the dose from the plans to create a bias dose plan.

Figure 17-52: IMRT Prescription Parameters dialog box ii. Then select OK. c. Select the IMRT Constraints so they are clinically relevant to the prescription. i.

The PTV3 7740 needs at least 1 target cost function. 1. For a more homogeneous result plan to the prescription dose for the PTV. For this example that would 21.60Gy. Make sure the Bias Dose column is not checked.

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Multiple Prescription Volume II of IV Monaco Training Guide

Multiple Prescriptions – Bias Dose Plan Bias Dose Plan (cont.) Prescription C (cont.) ii.

Put in the OAR Constraints so they are clinically relevant to the prescription. 1. For a Bias dose plan you want to put in constraints for the OARs that includes the dose from all bias dose contributors. Make sure the Bias Dose column is checked on the IMRT Constraints tab. For this example you would plan for 77.40Gy

iii.

The contour you use as the external structure such as (Skin, Patient, Body) needs at least 1 cost function.

8. When the optimizer completes the calculation review and evaluate the plan. Make changes if necessary. a. When you evaluate a plan with multiple prescriptions you can choose which prescription doses you evaluate.

Monaco

i.

Select Beam Visibility.

ii.

Check the check box in the Dose column next to the prescription and/or beams you dose to appear in the T/S/C and DVH views

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Bias Dose – Head and Neck Volume II of IV Monaco Training Guide

Bias Dose – Head and Neck Bias Dose – Head and Neck Exercise This exercise shows you how to create a bias dose plan on an existing base plan. In this case, the patient lost weight during treatment. Create the bias dose plan on the new CT taken after the patient lost weight. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1. This exercise includes these tasks: Task 1. Fuse Base Plan CT with Bias Dose Plan CT Task 2. Review the Base Plan Task 3. Create a Bias Dose plan from a Base Plan Task 4. Enter the Bias Dose Prescription Task 5. Start the Optimization and Dose Calculation

Prescription Goals

Target Structures GTV

Base Dose Plan 95% to 54 Gy Bias Dose Plan 95% to 18 Gy Total Dose Plan 95% to 72 Gy

Organs at Risk (OAR) Spinal Cord Rt Parotid Lt Parotid

Limit Total Dose to 45 Gy for the composite plan Limit Mean Dose to 30 Gy for the composite plan NOTE: Due to the proximity of the Rt Parotid to the GTV, the Rt Parotid dose limit will be exceeded.

Oral Cavity

Limit Mean Dose to 45 Gy for the composite plan

Unspecified Tissue

Keep Hot spots inside GTV and limit them in unspecified tissue

Monaco®

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Bias Dose – Head and Neck Volume II of IV Monaco Training Guide

Bias Dose – Head and Neck Bias Dose – Head and Neck Exercise (cont.) Task 1. Fuse Base Plan CT with Bias Dose Plan CT There are two studysets for the Bias Dose patient. Phase 1 is the studyset on which you planned the base dose. Phase 2 was taken later and is the studyset you use to plan the Bias Dose plan. The first step, if you are to create a bias dose plan on a different studyset, is to fuse the studysets. 1.

On the Patient Selection dialog box, select the patient Bias Dose and click OK.

2.

Select the Image Fusion Workspace.

3.

Click the Fusion Ribbon.

4.

Load / Activate the plan BaseHnN.

5.

Right-click on Phase2 and select Load/Set As Secondary to load the studysets into Fusion activity.

6.

to register the studysets. Click Start Auto Registration You can make manual adjustments to the fusion if necessary.

7.

Once the registration completes, close the Image Fusion Progress dialog box and click the Save

button.

Task 2. Review the Base Plan For this exercise, a base plan is available to use as the start point for you to create a Bias Dose plan. The Base plan dose prescription is GTV to 54 Gy.

18-2

1.

Select Activities | Planning.

2.

Review the prescription, IMRT Constraints, dose distribution, DVH statistics, Calculation Properties, and Sequencing Parameters to become familiar with the Base plan.

Bias Dose – Head and Neck Volume II of IV Monaco Training Guide

Bias Dose – Head and Neck Bias Dose – Head and Neck Exercise (cont.) Task 3. Create a Bias Dose Plan from a Base Plan This task demonstrates how to create the Bias Dose plan from an existing Base plan. 1.

Right-click on BaseHnN and select New Bias Dose Plan| Phase 2. NOTE:

The system adds a yellow B next to the BaseHnN plan in the Workspace control to designate it as a Base plan.

2.

On the New Plan Template dialog box, use the default template BASE: BaseHnN.

3.

Select Center of GTV for the Isocenter.

4.

For this exercise, use the default values for the Machine and Delivery Mode, then click OK.

5.

Click Workspace | Controls |Beams to open the Planning Control – Beams tab. Review the Delivery Mode, Machine ID, and Isocenter Location, and then click OK.

Task 4. Enter the Bias Dose Prescription Type the prescribed dose to the Bias Dose plan only on the Prescription tab of the Planning Control.

Monaco®

1.

Click the Prescription tab and type the Rx Site.

2.

Type 9 for the number of fractions and 18 Gy for the Prescription dose.

18-3

Bias Dose – Head and Neck Volume II of IV Monaco Training Guide

Bias Dose –Head and Neck Bias Dose – Head and Neck Exercise Task 4. Enter the IMRT Constraints (cont.) 3.

Click IMRT Constraints tab on the Planning Control. Make these changes to the prescription. (An example prescription is at the end of this exercise.) •

Uncheck the box under Bias Dose for all cost functions on the GTV and the patient. You only take bias dose into account on the OARs you want to spare.

•

Scale the Quadratic Overdose for the GTV to reflect only the Bias Dose prescription (18Gy).

•

Scale the Quadratic Overdoses on the patient structure to what you would use for only the Bias Dose plan.

•

All other structures reflect values for the composite plan. We suggest you leave these values first, then optimize and see where you need to make adjustments.

Task 5. Start the Optimization and Dose Calculation Optimize and review the DVH and isodoses until you have an acceptable plan. Then generate segments and calculate dose. Adjust the prescription as needed to meet the prescription goals. 1.

Click Workspace | Controls | Optimization Console to show the console window.

2.

Click the Start Optimization NOTE:

18-4

button.

Should you receive an optimization failure soon after ray creation, you may have a prescription parameter that needs a slight adjustment. On the prescription panel, look for a cost function that has a relative impact with four plus (+) signs. Loosen the isoconstraint for that cost function slightly and re-optimize.

Bias Dose – Head and Neck Volume II of IV Monaco Training Guide

Bias Dose – Head and Neck Bias Dose – Head and Neck Exercise Task 5. Start the Optimization and Dose Calculation (cont.) 3.

After stage 1 optimization completes, review your DVH statistics, change your prescription, and re-optimize as needed.

4.

When you are satisfied with your optimized plan, click the Start Optimization button to begin stage 2. Change your prescription and re-optimize, as needed.

5.

To save your final plan, select the Monaco Applications Menu | Save Plan As and type the plan name: CompositePlan. Checkmark the option to Include Base Doses so that the saved plan represents a composite plan.

Figure 18-1: Example IMRT Constraints 6.

Monaco®

Change the Power Law Exponent to 14.0 on the Spinal Cord structure to help lower the Max Dose.

18-5

MR Planning Volume II of IV Monaco Training Guide

MR Planning Oblique MR Planning You can use oblique and transverse MR Images to create treatment plans. If you use oblique images you can contour on the oblique images, and copy the contours to a transverse studyset for planning purposes. If you use a transverse studyset you can both contour and plan on the studyset. This section contains two exercises. In the first exercise you contour on an oblique MR studyset and plan on a transverse CT studyset. In the second exercise you both contour and plan on a transverse MR studyset. This exercise and the information provided is subject to the disclaimer included in the Overview section of Volume 1, Section 1.

Monaco®

19-1

MR Planning Volume II of IV Monaco Training Guide

MR Planning Oblique MR Planning (cont.) In this exercise, you import an oblique MR studyset and a transverse CT studyset. You then contour on the MR studyset, copy the contours to the CT studyset and plan on the CT studyset.

Import the New Patient 1.

Navigate to the location where the DICOM files for the TiltedMRwithCT patient is stored.

2.

Import both the CT and the MR studysets.

Figure 19-1: Importing CT and MR studysets for a new patient

19-2

MR Planning Volume II of IV Monaco Training Guide

MR Planning Oblique MR Planning Import the New Patient (cont.) 3.

Load both the MR and CT studysets in Fusion and fuse them together. You can use either the automatic or manual fusion tools.

Figure 19-2: Image fusion with the CT and MR studysets

Monaco®

4.

Click the Planning button to switch to Planning mode. Save your changes before you load the MR studyset as the primary studyset and the CT studyset as the secondary studyset.

5.

Use the tools on the Contouring tab to create the CTV and PTV on the MR studyset. Copy the CTV and PTV to the CT studyset.

6.

Load the CT studyset as the primary studyset. Contour the Patient (Skin), Brain Stem, Right and Left Optic Chiasm, Right and Left Optic Nerve, Right and Left Retina, Right and Left Lens and the Brain. Add a 2mm margin to the each Optic Nerve and Optic Chiasm to create the Optic Nerve PRV and Optic Chiasm PRV.

19-3

MR Planning Volume II of IV Monaco Training Guide

MR Planning Oblique MR Planning Import the New Patient (cont.) 7.

Create an IMRT plan.

Target Structures PTV 95% to 46.0 Gy 23 fx No more than 50.6 Gy hot spot Sequential Boost for an additional 7 fractions to PTV 60 Gy 7 fx

Organs at Risk (OAR) Brain Stem Max Dose 55 Gy Spinal Cord Max Dose 45 Gy OpticChiasm_PRV Max Dose 55 Gy Optic Nerve L PRV or Optic Nerve R PRV Max Dose 55 Gy Retina L or Regina R Max Dose 45 Gy Lens L or Lens R Brain Limit 5% to 78.7 Gy

Figure 19-3: NRG-BN001 – Plan Scoring Criteria

19-4

2.0 Gy/fx

2.0 Gy/fx

MR Planning Volume II of IV Monaco Training Guide

MR Planning Transverse MR Planning In this exercise you start with an existing transverse MR studyset. You contour and plan on the MR studyset.

General Planning Instructions RTOG 1115 – Plan Scoring Criteria

Monaco®

1.

Use patient Fusion Prostate for planning.

2.

Load/Activate the MR1 studyset.

3.

Contour the Patient (Skin), GTV, CTV, PTV, Bladder, Rectum, Left Femoral Head, Right Femoral Head, and Penile Bulb. The GTV includes the prostate. The CTV is an expansion of the GTV of 80 Gy No more than 25% receives >75 Gy No more than 35% receives >70 Gy No more than 50% receives >65 Gy No more than 15% receives >75 Gy No more than 25% receives >70 Gy No more than 35% receives >65 Gy No more than 50% receives >60 Gy Less than 50% receives >52.5 Gy Less than 10% receives >52.0 Gy

Figure 19-4: RTOG 0831 Target Structures and Organs at Risk

19-6

1.8 Gy/fx

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases These exercises assume you are familiar enough with planning in Monaco that you no longer require specific steps. You can use the steps in the Prostate Plan as a reference if you need it. This exercise includes prescription objectives and the contours are already drawn for you. The exercises in this section and the information provided are subject to the disclaimer included in the Overview section of Volume 1, Section 1. This stepwise task list helps you in your planning process. You may or may not do all of the tasks on this list to complete your plan.

Monaco®

•

Select Patient and Open Studyset

•

Start a Plan

•

Add Beams or Sequences in Planning Activity

•

Enter/Update the Prescription

•

Edit Calculation Parameters

•

Edit Sequencing Parameters

•

Save a Template

•

Optimize Fluence (Stage 1)

•

Evaluate Optimized Fluence and Dose

•

Re-Optimize and Evaluate (Optional)

•

Optimize /Calculate Dose (Stage 2)

•

Evaluate Final Plan

•

Save Plan

•

Print the Plan

•

Create/Calculate a QA Plan

•

Edit QA Plan Beam Weights

•

Save the QA Plan

•

Export the Dose Profiles

•

Print the QA plan

20-1

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Esophageal Case General Planning Instructions 1.

Use patient ESOPHAGUS for planning.

2.

Place the isocenter at the center of the structure PTV.

3.

Select a 6MV treatment machine that best represents a machine that you use clinically (Elekta, Varian or Siemens).

4.

Create a plan. Use seven (7) beams spaced evenly around the patient, or create a sequence for VMAT planning.

Target Structures PTV 95% to 50.4 Gy No more than 55.45 Gy hot spot Organs at Risk (OAR) Lungs Spinal Cord Heart

Less than 25% of both lungs should receive greater than or equal to 20 Gy Max Dose 45 Gy 33% less than 50 Gy 66% less than 45Gy

Figure 20-1: Plan Scoring Criteria

20-2

28 fx

1.8 Gy/fx

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Rectal Case General Planning Instructions RTOG 0822 – Plan Scoring Criteria 1.

Use patient Rectum for planning.

2.

Place the isocenter at the center of the structure CTV_5400.

3.

Select a 6MV treatment machine that best represents a machine that you use clinically (Elekta, Varian or Siemens)

4.

Create a plan. Use seven (7) beams spaced evenly around the patient, or create a sequence for VMAT planning.

Target Structures CTV_5400

PTV_4500

Organs at Risk (OAR) Bladder

Small Bowel

Femoral Heads

95% to 54 Gy 30 fx No more than 5% to receive greater than 56.7 Gy (105% hot spot) 95% to 45 Gy 30 fx Limit 25% to 49.5 Gy Limit 10% to 54 Gy

1.8 Gy/fx

1.5 Gy/fx

40% to 40 Gy 15% to 45 Gy Max Dose 50 Gy 10% (180cc) to 35 Gy 6% (100cc) to 40 Gy 4% (65 cc) to 45Gy Max Dose 50 Gy 40% to 40 Gy 25% to 45Gy Max Dose 50 Gy

Figure 20-2: Target Structures and Organs at Risk

Monaco®

20-3

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Head and Neck Case II General Planning Instructions Use the patient named AdvHnN for planning. Target Structures PTV70 PTV60 PTV50

95% of PTV70 is at or above 70Gy 95% of PTV60 is at or above 60Gy 95% of PTV50 is at or above 50Gy

Organs at Risk (OAR) Trachea Brainstem Spinal Cord Optic Chiasm Left and Right Lens Left and Right Optic Nerve

40 Gy 54 Gy 40 Gy 35 Gy to 50% 9 Gy each 54 Gy each (add a 3 mm margin)

Left and Right Parotids

30 Gy to 50% each parotid

Figure 20-3: HnN Case – II-Plan Scoring Criteria

20-4

35 fx 35 fx 35 fx

2.0 Gy/fx 1.7 Gy/fx 1.4 Gy/fx

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 1. IMRT and QA This exercise helps you understand the IMRT and QA planning workflow. It is assumed that you have reviewed the sections IMRT Tools and QA Tools. You can use them as a reference as you walk through the software.

Create an IMRT Plan

Monaco®

•

Open Monaco and select the Patient Fusion Prostate

•

Load the Studyset CTClean (If you have not completed the exercise in Section 5 of this training guide, use the Studyset CT1, it already has contours.)

•

Apply the IMRT Template DEFAULTSNS

•

Place the Isocenter at the center of the PTV

•

Select any Machine from the drop-down list

•

Click on the IMRT Constraints tab on the Planning Control and resolve any Structure Mismatches (Apply)

•

Open Console

•

Set the Grid Spacing to 0.2 cm

•

Start Optimization (Stage1)

•

Watch Progress Meter during optimization

•

Review Sensitivity

•

Use the Dose Cursor Tool

•

Enter and Review DVH Statistics

20-5

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 1. IMRT and QA Create an IMRT Plan (cont.) •

Change the Normalization (Absolute/Percent, Gy/cGy)

•

Start Optimization (Stage 2)

•

Use the Fluence Toolbar (Review beams, segments and MU values in BEV)

•

Save the plan

•

Print Plan Reports

Create a QA Plan

20-6

•

Start a New QA Plan with the IMRT Plan you created

•

Change the Grid Spacing to 0.2 cm

•

Select Isocenter Center of Skin

•

Start QA dose calculation

•

Edit the Beam Weights

•

Save the QA Plan

•

Export the QA dose profiles (using any option)

•

Close the Patient and Reopen to see the updated icons in the Workspace Control

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 2. Plan Review This exercise lets you practice using the plan review tools available in Monaco. It is assumed that you have reviewed the section Plan Review Activity. You can use it as a reference as you practice with these tools.

Monaco®

•

Open Monaco and Select the Patient HeadandNeck

•

Select and Load the three plans MonPlan1, MonPlan2 and tonsil

•

Change the Isodose Display

•

Change the Dose Transparency

•

Show/Review Beam Summary

•

Show/Hide Structures

•

Use Reference Doses, DVH cursors and DVH Statistics

•

Create Structure Combinations

•

Change to Multiple Plan Display

•

Show/Modify a Dose Subtraction

•

Show/Modify a Dose Summation

•

Show/Modify Dose on a 3D image

20-7

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 3. Editing IMRT Prescription Elements This exercise lets you practice editing elements of the IMRT Constraints dialog box in the Planning Activity. It is assumed that you have reviewed the section Monaco Planning and Workflow. You can use it as a reference as you practice using these tools.

20-8

•

Open Monaco and select the Patient Fusion Prostate

•

Open a Saved Plan in Planning activity (If the saved plan has dose, you have to change from Plan Review activity to Planning Activity once the patient is loaded.)

•

Remove an cost function from a structure on the IMRT Constraints Planning Control

•

Remove a structure

•

Add a structure

•

Add a cost function to the structure

•

Edit the Structure’s Cost Function Properties

•

Edit an existing Structure’s cost function properties

•

Change the layering order

•

Edit the References Doses, Multicriterial, Isoconstraint, and Enabled directly on the IMRT Constraints Planning Control

•

Print the IMRT Constraints

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 4. Optimization and Plan Evaluation This exercise lets you practice using the optimization, sequencing, and plan evaluation tools available in Monaco. It is assumed that you have reviewed the section Monaco Planning and Workflow. You can use it as a reference as you practice using these tools.

Monaco®

•

Open Monaco and select the Patient Fusion Prostate

•

Open a Saved Plan in IMRT activity (If the saved plan has dose, you have to change from Plan Review activity to Planning Activity once the patient is loaded.)

•

Click on IMRT Constraints tab in Planning Control

•

Open the Console

•

Edit the Calculation Parameters

•

Start the Optimization (Stage 1)

•

Edit the Isoconstraint, Multicriterial, or Enabled options during optimization

•

Evaluate Optimized Plan using available plan evaluation tools

•

Edit various IMRT Constraints and Re-optimize as needed (Try changing any of the elements previously discussed. Examples, Structure Optimization Properties and Cost Function Properties.)

•

Start the Optimization (Stage 2)

•

Review the Final Plan using the Plan Evaluation Tools

20-9

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 5. Serial Power Law (k) This exercise demonstrates how the OAR DVH curve is affected when you adjust the Serial Power Law (k). It includes these tasks: •

Task 1. Select Patient and Open Studyset

•

Task 2. Adjust Power Law and Run IMRT Plans

•

Task 3. Plan Review

Task 1. Select Patient and Open Studyset Adjust the Power Law (k) value to show the effects to the Serial Cost Function. 1.

Open the Monaco software to show the Patient Selection dialog box.

2.

Click to select the patient Fusion Prostate.

3.

Click OK. The system loads the patient information into the Patient Workspace Control.

4.

Click to select the Exercise plan under CT1; then click Load. The patient loads in the Planning activity.

Task 2. Enter/Adjust Power Law and Optimize IMRT Plans

20-10

1.

Select the IMRT Constraints tab on the Planning Control to show the prescription dialog box. The PTV and patient have cost functions applied to them.

2.

to add a new structure to the list.

3.

Select RECTUM in the drop-down menu of the new structure line.

4.

Right-click in the Rectum field and select Add Cost Function | Serial.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 5. Serial Power Law (k) Task 2. Enter/Adjust Power Law and Optimize IMRT Plans (cont.)

Monaco®

5.

Use a Power Law Exponent of 10 with an EUD of 6000 cGy. Check Optimize Over All Voxels in Volume to keep hot spots to a minimum throughout the entire structure.

6.

Put the structures in this layering order: PTV, Rectum, and Patient. Highlight the structure you want to move, Click the up or down arrow on the left side of the IMRT Constraints dialog box to layer the structures.

7.

Click OK.

8.

Click the Start Optimization process.

9.

Once stage one of the optimization completes, the system shows a dialog box with the message “Full Fluence Modulation Complete. Press Start to Begin Segmentation.” Click OK to acknowledge.

10.

Click the Start Optimization process.

11.

Once Phase 2 is complete, the system shows a dialog box with the message “Segmentation Complete”. Click OK to acknowledge.

12.

Click on the Monaco Application Menu button followed by Save Plan As….

13.

In the Save As Plan dialog box, type k10 for the Plan Name.

14.

Click on the IMRT Constraints tab on the Planning Control. Right-click over the Rectum Serial cost function and select Properties to change the Power Law Exponent to 2.

15.

Change the Power Law Exponent of Rectum to 2 and restart the optimization process.

button to start stage one of the optimization

button to start stage two of the optimization

20-11

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 5. Serial Power Law (k) Task 2. Enter/Adjust Power Law and Optimize IMRT Plans (cont.)

20-12

16.

Once Phase 2 is complete, click the Monaco Application Menu button then Save Plan As….

17.

Type in k2 for the Plan Name.

18.

After you save the plan, go to the IMRT Constraints dialog box and change the Power Law Exponent of Rectum to 18. Restart the optimization process.

19.

Click the Monaco Application Menu button then click Save Plan As…

20.

In the Save As Plan dialog box, type k18 for the Plan Name.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 5. Serial Power Law (k) (cont.) Task 3. Plan Review 1.

In the Patient Workspace Control, hold down the shift key and highlight the three plans (k10, k2, and k18) to select all three of them for Plan Review.

2.

Once you highlight the plans, right-click and select Load Into Plan Review.

3.

Right-click in the DVH window and select Multiple Plans. The system shows All three plans.

4.

Review the DVH curve of the Rectum for each plan to see the variation based on the changed Serial Power Law (k). The Serial Power Law Exponent (k) controls the high dose when you use a high (k) value (18). When the (k) value is medium-high (10), the oar DVH curve shows a steep dose gradient. While a low (k) value (2) controls the mean dose, it does not put a primary focus on one point and works on the overall curve of the oar DVH.

Figure 20-4: Serial Power Law Exponent

Monaco®

20-13

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) Task 1. Select Patient and Open Studyset 1.

Adjust the Power Law (k) value to show the effects to the Parallel Cost Function.

2.

Open the Monaco software to automatically show the Open Patient Selection dialog box.

3.

Click to select the patient HnN Plan, then click OK. The system loads the patient information into the Patient Workspace Control.

4.

Select the CT studyset HnNss

Task 2. Load IMRT Template

20-14

1.

Select New Plan

on the Planning tab to select a plan type.

2.

Select New Monaco Plan in the drop-down list. This opens the New Monaco Plan dialog box (Figure 13- ).

3.

Type in a plan name and description.

4.

Select Step and Shoot IMRT for the Delivery

5.

Place a checkmark by the Template: DEFAULTSNS (Rx Site: , Rx Dose: , Total Beams: 7)

6.

Select Head First for the Treatment Orientation.

7.

Select TRNElekta80 for the treatment unit.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) Task 2. Load IMRT Template (cont.) 8.

Select the isocenter location: Center of PTV TOTAL.

Figure 20-5: New Monaco Plan dialog box 9.

Monaco®

Click OK to load the template and open the patient in Planning activity.

20-15

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) (cont.) Task 3. Enter the Prescription 1.

Select the Prescription tab on the Planning Control.

2.

Select Plan Isocenter in the Prescribe To column.

3.

Type 33 in the Number of Fractions column.

4.

Type 2.00 in the Fractional Dose (Gy) column. The Rx Dose (Gy) column updates with 66.00 as the value.

5.

Click on the IMRT Constraints tab to enter the necessary values.

Task 4. Enter the IMRT Constraints

20-16

1.

Click on the IMRT Constraints tab on the Planning Control.

2.

Replace PTV and SKIN with valid structure names to use in the prescription.

3.

to add a new structure to the list.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) Task 4. Enter the IMRT Constraints (cont.) 4.

Use the data in the table below for the prescription (Figure 20-6). Prescription (Gy): 60.00 Target Penalty:

PTV60

Minimum Volume: 96.00

LT PAROTID (optimize over all voxels)

Max Dose (Gy): 62.00 Quadratic Overdose:

RMS(Gy): 1.00

Reference Dose (Gy): 35.00 PARALLEL:

Mean Organ Damage (%):45.00 Power Law (k): 1.5 Max Dose (Gy): 66.00

patient

Quadratic Overdose:

RMS(Gy): 0.3 Shrink Margin: 0.4

Figure 20-6: IMRT Constraints Table 5.

Once you type the constraints data, layer the structures in this order (Figure 207).

Figure 20-7: IMRT Constraints: Layering

Monaco®

20-17

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) Task 5. Enter Calculation Properties 1.

Click on

2.

In this dialog box, update this information: • •

3.

Calculation Properties on the Planning tab.

Grid Spacing: 0.40 Statistical Uncertainty (%): 2

Click OK.

Task 6. Enter IMRT Parameters 1.

Click IMRT Parameters on the IMRT Constraints tab.

2.

In the dialog box, update this information: •

3.

20-18

Target Margin: Narrow (3-4 mm)

Click OK.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) (cont.) Task 7. Adjust Power Law (k) and Optimize IMRT Plans

Monaco®

1.

Click the Start Optimization process.

button to start stage one of the optimization

2.

Once stage one of the optimization completes, the system shows a dialog box with the message “Full Fluence Modulation Complete, Press Start to Begin Segmentation”.

3.

Click OK to acknowledge.

4.

Click the Start Optimization process.

5.

Once Phase 2 is complete, the system shows a dialog box with the message “Segmentation Complete”. Click OK to acknowledge.

6.

Click on the Monaco Application Menu button followed by Save Plan As….

7.

In the Save As Plan dialog box, type in klow for the Plan Name.

8.

Type K Power Law Plan for the Description.

9.

Right-click over the Lt Parotid Parallel cost function on the IMRT Constraints tab on the Planning Control and select Properties to change the Power Law Exponent to 3.5 and restart the optimization process.

10.

Once Phase 2 is complete, click on the Monaco Application Menu button followed by Save Plan As… and type in khigh for the Plan Name.

button to start stage two of the optimization

20-19

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) (cont.) Task 8. Plan Review 1.

In the Patient Workspace Control, hold down the shift key and highlight both plans (klow and khigh) to select the two plans for Plan Review.

2.

Once you highlight the plans, right-click and select Load Into Plan Review.

3.

Turn all structures off in the DVH window. Click each structure name in the structure list. Leave the Lt Parotid structure turned on (Figure 20-8).

Figure 20-8: Structure List 4.

20-20

Review the DVH curve of the Lt Parotid for each plan to see the variation based on the changed Parallel Power Law (k).

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 6. Parallel Power Law (k) Task 8. Plan Review (cont.) 5.

The Parallel Power Law Exponent (k) places emphasis on the volume of dose to a given point of the DVH curve assigned in the prescription, but also works on the other points of the curve. The oar DVH curve has a steep slope when you use a higher Power Law Exponent (k). A lower Power Law Exponent (k) creates a wider slope in the oar DVH curve (Figure 20-9).

Figure 20-9: K value comparison in DVH

Monaco®

20-21

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 7. Multiple Prescriptions This exercise lets you practice using multiple prescriptions to make a plan with a boost. It is assumed that you have reviewed the section Monaco Planning and Workflow. You can use it as a reference as you practice using these tools.

20-22

•

Open Monaco and select the Patient GlioLeftTRN.

•

Select New Monaco Plan for Studyset SS_CT1.

•

Start a new IMRT plan for Phase I of the treatment using a saved template and a treatment machine similar to what you would use in your clinic. Phase 1 treats PTV46 to 46 Gy in 23 fractions.

•

Edit the Beams and IMRT Constraints.

•

Optimize your plan.

•

Review the isodose lines and DVH for the PTV46 and Organs at Risk to determine if the planning criteria are met. If necessary, edit the IMRT Constraints to better meet the planning criteria.

•

Save your Plan.

•

On the Prescription tab, click Add Rx to add a new Prescription. Phase II treats PTV60 to 60 Gy in an additional 7 fractions.

•

Select New Plan | New Monaco Plan to add additional beams to the plan.

•

Review the Composite DVH and 66 Gy, 57 Gy, 48 Gy, 44 Gy and 40 Gy isodose lines to determine if the planning criteria are met.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 7. Multiple Prescriptions •

The planning criteria are shown in Figure 20-10:

Target Structure PTV46 PTV60

95% of PTV46 is covered by 46 Gy 95% of PTV60 is covered by 60 Gy 99% of PTV60 is covered by 54 Gy Maximum dose of 66 Gy

23 fx Add’l 7 fx

2.0 Gy/fx 2.0 Gy/fx

Organs at Risk (OAR) Lenses Retinae Optic Nerves Optic Chiasm Brainstem

Maximum Dose of 7 Gy Maximum Dose of 50 Gy Maximum Dose of 55 Gy Maximum Dose of 56 Gy Maximum dose of 60 Gy

Figure 20-10: RTOG 0825 Target Structures and Organs at Risk

Monaco®

20-23

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 8. Head and Neck III This exercise lets you practice making an IMRT Plan. It is assumed that you have reviewed the section Monaco Planning and Workflow. You can use it as a reference as you practice using these tools.

20-24

•

Open Monaco and select the Patient ClivusTRN.

•

Select New Monaco Plan for Studyset SS_CT1.

•

Start a new IMRT plan for the treatment using a saved template and a treatment machine similar to what you would use in your clinic.

•

Edit the Beams and IMRT Constraints.

•

Optimize your plan.

•

Review the isodose lines and DVH for the Targets and Organs at Risk to determine if the planning criteria are met. If necessary, edit the IMRT Constraints to better meet the planning criteria.

•

Save your Plan.

Additional Cases Volume II of IV Monaco Training Guide

Additional Cases Practice Exercise 8. Head and Neck III (cont.) •

The planning criteria are shown in Figure 20-11:

Target Structure ptv PTV LT node PTV RT node ptv boost

95% of ptv is covered by 54 Gy Maximum dose of 59.4 Gy 95% of PTV is covered by 60 Gy 95% of PTV is covered by 60 Gy Maximum dose of 66.0 Gy 95% of ptv boost is covered by 66 Gy Maximum dose of 72.6 Gy

33 fx

1.6

33 fx

1.8 Gy/fx

33 fx

2.0 Gy/fx

Organs at Risk (OAR) Patient Brain Stem Cord+5 Mandible Parotid Oral Cavity

Maximum dose of 69 Gy Maximum Dose of 54 Gy, 1cc cannot exceed 60 Gy 45 Gy, 1cc cannot exceed 50 Gy No more than 5% of the volume ≥ 66 Gy Mean dose < 23 Gy (at least one parotid) Minimum of 20 cc of combined volume < 20 Gy Low as possible, mean dose < 35 Gy

Figure 20-11: Planning Criterial for Target Structures and Organs at Risk

Monaco®

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QA Tools Volume II of IV Monaco Training Guide

QA Tools Overview This activity defines the options you have available when you create a QA Plan. It describes a workflow you can use to create, calculate, export dose profiles of, and print QA plans. These tools discussed in this section are available for QA Plans. You can use the same tools on a QA plan that you can use in treatment planning. You can open and review a QA Plan in both the Planning and Plan Review activities. When you complete this section, go to the Additional Exercises section in Vol II, of this guide.

Dose Calculation Tools Calculate the QA plan from the Dose Calculation toolbar (Figure 21-1). All imported prescriptions from a multiple Rx treatment plan are combined into one Rx called ‘QA’.

Figure 21-1: Dose Calculation Toolbar This is the Start Dose Calculation button. This is the Reset Calculation Engine button. When you select Reset Calculation Engine, the system abandons the dose calculation.

Monaco®

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QA Tools Volume II of IV Monaco Training Guide

QA Tools Beam Tools You click the Planning tab to edit the plan. The New Beam button lets you add a new beam to the plan. You can add a duplicate beam of the active beam to the plan. You have the option of opposing the duplicate beam. You can use the option on the Planning Control to add beams to an existing QA plan for the purpose of acceptance testing and commissioning, while preserving the integrity of the original plan. You can add Static, Arc, and Dynamic QA beams to the QA plan. You can only add Dynamic QA beams to a QA Plan. A Dynamic QA beam delivers a uniform rectangular field to the phantom. Click the option on the Planning Control to add a new beam. You must change the Delivery of the new beam to Dynamic QA. You can define the Window Width of the Dynamic QA beam. You cannot edit the Jaw Trailing field. The Field Type field can be ‘MLC Only’ or ‘Jaws and MLC’ if the selected Machine has dynamic jaws. Type in Monitor Units to reweight the beam. In the BEV, Monaco shows a window of the length of the field and the specified width that starts at the left edge of the field, and ends at the right edge of the field.

Figure 21-2: Beam tab of the Planning Control button lets you delete the currently active beam The Delete Beam (appears in red in the SPV). This could be a beam from the original plan, or a new beam you added to the QA Plan.

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QA Tools Fluence Toolbar Fluence analysis and visualization tools are available on the Planning tab (Figure 21-3) and have the same functionality as described in the IMRT Tools section.

Figure 21-3: Fluence Toolbar-IMRT, dMLC and Conformal RT Plans

Figure 21-4: Fluence Toolbar-VMAT and Dynamic Conformal Arc Plans To show the fluence image view, right-click in the BEV and select Show MU/Fluence. Other right-click fluence options are available as described in the IMRT Tools section.

Monaco®

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QA Tools Fluence Toolbar (cont.) Beam and Dose Visibility Control You can toggle individual beams or sequences and/or dose display on or off from the Beam Tab of the Planning Control. Monaco highlights the active beam/sequence in red. Monaco highlights all other beams/sequences in blue.

Figure 21-5: Beam Visibility Control

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1.

Left-click on any beam/sequence name to toggle the beam visibility on or off.

2.

Left-click on the heading Beam to toggle all beams/sequences on or off.

3.

Left-click in any checkbox under the Dose heading to toggle the dose display on or off.

4.

Left-click on the heading Dose to toggle all doses on or off.

QA Tools Volume II of IV Monaco Training Guide

QA Tools Dose Plane Output Click the Output tab to access the reports and dose information. The Dose Export Tool button launches the Dose Plane Output dialog box (Figure 21-6). Here you can export QA Dose planes. This tool is only available once dose is calculated. You can export Dose Planes for all beams which contain dose, including frozen dose and all beams in a multiple Rx plan. Turn of a beam’s Dose visibility and select As Viewed on the Beam Visibility dialog box if you do not want to export an individual dose plane for that beam. Select All Beams if you want to export a dose plane which contains dose from all beams in the plan which contain dose. If you want to export a single dose plane which contains dose for one Rx in a multiple Rx plan, you must: 1.

Save the plan.

2.

Delete the unwanted beams.

3.

Export the dose plane using the All Beams option.

4.

You select the Combine Split Fields option to export one file for beams which split. Click OK to close the dialog box and export the selected QA plans to file. You can find the files under the Focal Data folder in a folder labeled “DosePlanes.”

Figure 21-6: Dose Plane Output dialog box

Monaco®

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QA Tools Volume II of IV Monaco Training Guide

QA Tools Show Dose Extents If you want to see a graphical representation of the calculation volume on the button on the transverse, sagittal and coronal views, select the Show Dose Extents Plan Options tab. This option is available in Planning and Plan Review.

Measure and Interest Point Tools

Figure 21-7: Tools Toolbar The Measure, Interest Point and Anatomical Groups Tools are available in all activities. See the Planning Tools and IMRT Tools sections for more detailed information on the use of these tools. See the Contouring section for more information on Anatomical Groups.

Dose Reference Points You can review the dose to dose reference points on the QA phantom on the Dose Reference Points tab of the Planning Control dialog box.

Figure 21-8: Dose Reference Points tab

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QA Tools Create a QA Plan After you create and save a treatment plan, follow these instructions to create a QA plan. 1.

When you have a treatment plan which was calculated in Monaco open and are in the Planning Activity, click the New Plan option.

button then the New QA Plan

OR In the Workspace, right-click on any plan with dose which was calculated in Monaco and select New QA Plan to open the New QA Plan dialog box (Figure 21-9).

Figure 21-9: New QA Plan dialog box for multiple prescriptions and a single prescription 2.

Monaco®

Select a Studyset for which you want to create the QA plan. This could be a phantom or any other studyset associated with this patient. You cannot use an MR studyset for a QA plan.

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QA Tools Create a QA Plan (cont.) 3.

Select the Studyset Orientation for QA Plan. If you change the QA Plan Orientation so that it differs from the Treatment Plan, Monaco shows a message for you to verify this information (Figure 21-10).

Figure 21-10: QA Studyset Orientation Message

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4.

To create a QA plan, use the plan beam angles or set the Gantry, Collimator and/or the Couch to nominal, check the associated boxes under Reset Beams to Nominal Angles. You can click Reset All to quickly check all the boxes at once.

5.

Select the Algorithm you want to use when you calculate the QA plan.

6.

Select the Calculation Volume Grid Spacing that you want to use for the QA plan.

7.

For plans calculated using the Monte Carlo algorithm, type the Statistical Uncertainty Per Control Point or Per Calculation you want to use.

8.

Select Calculate Dose Deposition to Medium or Water.

9.

Select the Rx you want the QA plan to include. •

If there is only one prescription Rx A is the only option.

•

If there are multiple prescriptions, select the check box next to the prescriptions you want to include.

QA Tools Volume II of IV Monaco Training Guide

QA Tools Create a QA Plan (cont.) 10.

Click OK to open the Set Up QA Plan dialog box (Figure 21-11).

Figure 21-11: Set Up QA Plan dialog box 11.

Select the Isocenter for the QA plan. If you have multiple isocenters, you can set them all to a common isocenter. Place a checkmark next to the option Use Common Isocenter.

12.

Click OK to create the QA plan. NOTE:

13.

(Optional) Open the console window from the Workspace tab. Select Controls | Optimization Console. This window gives feedback as to the status of the QA dose calculation.

14.

(Optional) Before or after dose calculation, you can add new beams of type Static, Arc or Dynamic QA to the plan. If you add them after dose calculation, re-calculate to include the new beam.

15.

Start the Dose Calculation from the Planning tab. Click the Calculate button.

16.

(Optional) Click the Beams tab of the Planning Control to edit the MU weighting and number of fractions. NOTE:

Monaco®

Couchtop structures do not automatically import into QA from the IMRT plan. You must add couchtop structures to your phantoms for use in QA.

Beam monitor units are automatically scaled to one fraction’s monitor units per beam. When you change the number of fractions, the graphical representation of the multiplied dose appears.

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QA Tools Volume II of IV Monaco Training Guide

QA Tools Edit Dose Calculation Properties Once you open your QA plan, you can edit your dose calculation properties. 1.

button on the Click the Calculation Properties Planning tab to show the Dose Calculation Properties dialog box (Figure 21-12).

Figure 21-12: Calculation Properties dialog box

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2.

Edit the Grid Spacing (cm).

3.

Edit the Calculate Dose Deposition to option.

4.

Edit the Force entire volume to be treated as water option.

5.

Edit the Statistical Uncertainty per Control Point or Per Calculation. This option is only available when Monte Carlo is the selected algorithm.

6.

Click OK to close the dialog box.

QA Tools Volume II of IV Monaco Training Guide

QA Tools Edit Assigned Electron Densities Once you open your QA plan, you can edit your assigned electron densities. 1.

Click the Structures tab of the Planning Control to assign structure densities.

Figure 21-13: Assign Densities dialog box 2.

You can use the Electron Densities calculated from the CT image. You can Force the Electron Density or Fill the Electron Density.

3.

If you Force ED or Fill ED, type the Electron Density in the Relative ED field.

Save the QA Plan

Monaco®

1.

Once the QA plan completes, save it.

2.

Click the Monaco Application button then the Save Plan As option to save the QA plan. Monaco saves the QA plan with the patient and uses the name and description given by you.

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QA Tools Export the QA Plan 1. Once dose is calculated, click the Output tab then the DICOM Export button . 2. You can DICOM export images, structure sets, plans, and dose from within a QA Plan. Monaco updates the DICOM fields for exported QA plan images. The Study and Demographic modules are updated.

Figure 21-14: DICOM Export dialog box

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QA Tools Volume II of IV Monaco Training Guide

QA Tools Tips When Creating a QA Phantom 1.

Import your phantom into the Installation/QA clinic. This lets you keep your phantoms separate from your clinical patients.

2.

Create a CT-to-ED file and save that file in the Installation/QA clinic. It is recommended that you save an existing CT-to-ED file to the QA clinic and use the Save As… option located on the CT-to-ED Conversion Files dialog box. See the Planning Tools section of this training guide for more information on how to create, edit, and save a CT-to-ED file in Monaco.

Exercise Go to the Additional Cases section in Volume II, Sec 22 of this guide to complete the “IMRT QA” exercise.

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QA Exercise Volume II of IV Monaco Training Guide

QA Exercise This section walks you through the steps for each of these processes. •

Create an IMRT QA Phantom

•

Use a couchtop with a QA plan

•

Create an IMRT QA plan

•

Create QA verification beams

Creating an IMRT QA Phantom Import your phantom into the Installation/QA clinic. This lets you keep your phantoms separate from your clinical patients.

Monaco®

1.

Start Monaco.

2.

Select Import New Data from the Patient Selection dialog box.

3.

On the DICOM Import – 3D dialog box in the DICOM Patient field, browse to: C: Users/All Users/Public/Public Documents/CMS/FocalData/DICOM/Import.

4.

Click Calib_5mm to highlight it.

5.

Click OK. Monaco loads the data.

6.

Select Calib_5mm from the DICOM Patient drop-down list.

7.

Click CT1 to highlight it.

8.

Select Installation for the Local Installation field.

9.

Select QA Clinic for the Local Clinic field.

10.

Type QAExample in the Patient ID field.

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QA Exercise Creating an IMRT QA Phantom (cont.) 11.

Type phantom in the Patient Name field.

12.

Click Add. Monaco shows the studyset information and images. NOTE:

13.

Right-click on the name of the studyset (currently CT1) and rename it.

14.

Select a CT- to-EE file from the CT-to-ED Assignment field. NOTE:

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You can use any studyset in the QA clinic for the QA plan, except for a studyset that has the same modified date as the studyset that belongs to the patient. If you select a QA studyset that has the same name as a studyset that belong to the patient, the system prompts you to rename the studyset.

CT-to-ED files are only available if you saved them in the clinic where the patient/phantom resides. You must copy the CT-to-ED file used with the phantom to the clinic that contains the Monaco patients. We recommend that you save a previously created CT-toED file to the QA clinic. Use the Save As… option located on the CTto-ED Conversion Files dialog box. See the Planning Tools section of this training guide for more information.

15.

Click Import.

16.

Click Close to close the DICOM Import dialog box.

17.

Select the Open Patient

18.

Select the QA Clinic folder. The new phantom appears in the list.

19.

Select the new phantom.

20.

Click OK.

button to open the Patient Select dialog box.

QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Creating an IMRT QA Phantom (cont.) 21.

Name the exterior contour of the phantom the same name that you use for the external contour of a patient.

22.

Click the Phantom Studyset, and select Load/Activate from the mouse menu.

23.

Contour the phantom. See the Contouring Tools section of the Monaco Training Guide for instructions on the contour tools available in Monaco.

24.

Select the Monaco Application Monaco.

button and Exit to save the change and exit

Add a Couchtop to an Existing Studyset 1.

Open Monaco and select the Patient Fusion Prostate.

2.

Load the studyset MonacoPhantom.

3.

Select the Plan Options tab.

4.

Select the Import Positioning Device

5.

Select sampleElekta from the list of available couchtops.

6.

Click OK to close the dialog box and add the couch to the phantom. NOTE:

7.

Monaco®

button.

The action adds the couchtop to all QA plans for Patient FustionProstate which uses the MonacoPhantom studyset. This does not invalidate doses for existing plans.

Click Done to accept the default couch location.

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QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Add a Couchtop to an Existing Studyset (cont.) 8.

You must assign a couch to the beams in order for the dose calculation to take it into account. This option is on the Treatment Aids section of the Beams tab on the Planning control.

Figure 22-1: Beams tab

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QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Create an IMRT QA Plan 1.

Load the Plan MonProstate.

2.

Click the Planning to switch to the Planning Activity.

3.

Click on the Plan MonProstate and select New QA Plan from the mouse menu. If prompted, click No to saving the changes.

4.

Select TrainingClinic: PROSTATE: MonacoPhantom from the drop-down list as the Studyset for QA Plan.

5.

Check the option(s) to Reset Beams to Nominal Angles. You can reset the Gantry, Collimator, Couch or Reset All.

6.

Select the Algorithm you want to use when you calculate the QA plan. NOTE:

7.

Monaco®

The recommended grid spacing for clinical patient QA is 0.3 cm.

For plans calculated that use the Monte Carlo algorithm, type the Monte Carlo Standard Deviation per Control Point or per Calculation you want to use. The suggested Standard Deviation for this practice exercise is 4.00 %. NOTE:

9.

The suggested algorithm for patient QA is Monte Carlo.

Select the Calculation Volume Grid Spacing that you want to use for the QA plan. Suggested grid spacing for this practice exercise is 0.4 cm. NOTE:

8.

button on the Workspace control

The recommended Standard Deviation for clinical patient QA is 1.0 %.

Click OK to show the Setup QA Plan dialog box.

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QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Create an IMRT QA Plan (cont.) 10.

Change the isocenter coordinates to X (cm): 0.37 Y(cm): 0.25 Z (cm): 1.90 and click OK. This places the isocenter of all the beams at a depth of 10 cm in the phantom. NOTE:

If you have a plan with multiple isocenters, you have the option to set the same isocenter for all the beams when you check the box Use Common Isocenter.

11.

Verify the isocenter is at a depth of 10 cm in the phantom. Use the Measure . Tool

12.

Create an Interest Point at the isocenter and at any other required positions in the phantom. Click the Interest Points/Markers

13.

button and add points.

On the Interest point and Marker dialog box, type 0.5 cm as the radius for the volume sphere you want around the interest points. NOTE:

When you use an ion chamber to compare measurements, the Radius value is approximately the radius of the chamber.

14.

Click DONE to close the Interest Point and Marker dialog box.

15.

Click the Calculate

16.

Review status of QA dose calculation. Open the console window, click the

button.

Workspace tab, then select Optimization Console from the Controls button.

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17.

Once dose calculation completes, click on the Prescription tab on the Planning Control dialog box.

18.

Edit the MU weighting of each beam to 100 MU and number of fractions of each beam to 1.

QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Create an IMRT QA Plan (cont.) 19.

Review the total weight (cGy) of each beam. Click the Reports, Individual Reports drop-down menu and select the Plan option.

20.

Review the mean dose to the interest point radius. Click the Interest Points/Markers

Monaco®

button.

21.

Save the QA plan. Click the Save

button.

22.

Verify on the navigation toolbar that the coronal slice shown is at C (z): 1.90. This is the coronal plane at 10 cm depth in the phantom.

23.

Click the Output tab. Click the Dose Plane Output dialog box.

24.

Export the Coronal absolute dose plane. Place a checkmark next to Coronal.

25.

Create individual dose plane files for each beam. Select Individual Beams.

26.

Click OK to export the dose profile to a file.

27.

Create a composite dose plane file. Re-open the Dose Profiles dialog box and select All Beams. Click OK to export them to file.

28.

Exported dose plane files are located in the …\CMS\FocalData\ DosePlanes folder.

29.

You can review the available reports from the Output tab as well.

button to open the Dose Plane

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QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Create QA Verification Beams 1.

In the Workspace, click on a saved plan and select New QA Plan from the mouse menu.

2.

Use TrainingClinic: PROSTATE:MonacoPhantom as your QA phantom.

3.

Force the density of the phantom to a uniform density of 1.00. Place All Beams/Sequences at Nominal Angle.

4.

Select the Monte Carlo dose calculation algorithm.

5.

Type a Calculation Volume Grid Spacing of 0.4 cm.

6.

Type a Monte Carlo Standard Deviation per Calculation of 4.00 %.

7.

Click OK to open the Setup QA Plan dialog box.

8.

Set the isocenter of beams to X (cm): 0.37 Y(cm): 0.25 Z (cm): 1.90.

9.

Click OK. Monaco positions the beams.

10.

Click the Beams tab of the Planning Control.

11.

Delete all existing beams except Beam 1 (you delete this one in a future step). Delete individual beams. Select the beam number to delete on the click the Delete Beam

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button.

QA Exercise Volume II of IV Monaco Training Guide

QA Exercise Create QA Verification Beams (cont.) 12.

Create four new beams. To do this, click the New Beam parameters for each beam:

button. Use these

a. Width 10 cm, Length 10 cm b. Width 5 cm, Length 15 cm c. LW 0 cm, RW 10 cm , UL 0 cm, LL 5 cm d. LW -2 cm, RW 5 cm , UL -3 cm, LL 5 cm e. Set Gantry, Collimator and Couch angles to nominal f.

Select Jaws Only to use the width and length jaws to form the fields

g. Set MU/fx to 100 MU

Monaco®

13.

Delete Beam 1. You do not need it for the task.

14.

Place interest points at appropriate locations.

15.

Click the Calculate

16.

Once the dose calculation completes, review the dose to the interest points.

button.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Outline for Stereotactic Planning with Monaco Section Learning Objectives Introduction: Stereotactic Planning with Monaco Workflow Diagrams Stereotactic Cone Configuration and Graphical Preferences Monaco Planning with Stereotactic Cones • • • • • • • • •

Delineate additional structures if needed New Plan & Stereotactic Cone Templates Dose Prescription Stereotactic Cone Selection Stereotactic Cone Visualization Beam Spreadsheet Dose Calculation Plan Evaluation Practice Exercise: Brain Mets with 3D Static Arc/Stereo Cones

MLC Stereotactic Planning: Training Guide Practice Exercises • • •

Lung with VMAT Lung with DCA Spine with VMAT

Training Data Six practice cases for stereotactic planning • • • • • • NOTE:

Monaco®

Brain5TargetsTRN LeftLungSBRTTRN SpineSingleTRN BrainAVMTRN BrainTrigemTRN Spine2TargetsTRN Use your clinic’s procedures for Quality Assurance to every part of the stereotactic process, beginning with patient positioning and immobilization all the way through to image-guided verification at treatment.

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Stereotactic Planning with Monaco Learning Objectives •

Describe the use of Stereo Cone Parameters in the Settings dialog box for stereo cone configuration

•

Explain how the Visibility Increment for 3D Static Arc delivery is created and applied

•

Discuss one way to use a stereotactic cones dose prescription in the Physician’s Intent and Beam Weights section

•

Identify where to select the Applicator ID for the relevant stereo cone size after you determine the target size

•

Recognize how stereotactic cones look in the 2D, 3D, DRR view types, and how to change their visualization

•

Examine the beam spreadsheet to verify accurate information in all fields

•

Use Isodose Tools and DVH statistics to analyze target dose conformity, gradient, heterogeneity; and dose to normal tissue

•

Use Dynamic Conformal Arc and VMAT delivery types to create, optimize, calculate and evaluate Lung and Spine SBRT treatment plans.

Introduction: Stereotactic Planning In the Monaco Stereotactic Planning section of the training guide, you first review a general workflow of the stereotactic process, and how Monaco treatment planning fits into the stereotactic workflow. Next, you go into greater detail of Monaco stereotactic planning as you learn how to use stereotactic cones with 3D Static Arcs throughout the treatment planning process. Then, work through exercises that give you the opportunity to practice planning not only with 3D Static Arc & Stereo Cones for a brain metastases example, but also, as you use Dynamic Conformal Arc and VMAT with MLC for spine and lung targets. Disclaimer The examples and exercises used throughout this section are for illustrative purposes only, and are in no way to be construed as Elekta acting in any way to give medical direction or advice. 23-2

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Workflow Diagrams Monaco Stereotactic Planning Workflow

General Stereotactic Workflow

Positioning, Imaging, Fusion, QA Delineate Target and Normal Structures

Positioning, Frame/Frameless Immobilization

QA Positioning and Fixation

Imaging (may occur prior to the day of treatment)

QA Imaging

Start New Monaco Plan Select and Import Template

Use visualization tools to evaluate beam geometry and shaping devices

Enter Dose Prescription (Physician’s Intent, Beam Weights)

Measure Target and Select Cone (3D Static Arc Delivery)

Import Images MLC QA Image Fusion

Image Fusion

Verify and Determine Beam Geometry

Monaco Treatment Planning Set IMRT Constraints if DCA/VMAT

Set Calculation Parameters

Localization, QA, Image Verification, Treatment Localize Stereotactic Frame

Calculate Plan Export Plan to Localizer Analyze Plan Quality: Isodoses; Target Conformity, Gradient &, Heterogeneity

Approve Plan

Send information to MOSAIQ

Verify Plan Information in MOSAIQ

QA: Linear Accelerator

QA: Treatment Plan, Isocenter at Linear Accelerator

Export Plan to MOSAIQ

Image Verification

Calculate/Verify MU

Treat Patient

Figure 23-1: Monaco Stereo Planning Workflow and General Stereotactic Workflow

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Stereotactic Cone Configuration Configure your clinic’s stereotactic cones from the Stereo Cone Parameters section of the Settings window.

Figure 23-2: Stereo Cone Parameters in Settings Window Refer to the Settings section of Appendix C for more information.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Visualization Increment in Graphical Preferences In the Settings window (Figure 23-3) under Graphical Preferences, type the desired Visualization Increment you want to use while you view each beam arc. Remember, this increment does not affect the dose calculation.

Figure 23-3: Visualization Increment in Settings Window While you are in Planning Mode, from the Fluence ribbon, select or scroll through the 10° visualization increments with the up/down arrows to the right of the Gantry angle. The Beam’s Eye View (BEV) updates as you select the respective arc increment. In the next two figures, notice the BEV as you view the stereotactic cone field relative to the target and adjacent normal structures throughout the arc. In a Single Planar View (SPV), you see the stereotactic cone start/stop positions and beam path of the corresponding increment angle.

Monaco®

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Stereotactic Planning with Monaco Visualization Increment in Graphical Preferences (cont.)

Figure 23-4: Transverse SPV and the BEV at the Stop angle of 340°

Figure 23- 5: Next visualization increment at 330°, which is 10° off the Stop Angle of this arc

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones 1.

Additional Structures Add more structures for planning, if needed.

2.

New Monaco Plan Begin a treatment plan that uses stereotactic cones the same way you start any new Monaco plan. Select a delivery type, template, and desired beam information.

3.

Stereotactic Cone Templates with 3D Static Arc Use the beam information from your template for planning and treatment, or use it as a starting point from which you may adjust parameters. Notice that Monte Carlo is the algorithm for 3D Static Arc with Stereotactic Cones. Here is an example of a template for 3D Static Arc with Stereo Cones (Figure 23-6).

Figure 23-6: Example of a template for 3D Static Arc with Stereo Cones

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) 4.

Dose Prescription The method in which the Dose Prescription is described for stereotactic treatments can vary from non-stereotactic treatments. Throughout the exercises, you can use different Physician’s Intent entries and Beam Weights based on the delivery mode. Start with equal weights, and then adjust later as you evaluate the plan (Figure 23-7).

Figure 23-7: Example of one type of prescription used with Stereo Cones and 3D Static Arc 5.

Stereotactic Cone Selection To determine the stereotactic cone applicator size, use the Measure Tool to measure the target on the transverse, sagittal, and coronal single planar views. Then, select the relevant cone size in Applicator ID of Treatment Aids section of the Beams tab.

Figure 23-8: Stereo Cone Applicator ID selection in the Beams window

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Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) 6.

Stereotactic Cone Visualization Use the various Monaco Views to assist in visualization of stereotactic cone beams.

Figure 23-9: BEV and SPV of beam arc with Stereo Cones

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.)

Figure 23-10: 3D representation of arc beam with stereo cones

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) For an example of how you use block transparency for stereotactic cones, look at a non-arc beam with a beam modulator treatment machine in the figures below. Set block transparency while inside the Single Planar View. Right-click and select Options Menu | Block Transparency. This turns on and off transparency that covers the image.

Figure 23-11: Block Transparency for Stereotactic Cone Notice the two sets of collimators: 1) stereotactic cone, 2) default field size.

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) In this example, the inner set represents the stereo cone applicator. The outer set represents the 2x2 cm. default field size of the leaf bank, set during cone configuration and data collection. For other treatment machines, this outer set represents the default jaw settings.

Figure 23-12: Field Edge Representation of Stereo Cone Applicator and Default Collimator You can set the stereo cone display graphics in the 2D Treatment Aid Display from the Options menu.

Figure 23-13: 2D Stereo Cone Display

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) 7.

Visualization while you plan the arc angles You can use several methods to visualize and adjust the arcs to avoid normal structures in the beam’s path. One method is that described earlier when you use visualization increments in the BEV and SPV. Another way is to keep a 3D view and Single Planar View together on the screen, and watch the arc path in the 3D view as you drag the start/stop arc in the 2D view (SPV).

8.

Beam Spreadsheet In the Beam Spreadsheet, you can modify information previously set in the New Monaco Plan template. In the figure of the General section, notice that for 3D Static Arc, you use Monte Carlo algorithm. You cannot use Collapsed Cone algorithm.

Figure 23-14: General Tab

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) In the Geometry section, as you evaluate the target volume relative to the normal tissue, you may decide to change the number of beams, gantry, couch, and collimator parameters. Remember, you cannot set an arc increment for the calculation.

Figure 23-15: Geometry Tab In the Treatment Aids section, you can select the desired stereotactic cone applicator for each beam.

Figure 23-16: Treatment Aids Tab

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) 9.

Dose Calculation Use Monte Carlo algorithm for the dose calculation. Initially, use coarse (high) values for the calculation parameters to minimize the calculation time. Then, tighten the values as you refine beam and dose planning parameters. The Calculation Properties dialog box below shows an example of values to use after you have refined your beam parameters. NOTE:

Remember not to lower the grid spacing below that specified in your beam modeling parameters.

Figure 23-17: Calculation Properties dialog box

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Monaco Planning with Stereotactic Cones (cont.) 10.

Plan Evaluation You begin stereotactic cone plan evaluation early in the planning process, as described previously. Use isodose curves to determine if your dose prescription is adequate to meet your physician’s prescribed percent tumor coverage. Also, use the isodose curves to check general conformity to the target. Use Isodose Tools (Isodose to Structure, etc.) and Dose Volume Histogram statistics to evaluate Organ at Risk sparing and plan quality. Specifically: •

Dose Conformity to the target

•

Dose Gradient outside the target

•

Dose Heterogeneity within the target

Several models exist in the literature and protocols to determine these values. Use the model your clinic has adapted in its procedures. In the exercises, you review a couple of examples. NOTE:

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Use your clinic’s procedures for Quality Assurance for every part of the stereotactic process, beginning with patient positioning and immobilization all the way through to image-guided verification at treatment.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Disclaimer:

This Practice Exercise uses example values from legitimate, authoritative third parties for training purposes only. In no way is Elekta providing medical direction or advice. Table 23-1: Overview of Tasks for Stereotactic Brain Metastasis Exercise. Task # 1 2 3 4 5 6 7 8

Task Pre-Exercise Work and Select Patient Add planning margin Start a New Monaco Plan and Import Template Enter Dose Prescription Determine Stereotactic Cone Size Determine arc-beam number and geometry Set Calculation Properties and calculate dose Evaluate plan with isodose tools and DVH statistics

References The references listed at the end of the Stereotactic Planning Section of the training guide were used for the Tasks in this exercise.

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 1. Pre-Exercise Work and Select Patient In preparation of this exercise, you must make a few edits to the Structure Set of the example patient. If you want to save the original Image/Structure Set, follow the steps below to copy the file. Otherwise, skip to step number 2. 1.

Find the Image & Structure Set folders to make copies. a) Access your Training Clinic Folder in Microsoft Windows. b) The file path may vary depending upon your training clinic’s file structure, but an example is: |Focal Data | Installation | Training Clinic. c) Open the folder of the example case: Brain5TargetsTRN. d) Copy the Image & Structure Set folder labeled CT1_Clean and place the newly copied folder CT1_Clean_Copy in the same Brain5TargetsTRN folder. e) Inside the CT1_Clean_Copy folder, rename the CT1_Clean folder that contains the index.DAT file to CT1_Clean_Copy. This is the file name you see in the Monaco application Workspace. f) Use this new copy to edit the structures.

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2.

After you open the example patient Brain5TargetsTRN in Monaco, select the desired Structure Set from the Monaco Workspace.

3.

Set patient contour type to External.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Task 1. Pre-Exercise Work and Select Patient (cont.) 4.

Optional: Delineate the right cochlea and left cochlea.

5.

Despite the patient name, plan for only one target, called tumor-cerebel in this exercise.

6.

Turn off the visibility of the other four tumor structures.

Figure 23-18: Tumor Structure

Task 2. Add Planning Margin

Monaco®

1.

Use Auto Margin to add a 2 mm uniform margin around tumor-cerebel.

2.

Name the new structure PTV_cerebel.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 3. Start a New Monaco Plan & Import Template 1.

Click the Planning tab and select New Monaco Plan from the New Plan menu.

Figure 23-19: New Plan Menu 2.

Create a New Plan Name and Description.

3.

Verify the Scan Orientation and the Treatment Orientation.

4.

In the New Monaco Plan window, select the values shown in the table below for the respective information type. Table 23-2: Value Entry for New Monaco Plan Window Information Type Delivery Type Template to Import Treatment Unit Algorithm Isocenter Location Port Options

5.

Value 3D Static Arc Template: StereoCones > 3D Static Arc StConesBM06x Monte Carlo Center of tumor-cerebel Import Beams Only

If your clinic uses standard beam information, set your standard parameters and save as a New Monaco Plan template for future use. See the Template section in the training guide for more information to save templates.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 4. Enter Dose Prescription In stereotactic planning, you can describe the dose prescription several ways. For this exercise, normalize the plan to the Max Dose and prescribe to a Prescription Isodose, which is the isodose line that encompasses the target. •

Plan normalized to:

Max Dose

•

Prescribed Target Dose:

20 Gy

•

Prescription Isodose:

80%

1.

Type a prescription in the Physician’s Intent section.

2.

Type Brain in the Rx Site field if it is not already listed in the drop down menu.

3.

Click the Prescribe to drop-down menu and select Center of tumor-cerebel.

4.

Type an Rx Dose of 25 Gy to the PTV isocenter. In this example, you begin with 25 Gy as maximum dose, where the prescription is 20 Gy at the 80% isodose surface.

5.

Monaco®

Type the number of fractions: 1fx.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 5. Determine Stereotactic Cone Size 1.

Set up a transverse, sagittal, and coronal view (SPV) on the screen. Scroll to the largest extent of the PTV on each slice.

2.

to measure the target on all three SPV images. From Use the Measure Tool these values, determine which stereotactic cone to use.

Figure 23-20: Measurement Value in SPV views, with BEV to Show Cone Size and Target 3.

Inside Beams spreadsheet, select a stereotactic cone from the Applicator ID drop down menu for each beam. For this exercise, you can start with a 14 mm or 18 mm cone. NOTE:

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Once you select the Stereo Cone Applicator, the collimator angle automatically sets to the default value set during Data Collection. (See Stereo Cone Parameters under the Settings section of the Training Guide.)

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 6. Determine Beam Geometry, Information, and Number of Beams With a BEV on the screen, scroll through all beam arcs to view target coverage and normal structure blocking. 1.

Use the visualization tools to evaluate if you want to adjust the number of beams and/or the beam geometry relative to the target and normal structures. Remember to toggle through the gantry visualization arc increments in the Fluence ribbon as you watch the beam and cone geometry move relative to the structures in a BEV. NOTE:

2.

Refer to the visualization information in the earlier part of this training guide section for more information.

The table below shows the beam geometry from the template you selected earlier in the exercise. You can keep these parameters and calculate the plan, or you can adjust the parameters based on your evaluation in the previous step. Table 23-3: Beam Geometry Set in New Monaco Plan Template

Monaco®

Beam

Direction

Gantry Start

Arc

Couch

1: RtArc 2: Rt45Arc 3: VertexArc 4:Lt45Arc 5:LtArc

CW CCW CW CCW CW

200 340 200 160 20

140 140 140 140 140

10 45 90 315 350

3.

Then, while you plan, adjust the parameters as needed.

4.

If needed, change the Stereotactic Cone Applicator in the Treatment Aids sheet.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 7. Set Calculation Properties and Calculation 1.

Verify in the Beams Spreadsheet that you have set the algorithm to Monte Carlo.

2.

From the Calculation ribbon in the Planning tab, select the Calculation Properties for the plan.

Figure 23-21: Calculation Properties 3.

Initially, set a high value, such as 3.0 mm, for the grid spacing to minimize the calculation time. Then, lower the grid value within a range of 1.0 mm - 2.0 mm as you refine the beam and prescription parameters during planning. NOTE:

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Remember not to lower the grid spacing below that specified in your beam modeling parameters.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Task 7. Set Calculation Properties and Calculation (cont.) The figures below show an example of grid spacing early and late in the planning process.

Figure 23-22: Early in Planning Process

Monaco®

Figure 23-23: Late in Planning Process

4.

For this example, set Calculate dose to: Medium, and set 1% Statistical Uncertainty per Calculation.

5.

Click OK to apply the new properties.

6.

To start the calculation, click the Calculate icon

7.

Once the calculation completes, proceed to plan evaluation.

.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.) Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics You can use a variety of tools to evaluate, and strategies to re-optimize your stereotactic cones plan. In this exercise, you apply Monaco’s isodose tools and DVH information to analyze dose quality relative to the target, and dose volume information to the normal structures. Terminology used in this Plan Evaluation Task:

1.

PIV:

Prescription isodose volume

PIV 0.5 :

Volume receiving half of the PIV

PCI:

Paddick Conformity Index

GI:

Gradient Index

HI:

Heterogeneity Index

In the Isodoses tab, set these initial isodose values: Table 23-4: Isodose values for Plan Evaluation Isodose Value (Gy) 25* 20 10 4 2

Description of Dose 125% (or max dose)* Prescription Dose 50% Prescription Dose 20% 10%

*The max dose may change as you evaluate and modify the plan to achieve target coverage by the 20Gy isodose line and improve CI, GI, HI.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics (cont.) 2.

Use the Normal Tissue tolerances below as you evaluate the plan. Table 23-5: Normal Tissue Tolerances Structure Brainstem Avoid if possible Optic Chiasm Right Optic Nerve Left Optic Nerve Right Eye Left Eye Right Cochlea* Left Cochlea* Brain

Maximum Dose (Gy) 10

Volume

10 10

< 0.2 cc < 0.2 cc

10

< 0.2 cc

10 10 9

< 0.2 cc < 0.2 cc Point

9 12

Point

< 0.5 cc

*Optional delineated structure for this exercise. 3.

You can use many strategies to evaluate and optimize your plan. a) Do a visual check of the overall shape or conformity of the prescribed isodose distribution. b) If the dose is not conformal to the target, repeat the beam geometry optimization by gantry angles, arc start/stop angles, couch rotation, and number of beams, cone size, isocenter location. c) Look at dose to the normal structures and determine if you need to adjust beam geometry. d) Change the isocenter, if necessary. e) Change the cone size, if necessary.

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics (cont.) f) In general, find the proper combination of modifications to the variables below to achieve the best conformity (CI), dose gradient (GI):

4.

•

Number of beams

•

Gantry angle

•

Arc increment per beam

•

Couch angle

•

Collimator angle

•

Cone size

•

Isocenter or Cone placement

•

Prescription Dose - renormalize

Apply the parameters your clinic uses to evaluate measures for target conformity, gradient, and heterogeneity. NOTE:

Several models exist in the literature and protocols to determine these values. Use the model your clinic adapted in its procedures. In the exercises, you view the examples below.

Abbreviations you use in this exercise are:

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TV:

Target Volume

PIV:

Prescription Isodose Volume

PCI:

Paddick Conformity Index

GI:

Gradient Index (Paddick and Lippitz)

HI:

Heterogeneity Index

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics (cont.) For 3D Static Arc plans, use Monaco isodose tools and DVH statistics to calculate these factors. Table 23-6: Example of the heterogeneity, conformity, and gradient indices Index/ Measurement *PCI

GI

HI

What it measures

Formula

Conformity of the dose prescription to the size & shape of the target Description of the steep dose gradient outside the target Dose heterogeneity within the target

(TV covered by PIV)2 / TV x PIV PIV 0.5 / PIV

Value to Achieve 1.0 is perfect

< 3.0

(D max – D min ) / Mean Dose

*PCI - Conformity The Paddick Conformity Index analyzes the quality of target volume (TV) coverage:

And the volume of healthy tissue receiving a dose larger than or equal to the prescription isodose volume (PIV):

Which gives the final formula: = (TV covered by PIV)2 / TV x PIV Monaco Evaluation Tools: To access variables needed to measure GI, use isodose and DVH tools described in earlier sections of the Monaco Training Guide. For example, create an isodose to structure to find the volume of PIV 0.5 .

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco MLC Stereotactic Planning: Training Guide Exercises Practice Exercise 2:

SBRT Lung with Volumetric Modulated Arc Therapy

Practice Exercise 3:

SBRT Lung with Dynamic Conformal Arc

Practice Exercise 4:

SBRT Spine with Volumetric Modulated Arc Therapy

Practice Exercise 2. SBRT Lung with VMAT Disclaimer:

This Practice Exercise uses example values from legitimate, authoritative third parties for training purposes only. In no way is Elekta providing medical direction or advice. Table 23-7: Tasks for SBRT Lung Exercise with VMAT Task # 1 2 3 4 5 6 7 8 9 10 11 12

Task Pre-Exercise Work & Select Patient Add planning structures Start a New Monaco Plan, Import Template, Set Isocenter Enter Dose Prescription Set Beam Geometry Set Structure Optimization Parameters Set Calculation Properties and Sequencing Parameters Set Cost Functions and Dose Constraints Calculate Fluence – Optimization Phase 1 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate Calculate Segments – Optimization Phase 2 Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Reoptimize Phase 2, Re-evaluate

References The references listed at the end of the Stereotactic Planning Section of the training guide were used for the Tasks in this exercise.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 1. Pre-Exercise Work and Select Patient In preparation of this exercise, you reset a structure and target parameters.

Monaco®

1.

Open the Patient in Monaco and select the LeftLungSBRTTRN patient from the Training Clinic.

2.

Open Structure Set: SS_CT1_Clean2.

3.

Delete two (2) unwanted trachea contours on the image slices described below. -

At the left lung on Image Slice: 17.35.

-

Outside of patient’s left side on Image Slice: -4.90.

4.

Uncheck the structures R_Hilar_CTV45 and R_HilarPTV45. You do not use these structures for this exercise.

5.

Rename the LL_CTV to LL_ITV.

6.

In this exercise, use LL_PTV as the target.

7.

Create a new structure for the Left Chest Wall, which is 2cm expansion from ipsilateral lung, and extends 1.2 cm superior and inferior to the PTV.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 2. Add Planning Structures 1.

Optional: Use auto margin to create a uniform structure around PTV to use as a guide to evaluate dose gradient. For an example, create PTV + 2cm.

2.

In this example, you have not delineated brachial plexus, stomach, liver, or kidneys, however, with different beam geometry and in the clinical setting, you may need to define these structures. Follow your clinic’s procedures for normal structure delineation.

3.

Save your changes.

Task 3. Start a New Monaco Plan, Import Template, Set Isocenter

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1.

Click the Planning tab and select New Monaco Plan from the New Plan menu.

2.

Create a New Plan Name and Description.

3.

Verify the Scan Orientation and the Treatment Orientation.

4.

In the New Monaco Plan window, type a Name and Description.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT Task 3. Start a New Monaco Plan, Import Template, Set Isocenter (cont.) 5.

Select the training template and type the values that appear in the table below for the respective plan information. Table 23-8: Values for Plan Information Plan Information Delivery Type Template to Import Treatment Unit Algorithm Energy Isocenter Location* Port Options

Value VMAT Template: VMATTraining TRNElekAgility Monte Carlo 6.0 FFF Center of LL_PTV * Import Beams Only

* Optional: As an alternative to the Isocenter Location that appears in the table above, continue the exercise with the Isocenter Location set to the center of the Patient. Or, create an Isocenter Location that you use in your clinic for ease of patient setup. 6.

If your clinic uses standard beam information, set your clinic’s parameters and save as a New Monaco Plan template for future use. NOTE:

Monaco®

See the Template section in guide for more information on saving templates.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 4. Enter Dose Prescription The literature shows various dose prescription criteria for lung SBRT. For an example in this exercise, you use a prescription of 54 Gy in 3 fractions. Example Dose Prescription Criteria for this Exercise.

1.

•

Prescription Dose 54 Gy in 3 fractions

•

Prescription Isodose Surface must be ≥ 60% and < 90% of the maximum dose. Often it is 80%.

•

PTV Coverage (example) 99% of PTV must receive minimum of 90% of prescription dose (54Gy x 0.9 = 48.6Gy) 95% of PTV is conformally covered by the prescription isodose surface

In the Prescription tab, type the values from the table below for the Physician’s Intent. Table 23-9: Values for Physician’s Intent Information Type Prescribe To Rx Dose (Gy) Number of Fractions Fractional Dose (Gy)

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Value Center of LL_PTV 54.00 3 18.00

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT Task 4. Enter Dose Prescription (cont.) 2.

Type a prescription in the Physician’s Intent section. a) Type Lung in the Rx Site field if it is not already listed in the drop down menu. b) Click the drop-down menu in the Prescribe to: field and select Center of LL_ITV. c) Type an Rx Dose of 54 Gy to begin with. The actual dose changes after you set cost function constraints and optimize. d) Type the number of fractions: 3 fx.

Task 5. Set Beam Geometry 1.

Use the visualization tools to evaluate the appropriate beam geometry.

2.

Set a gantry angle and Arc length to best avoid organs at risk.

3.

For this exercise, set the arc beam geometry values as they appear below: Table 23-10: Beam Geometry Values Beam 1: Left Arc

Monaco®

Direction Gantry Start Arc Inc Collimator Couch CW

340

200

10

0

0

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 6. Set Structure Optimization Properties Some clinics override the PTV density. Follow the guidelines set by your clinic to determine if you want to force the PTV electron density (ED). For this exercise, use a relative electron density of 0.50.

Task 7. Set Calculation Properties, IMRT Parameters and Sequencing Parameters 1.

Verify in the Beams Spreadsheet that you have set the algorithm to Monte Carlo. NOTE:

For this exercise, you use Grid Spacing and Statistical Uncertainty values that reduce calculation time so you can complete the exercise during class. In your clinic, type tighter parameters for a more accurate calculation.

2.

From the Calculation ribbon in the Planning tab, select Calculation Properties .

3.

Type the Calculation Properties values that appear in the figure below.

Figure 23-24: Calculation Properties

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 7. Set Calculation Properties, IMRT Parameters and Sequencing Parameters (cont.) 4.

Type the IMRT Parameters that appear in the figure below.

Figure 23-25: IMRT Parameters

Monaco®

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT Task 7. Set Calculation Properties and Sequencing Parameters (cont.) 5.

Select the Sequencing Parameters icon values that appear in the Figure 23-26.

, then, start with the parameter

Figure 23-26: Sequencing Parameters: VMAT

Task 8. Set Initial Cost Function Constraints 1.

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Select the IMRT Constraints Tab, or access it by Workspace | Controls | IMRT Constraints.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT Task 8. Set Initial Cost Function Constraints (cont.) 2.

You can use a variety of approaches to set cost function constraints. The settings below are only one of many possible uses and combinations. Begin with the example constraints in the table below, and as you evaluate the plan, you can adjust the cost functions as needed during and after fluence optimization. Table 23-11: Example Dose Constraints Structure

Cost Function

LL_ITV**

Quadratic Overdose

LL_PTV**

Target EUD Target Penalty Quadratic Overdose

Left Lung (ipsilateral) Chest Wall Patient

Serial* Conformality Serial Quadratic Overdose

Required Parameters 64.0Gy Max Dose; 0.50 Gy RMS 60.0Gy; 0.50 Cell Sensitivity 54.0Gy; 98% Min. Vol. 60.0 Gy Max Dose; 2.0Gy RMS 16.0Gy EUD; 8.0 Exponent

Optional Physical Parameters

1.0cm Shrink Margin

0.70 Isoconstraint 25.0Gy EUD; 8.0 Exponent 25.0Gy Max Dose; .100Gy RMS

** With stereotactic planning, you want a steep dose gradient outside the target. To achieve this gradient, you have a more heterogeneous dose distribution inside the target volume, with hot spots of 120 – 130%. Carefully evaluate the hot spot location within the target, and make sure it is in the center of the target and not close to its periphery. *In this example, although the lung is considered parallel tissue, we use the serial cost function because we deliver a high dose to a small target and a small volume of overall lung tissue. As an optional exercise, you can use parallel cost function for the lung.

Monaco®

3.

At this point, select Save Template As to keep this template in case you make changes during and after optimization, and want to return to it.

4.

After you complete Cost Function & Dose Constraint entry, go to the calculation phase of planning.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 9. Calculate Fluence – Optimization Phase 1 1.

To start the fluence stage of dose optimization, select the Optimize icon from the Calculation ribbon in the Planning Control.

2.

Begin with loose parameters, then tighten isoconstraints during optimization.

3.

Once stage 1 is complete, evaluate the plan’s fluence.

Task 10. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate Several models exist in the literature to determine the values associated with target dose conformity, gradient and heterogeneity. For this exercise, use the model your clinic has adapted in its procedures to evaluate the plan quality, or use several parameters from RTOG 0915 and 0236. 1.

Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze the measures that determine dose quality relative to the target and organ at risk sparing. We use example criteria below to evaluate plan quality that includes: •

•

•

•

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Dose Heterogeneity within Target - As an example, monitor the location of the hot spot – keep in center of PTV and away from OARs, Maintain hot spot of about 125%. Dose Conformity to Target (High Dose Spillage) - As an example, any dose > 105% of prescription dose (56.7 Gy in this exercise) should occur primarily within the PTV itself and not within the normal tissues outside the PTV. Dose Gradient outside of Target (Low Dose Spillage) - As an example, the maximum dose 2cm from PTV cannot be greater than 50% of the prescribed dose (27 Gy). Use Monaco auto margin tools and Isodose to Structure tool to assist in evaluation. Target Dose Prescription (one example) - As in our example, 95% of PTV is covered by 99% of the prescription dose of 54 Gy.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT Task 10. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate (cont.) •

Organ at Risk Sparing, for example: - Use the table below as an example of SBRT threshold values when you evaluate how well your plan met normal tissue dose/volume constraints. Table 23-12: Example of Normal Tissue Dose/Volume Tolerances Structure Rib Chest Wall 2cm *Total Lung ITV Heart Spinal Cord Esophagus

Maximum Dose (Gy) 30Gy 30Gy 12Gy

Volume < 30 cc ≤ 70cc 1000cc

24 Gy 12.3 Gy 17 Gy

< 15cc < 1.2 cc < 5cc

Select Structure Combination from the options menu in the DVH to create Total Lung. 2.

3.

Monaco®

As you evaluate the plan and see it is not meeting your goals, among strategies to improve the plan are: •

adjust cost functions

•

renormalize or rescale the dose prescription

•

apply a Shrink Margin on normal structures adjacent to the PTV

•

refer to the Isoeffect values and adjust the Isoconstraints if needed

Re-optimize the Fluence calculation, re-evaluate, and continue on to Stage 2 optimization of Segment calculation.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 2. SBRT Lung with VMAT (cont.) Task 11. Calculate Segments – Optimization Phase 2 1.

Select the Optimize 2 icon from the Calculation ribbon to start.

2.

If you notice that target conformality degrades between stage 1 and stage 2 calculation, you may try to increase the number of Control Points.

Task 12. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize Phase 2, Re-evaluate 1.

2.

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As in plan evaluation after Fluence Optimization, use the Isodose Tools, DVH Statistics & Display, and your clinic’s procedures to analyze the plan for quality of: •

MLC Segments

•

MU Summary

•

Dose Conformity around the Target

•

Dose Gradient outside Target

•

Dose Heterogeneity inside the Target – Pay close attention to location and value of hot spot

•

Target Dose Prescription Constraints

Once the plan is acceptable, continue to plan approval and export.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Disclaimer:

This Practice Exercise uses example values from legitimate, authoritative third parties for training purposes only. In no way is Elekta providing medical direction or advice. Table 23-13: Overview of Tasks for SBRT Lung with DCA Exercise Task # 1 2 3 4 5 6 7 8 9 10 11 12

Task Pre-Exercise Work & Select Patient Add planning structures Start a New Monaco Plan, Import Template, Set Isocenter Enter Dose Prescription Set Beam Geometry Set Structure Optimization Parameters Set Calculation Properties and Sequencing Parameters Set Cost Functions and Dose Constraints Calculate Fluence – Optimization Phase 1 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Reevaluate Calculate Segments – Optimization Phase 2 Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize Phase 2, Re-evaluate

References The references listed at the end of the Stereotactic Planning Section of the training guide were used for the Tasks in this exercise.

Tasks 1 and 2. Pre-Exercise Work, Select Patient, Add Planning Structures Continue to Task 3 since the steps in Tasks 1 and 2 are identical to the previous SBRT Lung VMAT exercise.

Monaco®

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Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA (cont.) Task 3. Start a New Monaco Plan, Import Template, Set Isocenter 1.

Click the Planning tab and select New Monaco Plan from the New Plan menu.

2.

Create a New Plan Name and Description.

3.

Verify the Scan Orientation and the Treatment Orientation.

4.

In the New Monaco Plan window, type a Name and Description.

5.

Select Dynamic Conformal Arc (DCA) delivery type. The default Dynamic Conformal Arc template in Monaco has four (4) beams arcs. In this exercise, you modify the number of beams later on the Beam spreadsheet in the Planning activity.

6.

Refer to the figure below and select the listed beam information and isocenter.

Figure 23-26: New Monaco Plan

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Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 3. Start a New Monaco Plan, Import Template, Set Isocenter (cont.) *Optional: As an alternative to the Isocenter Location that appears in the figure above, continue the exercise with the Isocenter Location set to the center of the Patient, or, create an Isocenter Location that you use in your clinic for ease of patient setup. 7.

Use an Agility treatment unit. NOTE:

8.

If your clinic uses standard beam information, set your standard parameters and save as a New Monaco Plan template for future use. NOTE:

Monaco®

If you select the Apex unit, later in this exercise, We advise you not to use Segment Shaped Optimization. See the note in the Sequencing Parameters task.

See the Template section in the guide for more information to save templates.

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA (cont.) Task 4. Enter Dose Prescription 1.

In the Prescription tab, type the values in the table below for the Physician’s Intent. Table 23-14: Example entry for Physician’s Intent Information Type Prescribe To Rx Dose (Gy) Number of Fractions Fractional Dose (Gy)

2.

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Value Center of LL_PTV 54.00 3 18.00

Use the Dose Prescription criteria from the previous Lung SBRT (VMAT) practice exercise.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA (cont.) Task 5. Determine Arc Beam Number and Geometry 1.

Use the visualization tools to evaluate the appropriate beam geometry. Keep in mind, the MLC leaves appear after the optimization completes.

2.

Set a Gantry angle and Arc length to best avoid organs at risk. Table 23-15: Example Beam Geometry Values Beam

Direction

1: Left Arc

CW

Gantry Start 340

Arc

Inc

Collimator

Couch

200

10

0

0

Task 6. Set Structure Optimization Properties Some clinics override the PTV density. Follow the guidelines set by your clinic to determine if you want to force the PTV electron density. For this exercise, use a relative electron density of 0.50.

Task 7. Set Calculation Properties and Sequencing Parameters 1.

Verify in the Beams Spreadsheet that you have set the algorithm to Monte Carlo. NOTE:

For this exercise, you use Grid Spacing and Statistical Uncertainty values that reduce calculation time so you can complete the exercise in the training class. In your clinic, type tighter parameters for a more accurate calculation.

2.

From the Calculation ribbon in the Planning tab, select Calculation Properties .

Monaco®

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Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 7. Set Calculation Properties and Sequencing Parameters (cont.) 3.

Type the values for Calculation Properties that appear in the table below.

Figure 23-27: Calculation Properties

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Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 7. Set Calculation Properties and Sequencing Parameters (cont.) 4.

Type the IMRT Parameters that appear in the figure below.

Figure 23-28: IMRT Parameters 5.

Segment Shaped Optimization (SSO) is available with DCA.

Figure 23-29: Sequencing Parameters: Dyn. Conformal Arc with and without Segment Shape Optimization turned on

Monaco®

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Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 7. Set Calculation Properties and Sequencing Parameters (cont.) 6.

Optional: You can go through this exercise twice. Run the first plan with SSO unchecked and save the plan. Then, run the second plan with SSO checked. If you check SSO, we recommend you check Pilot Beamlets. *Keep in mind, the calculation with SSO checked takes more time. NOTE:

When you use an Apex treatment unit, if you check SSO for a Dynamic Conformal Arc delivery plan, the resulting plan may be undeliverable because the minimum dose rate is violated.

Task 8. Set Initial Cost Function Constraints 1.

Select the IMRT Constraints Tab, or access it by Workspace | Controls | IMRT Constraints.

2.

Begin with the dose constraints in the table below. Then, while you evaluate the plan, you can adjust the cost functions as needed during and after fluence optimization. Table 23-16: Example Dose Constraint Values Structure LL_PTV

Patient

Cost Function Target Penalty Quadratic Overdose Target Penalty Conformality

Required Parameters

Optional Physical Parameters

54 Gy; 98% 66 Gy; 2 Gy RMS Dose Excess 60 Gy; 95% 0.70 Isoconstraint

** With stereotactic planning, you want a steep dose gradient outside the target. To achieve this gradient, you have a more heterogeneous dose distribution inside the target volume. Carefully evaluate the hot spot location within the target, and ensure it is in the center of the target and not close to its periphery.

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3.

At this point select Save Template As to keep this template in case you make changes during and after optimization, and want to return to it.

4.

After you complete Cost Function & Dose Constraint entry, go to the calculation phase of planning.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA (cont.) Task 9. Calculate Full Fluence Modulation – Optimization 1.

To start the fluence stage of dose optimization, select the Optimize icon from the Calculation ribbon in the Planning Control.

2.

Once stage 1 completes, evaluate the plan’s fluence.

Task 10. Evaluate Plan, Adjust Cost Functions, Re-evaluate Several models exist in the literature to determine the values associated with target dose conformity, gradient, and heterogeneity. For this practice exercise, use the model your clinic has adapted in its procedures to evaluate the plan quality, or use the examples below. 1.

Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze plan quality measures relative to the target and organ at risk sparing. Use the example criteria for the qualities listed below: •

Dose Heterogeneity within Target -

•

Dose Conformity to Target (High Dose Spillage) -

•

As an example, the maximum dose 2 cm from PTV cannot be greater than 50% of the prescribed dose (27 Gy). Use Monaco auto margin tools and Isodose to Structure tool to assist in evaluation.

Target Dose Prescription (one example) -

Monaco®

As an example, any dose >105% of the prescription dose (56.7 Gy in this exercise) should occur primarily within the PTV itself and not within the normal tissues outside the PTV.

Dose Gradient outside of Target -

•

As an example, monitor location of hot spot –keep in the center of PTV and away from OARs, maintain hot spot of about 125%.

As in our example, 95% of PTV is covered by 99% of prescription dose of 54 Gy

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Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 10. Evaluate Plan, Adjust Cost Functions, Re-evaluate (cont.) •

Organ at Risk Sparing -

Use the table below as an example of SBRT threshold values when you evaluate how well your plan met the critical structure dose/volume constraints.

Table 23-17: Example of Normal Tissue Dose/Volume Tolerances e Structure Rib Chest Wall 2cm *Total Lung ITV Heart Spinal Cord Esophagus

Maximum Dose (Gy) 30Gy 30Gy 12Gy

< 30 cc ≤ 70cc 1000cc

24 Gy 12.3 Gy 17 Gy

< 15cc < 1.2 cc < 5cc

Volume

*Select Structure Combination from the options menu in the DVH to create Total Lung. 2.

3.

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As you evaluate the plan and see it is not meeting your goals, among strategies to improve the plan are: •

adjust cost functions

•

renormalize or rescale the dose prescription

•

apply a Shrink Margin on normal structures adjacent to the PTV

•

refer to the Isoeffect values and adjust the Isoconstraints if needed

Re-optimize the Fluence calculation, re-evaluate, then continue to Stage 2 optimization of Segment calculation.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 3. SBRT Lung with DCA Task 11. Final Calculation 1.

The final calculation automatically occurs. a) If you have SSO unchecked, notice a message at the bottom of the screen that indicates the Final dose calculation is complete. b) If you have SSO checked, notice a message at the bottom of the screen that indicates the segments are calculating for the second phase of optimization.

Task 12. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize Phase 2, Re-evaluate 1.

Monaco®

As in plan evaluation after Fluence Optimization, use the Isodose Tools, DVH Statistics & Display and your clinic’s procedures to analyze the plan for quality of: •

MLC Segments

•

MU Summary

•

Dose Conformity around the Target

•

Dose Gradient outside Target

•

Dose Heterogeneity inside the Target – Pay close attention to location and value of hot spot

•

Target Dose Prescription Constraints

2.

Once the plan is acceptable, continue on to plan approval and export.

3.

Optional Task: Repeat this Exercise, but use the Flattening Filter Free 6X Modality (6.0 FFF)

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT Disclaimer:

This Practice Exercise uses example values from legitimate, authoritative third parties for training purposes only. In no way is Elekta providing medical direction or advice. Table 23-18: Overview of Tasks for Stereotactic Spine Exercise Task # 1 2 3 4 5 6 7 8 9 10 11

Task Pre-Exercise Work & Select Patient Add planning structures Start a New Monaco Plan, Import Template, Set Isocenter Enter Dose Prescription Set Beam Geometry Set Calculation Properties and Sequencing Parameters Set Cost Functions and Dose Constraints Calculate Fluence – Optimization Phase 1 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Reevaluate Calculate Segments – Optimization Phase 2 Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Reoptimize Phase 2, Re-evaluate

References The references listed at the end of the Stereotactic Planning Section of the training guide were used for the Tasks in this exercise.

Task 1. Pre-Exercise Work and Select Patient In preparation of this exercise, delineate several additional organs at risk if you want to look at dose to these structures.

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1.

Open the Patient in Monaco and select the SpineSingleTRN patient from the Training Clinic.

2.

Open Structure Set: SS_CT_Clean2.

3.

Optional: delineate these structures: stomach, liver, right kidney, and left kidney in the Contouring tab.

4.

Continue to the Contouring tab.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT (cont.) Task 2. Add Planning Structures 1.

Create a structure called Spinal Cord + 1.0 mm to serve as a planning organ at risk volume (PRV)

2.

Optional: Create PTV + 1cm. Use this structure to identify hot spots outside the PTV.

3.

Save your changes.

Task 3. Start a New Monaco Plan, Import Template, Set Isocenter 1.

Click the Planning tab and select New Monaco Plan from the New Plan menu.

2.

Create a New Plan Name and Description.

3.

Verify the Scan Orientation and the Treatment Orientation.

4.

Select the training template and type the values that appear in the table below for the respective plan information: Table 23-19: Values for New Plan Information Plan Information Delivery Type Template to Import Treatment Unit Algorithm Energy Isocenter Location* Port Options

Monaco®

Value VMAT Template: VMATTraining TRNElekAgility Monte Carlo 6.0 FFF Center of PTV Import Beams Only

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT Task 3. Start a New Monaco Plan, Import Template, Set Isocenter (cont.) 5.

If your clinic uses standard beam information, set your clinic’s parameters and save as a New Monaco Plan template for future use. NOTE:

See the Template section in guide for more information on saving templates.

Task 4. Enter Target Dose Prescription The literature shows several dose/fractionation schemes when you treat Spine Metastases with stereotactic body radiotherapy. However, common PTV coverage is D90, where 90% of the PTV is covered by the prescription dose. In this exercise, you use 16 Gy in one fraction. 1.

Select the Prescription tab, and type the values in the table below for the Physician’s Intent. Table 23-20: Example of Physician’s Intent Information Type Prescribe To Rx Dose (Gy) Number of Fractions Fractional Dose (Gy)

2.

Value Center of PTV 16.00 1 16.00

In this exercise, you use the prescription and planning criteria. •

PTV coverage - Prescription isodose line is usually the 80% - 90% line - At least 90% of PTV must receive prescription dose

•

High dose spillage (conformity) - Dose outside of the target is limited to 105% to an area ≤ 2cc - Dose ≥ 105% of prescription dose must be within a 1cm region from the PTV edge

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT (cont.) Task 5. Set Beam Geometry 1.

Set the arc beam geometry values that appear in the table below. Table 23-21: Example values for beam geometry Beam 1: Spine

Direction Arc Rotation CW

Gantry Start 360

Arc

Inc

Collimator

Couch

360

30

90

0

Task 6. Set Calculation Properties, IMRT Parameters and Sequencing Parameters 1.

Verify in the Beams Spreadsheet that you have set the algorithm to Monte Carlo. NOTE:

For this exercise, you use Grid Spacing and Statistical Uncertainty values that reduce calculation time so you can complete the exercise during class. In your clinic, type tighter parameters for a more accurate calculation.

2.

From the Calculation ribbon in the Planning tab, select Calculation Properties .

Monaco®

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT Task 6. Set Calculation Properties, IMRT Parameters and Sequencing Parameters (cont.) 3.

For this exercise, type the Calculation Properties values that appear in Figure 23-29 below. Use 0.30 cm Grid Spacing.

Figure 23-29: Calculation Properties

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT Task 6. Set Calculation Properties, IMRT Prescripton Parameters and Sequencing Parameters (cont.) 4.

Type the IMRT Prescription Parameters that appear in the figure below.

Figure 23-30: IMRT Prescription Parameters . Then, set the parameters with

5.

Next, select the Sequencing Parameters icon the values that appear in the Figure 23-31.

6.

Start with 150 Control Points per Arc and increase this value, especially if during plan evaluation, you notice a conformality degrade between stage 1 and stage 2 optimization.

Figure 23-31: Sequencing Parameters: VMAT

Monaco®

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT (cont.) Task 7. Set Initial Cost Function Constraints 1.

Select the IMRT Constraints Tab, or access it by Workspace | Controls | IMRT Constraints.

2.

You can use a variety of approaches to set cost function constraints. The settings below are only one of many possible uses and combinations. Begin with the example constraints in the table below, and as you evaluate the plan, you can adjust the cost functions as needed during and after fluence optimization. After you evaluate the plan, determine if you want to add a constraint on the esophagus.

Table 23-22: Example Values for Dose Constraints Structure

Cost Function Target EUD

PTV

Spinal Cord + 1mm Patient

Quadratic Overdose Target Penalty Serial Conformality

Required Parameters 18 Gy; 0.50 Cell Sensitivity 17 Gy; 0.5 Gy RMS Dose Excess 16 Gy; 90% Exponent: 12.0 EUD: 9.0 Gy 0.70 Isoconstraint

Optional Physical Parameters

Multicriterial; Optimize over all voxels Multicriterial

** With stereotactic planning, you want a steep dose gradient outside the target. To achieve this gradient, you have a more heterogeneous dose distribution inside the target volume, with hot spots of 120 – 130%. Carefully evaluate the hot spot location within the target, and make sure it is in the center of the target and not close to its periphery.

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3.

At this point, select Save Template As to keep this template in case you make changes during and after optimization, and want to return to it.

4.

After you complete Cost Function & Dose Constraint entry, go to the calculation phase of planning.

Stereotactic Planning with Monaco Volume II of IV Monaco Training Guide

Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT (cont.) Task 8. Calculate Fluence – Optimization Phase 1 1.

To start the fluence stage of dose optimization, select the Optimize icon from the Calculation ribbon in the Planning tab.

2.

Begin with loose parameters. Then, tighten isoconstraints during optimization.

3.

Once stage 1 completes, evaluate the plan’s fluence.

Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Reevaluate 1.

You can use a variety of methods to evaluate, and strategies to re-optimize your plan. Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze the measures to determine dose quality relative to the target and organ at risk sparing. Use the example criteria below to evaluate your plan quality.

2.

These qualities include: •

Dose Conformity to Target and Gradient outside the Target - Several models exist in the literature to determine the values associated with target dose conformity, gradient, and heterogeneity. - For this exercise, use the model your clinic has adapted in its procedures to evaluate the plan quality. Or, use the example RTOG criteria discussed in the prescription task.

Monaco®

•

Dose Heterogeneity within Target

•

Organ at Risk Sparing

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Stereotactic Planning with Monaco Practice Exercise 4. SBRT Spine with VMAT Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Reevaluate (cont.) Use the table below as a guide when you evaluate how well your plan met the normal tissue dose/volume constraints. Table 23-23: Example of Normal Tissue Dose/Volume Tolerances Structure Spinal Cord Spinal Cord Heart Heart Total Lung - ITV Esophagus Esophagus NOTE:

3.

4.

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Volume ≤ 0.35 cc ≤ 0.03 cc Physics | Treatment Unit Store.

Select File > Select File to open a browse window.

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Adding Treatment Units (cont.)

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4.

Browse to the media that contains your treatment unit data.

5.

Select the XML files, and click Open. The treatment units will appear in the left column of the application.

6.

Click on a machine and drag it into the right column. To store a wedge or applicator, drag it from the left column to below the treatment unit in the right column.

7.

Type the User name and Password in the confirmation window. Contact Elekta Global Support for the User name and Password.

8.

Click Yes to confirm you want to transfer the machine data. Once the machine data is transferred, you can start Monaco.

Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units (cont.) Treatment Unit Mapping Navigate to the Treatment Units option on the Settings dialog box to make or edit treatment units. The Treatment Unit Mapping dialog box (Figure C-13) is only available to users with Physics Group permissions. The units are only available to the local clinic. A treatment unit lets you group Monaco machines associated with a specific linear accelerator together. For example, you can assign all the electron and photon energies for a linear accelerator to the same Treatment Unit. You cannot have multiple machines with the same energy and calculation algorithm assigned to the same Treatment Unit. For example, for the same physical linear accelerator, if you have a 3D machine and a machine specifically for extended SSD treatments with the same energy and calculation algorithm, you cannot assign them to the same Treatment Unit.

Figure C-13: Treatment Unit Mapping dialog box To open the dialog box select the Monaco Application Settings

Monaco®

button followed by the

button.

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) This dialog box is not available while a patient is open or more than one session of Monaco is open. In the spreadsheet, the treatment unit fields show options in alphabetic sequence. For fields that have one option, the spreadsheet populates the information. If a change is made to the beam model and the related fields no longer map to a valid logical machine, the cells turn red until conflicts are resolved. You are not able to plan with Treatment Units which have beams with conflicting fields. Table C-1: Treatment Unit Mapping dialog box field descriptions Name Installation Clinic Treatment Unit

TU Characteristics

Description Select an installation location from the dropdown list. Select your clinic from the drop-down list. Select a name from the treatment unit list or type a name with a maximum of 16 characters. Click the button to bring up the Treatment Unit Characterization Configuration dialog box. You can only edit Treatment Units with an Approval Status of Testing. Otherwise, you can review the TU Characteristics. Select the status of the plan approval. The options are available once the treatment unit orientation is set: • Testing – This is the default status for new

Approval Status

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treatment units. Treatment units with this status are available for users that have Physics permissions. This is the only state where you can change treatment unit orientation fields. Warnings show on this screen and on reports when treatment units are not approved for clinical use.

Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) Name

Description • Clinical – Treatment units with this status

are available to all users.

• Archived – Archive the treatment unit if

it is no longer necessary. The system keeps the mapping and other information for the unit. Treatment units with this status are not available when you select a treatment unit for a new plan or change a current plan. This status is only for use with a bias dose. It is not available for new plans. You can map a machine which is part of an Archived Treatment Unit to a new Treatment Unit. These functions are disabled when the active selection is Archived: - Dose Calculation or Dose

Optimization

- DICOM export - Change the treatment unit mapping

Show Unselected

Monaco®

Warning messages show on single plane views and reports when the plan is not approved for clinical use. Mark this check box to list all of the source options. It turns on/off machines that are not marked.

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) Name

Description Mark this check box to show the plans that are inconsistent. When a logical machine is active, other logical machines that are inconsistent with the selected machine parameters are disabled. This machine shows a warning icon with the inconsistencies shown in the tooltip. You can print a warning list that records the inconsistencies. You cannot open an inconsistent plan until you resolve the inconsistency.

Show Inconsistent

Select to show machines that are inconsistent with the current machine. Monaco compares these criteria to find a match: • • •

• • •

MLC Model MLC Leaf Number MLC Leaf Width – this has a 0.1mm tolerance, if the first and last leaf pairs are different MLC Direction MLC Position – this has a 1mm tolerance SAD – this has a 1mm tolerance

A warning message shows in the spreadsheet to show the type of inconsistency.

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) Name

Description You must click Save to save your changes and when you define a new Treatment Unit. This button is active before you save a new or edited treatment unit. Once saved, a treatment unit is available based on approval status. This button is disabled if there are no changes to the mapping of if the machine orientations are not defined.

Save

A warning message appears when you click the Save button to confirm edits made to an existing treatment unit mapping. A message appears if changes to these fields are made when completing a new mapping: • • • • •

OK Installation Clinic Treatment Unit Change tabs in the Settings dialog box

This field shows a warning message icon when necessary. A warning icon appears: as a tooltip when you hover over an inconsistency (triangle shaped) warning icon • as a printable warning that states inconsistencies when the round icon is clicked. Select a machine for treatment unit mapping. You cannot select machines with a warning icon. The machine information comes from the Focal machine files or an Oncentra database. •

Warnings

Check boxes

Monaco®

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) Name Source

Machine ID

Shows the ID of the treatment machine. Click the column head to sort the machines in alphabetic sequence. Click again to reverse the order.

Modality

Shows the type of treatment machine. Click the column head to sort the modality in alphabetic sequence. If you click the column heading once again, the sort reverses its sequence.

Energy

Algorithm

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Description Shows the source of the treatment machine data. Click the column head to sort the source in alphabetic sequence. Click again to reverse the order.

Shows the energy for the treatment machine. Click the column header to sort the energy in alphabetic sequence. Click again to reverse the order. Shows the algorithm the machine uses. Click the column head to sort the algorithm in alphabetic sequence. Click again to reverse the order.

Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) The Treatment Unit Characterization Configuration dialog box (Figure C-14) is available for Treatment Units with a TU Approval Status of Testing. For each machine assigned to the Treatment Unit you can change the default geometric settings. 1.

button. Monaco opens the Treatment Click the Define/View Unit Characterization Configuration dialog box.

2.

You can edit the values for each machine which are mapped to the selected Treatment Unit. The new values you enter are used in planning.

Figure C-14: Treatment Unit Characterization Configuration dialog box

Monaco®

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Appendix C Volume IV of IV Monaco Training Guide

Settings Treatment Units Treatment Unit Mapping (cont.) 3.

Select the Customize Labels button to enter labels for the X and Y jaws. Monaco shows the Collimator Jaw Labels dialog box (Figure C-15).

4.

If the Treatment Unit is in Testing state, you can enter labels for symmetric jaws, asymmetric jaws and the MLC leaf banks.

5.

Click OK to save your changes. Monaco shows the labels when you use this machine in a treatment plan.

6.

Click Save on the Settings dialog box to save the Treatment Unit.

Figure C-15: Collimator Jaw Labels dialog box

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Appendix D Volume IV of IV Monaco Training Guide

MLC Geometry Definitions General Information You must understand the nomenclature used in Monaco when you update the MLC Geometry Parameters. The diagrams in this section illustrate the MLC Geometry Parameters. The positions of all elements are given relative to their axis of motion, with the direction (x,y) being implicit. Units are mm for all parameters.Positions of paired elements are given on the same scale and with the same orientation (that is, in this example, Right Parallel Jaw has a positive position, while Left Parallel Jaw has a negative one). Hence, openings between paired elements are (Left-Right) and (UpperLower) respectively. You see the MLC assembly from the source, that is, in the direction of the beam.

Monaco®

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Appendix D Volume IV of IV Monaco Training Guide

MLC Geometry Definitions General Information (cont.) Below is the direction of movement for the parallel jaws:

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Appendix D Volume IV of IV Monaco Training Guide

MLC Geometry Definitions General Information (cont.) Below is the direction of movement for the transverse jaws:

Monaco®

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Appendix D Volume IV of IV Monaco Training Guide

MLC Geometry Definitions General Information (cont.) Below is the MLC Leaf Constraint Definitions:

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Appendix E Volume IV of IV Monaco Training Guide

DICOM Import Utility Scenarios The three import scenarios below are outlined in this appendix section. Select one or multiple image series from multiple modalities that may or may not include structure set, plan, and dose data, then import them. Import image data that you would like to fuse and use image fusion. Merge multiple image series from the same studyset into one studyset for import.

Import One or Multiple Series for the Selected DICOM Patient Use this scenario when you want to import any of these items: • DICOM CT images •

DICOM PET images

•

DICOM MRI images

•

DICOM 4D Images

•

Images for the same patient from multiple modalities (example, CT and MRI)

•

RT Structure Sets

•

RT Plans

•

RT Dose

In the window where you choose the patient, you can make any of these selections: • •

•

•

•

Monaco®

Select the Image data for one modality. Left-click on the modality (CT, PET, or MRI) under the selected patient name. Select the Structure Set data for one image set. Left-click on the RTSS file. Since the structure set is linked to an image set, the system automatically selects the referenced images. Select the RT Plan data for one image set. Left-click on the RTPLAN file. Since the plan is linked to a structure and image set, the system automatically selects the referenced structure set and images. Select the RT Dose data for one image set. Left-click on the RT Dose file. Since the dose is linked to a plan, a structure set and image set, the referenced plan, structure set and images are automatically selected. Select Multiple Image Sets, Plan sets, or Dose Data Sets. Left-click on the first set of data to select it. Hold down the control button [Ctrl] on your computer keyboard and select the second, third, etc.

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Appendix E Volume IV of IV Monaco Training Guide

DICOM Import Utility Scenarios Selecting Image Sets that have Different Patient IDs for Fusion Use this scenario to import images under the same patient ID so you can fuse them. •

Select and import the first image set for one modality. Left-click on the modality (CT, PET or MRI) under the selected patient name.

•

Select and import the second image set and change the Patient ID to the same name you used to import the primary image dataset.

The two image sets now reside under the same patient ID. You can fuse them in Image Fusion.

Merge and Import Multiple Image Series for the Selected DICOM Patient Use this scenario if you have a patient with multiple scan series. Use the same Study ID and frame of reference that you want to merge for planning purposes. Select multiple series for the same modality. Hold down the control [Ctrl] button on the keyboard and left-click multiple series. Click the Merge button. This action populates the destination column with the selected source data and merges them into one complete series.

Enter or Edit DICOM Settings These settings apply to data that you want to export to any application that receives DICOM. They do not apply when you send data to XiO. Use the DICOM Export button on the Output tab of the ribbon to do the actual export. An explanation of the export appears in detail after this section.

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DICOM Export Utility Setup your DICOM File Export Data Location Type the location where you would like to store DICOM Export data when you choose to export to a file. 1.

To type or edit the DICOM Export Settings, click on the Monaco Application button then the Setup| DICOM Settings to show the DICOM Menu Settings dialog box (Figure E-1).

Figure E-1: DICOM Settings dialog box

Monaco®

2.

The default location for the DICOM File Export data automatically appears. However, you can click the Browse button to set a new data location, if desired.

3.

The SCU Name is the name of the Monaco PC where you enter these settings. A default name is also given. However, you can edit it. The receiving application must have this name assigned in its DICOM Import program in order to receive the exported data.

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DICOM Export Utility (cont.) Setup Storage of Incoming Images for Future Export If you plan to export image data that was previously transferred into Monaco, you must have the Store Incoming DICOM Images box checked before you import the images. This makes a copy of the image data that you use when you export. Should you not want to export image data, do not put a checkmark  in this box. This will prevent your hard drive from filling with unnecessary image data. Setup DICOM Export Locations Type the location(s) where you would like to send DICOM Export data when you choose to export to an SCP location.

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1.

Type the Label for the location. This is the location label you select from the DICOM Export dialog box when you export to an SCP location.

2.

Type the AE Title for the receiving system.

3.

Type the resolvable hostname or a valid IP address for the receiving system.

4.

Type the Port Number you want to use for this DICOM transfer.

5.

Once you type in all the information for an export location, highlight the export location you want to test, and then click the Test button to verify communication between the two systems.

6.

If the test was successful, click OK when you are done entering or editing these settings.

7.

Add or Delete Export locations. Highlight the location you want to remove and click the Add or Delete button.

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DICOM Export Utility (cont.) Exporting via DICOM You can export these modalities via DICOM to a record and verify system or another treatment planning computer: • • • • • •

Images Specialty Images Structure Sets and/or individual structures RT Plans RT Images (DRR’s) Monaco dose - total and/or individual beam doses for single prescription, multiple prescription, and MR plans Monaco QA dose - total dose and/or individual beam doses DVH

• •

In Planning, click the DICOM Export button on the Output tab. NOTE:

If the Export option is not available, verify these two items: (1) You have a patient loaded. (2) You have turned on the proper DICOM license features.

Complete these steps to export data via DICOM: 1.

Click on the DICOM Export button on the Output tab to show the DICOM Export dialog box (Figure E-2).

Figure E-2: DICOM Export dialog box

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DICOM Export Utility Exporting via DICOM (cont.) 2.

Select the modalities you want to export. NOTES:

(1) Images and Structure Set options are only available if you checked the Store Incoming DICOM Images checkbox located in DICOM Settings. (2) The RT Plan option is only available if you have a plan loaded. (3) Dose options are only available if you have RT Plan selected. (4) You cannot DICOM export composite plans.

3.

(For Elekta non-micro MLC: Step and Shoot IMRT, VMAT, Conformal RT, and dMLC plans. Siemens: Step and Shoot IMRT and Conformal RT Plans only) When you check the RT Plan option, you can also check Composite Field Sequencing to group beams with a common couch angle into a single control point sequence. (For detailed information about composite field sequencing, refer to the Online Help).

4.

When you check the Include Setup Beams option, the system exports the setup beams created in the beam spreadsheet. The SetupBeams/Sequences are DICOM exported as SETUP with the RT plan.

5.

When you click on the Addt’l Options button, the Additional Plan Export Options dialog box shows a table of options you can DICOM export. You use these options to match the information defined in your record & verify system.

Figure E-3: Additional Plan Export Options dialog box 6.

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If you have RT images associated with your plan, you can select to export all the images, or select individual beam images. The RT images are exported with a fine resolution. Under RT Image Options, you can check the respective boxes to Add Overlays, Add Anatomy, and Add Annotation.

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DICOM Export Utility Exporting via DICOM (cont.) 7.

When you check Total Dose, the system exports the total composite dose for all the beams.

8.

When you check individual beams under total dose, the system exports individual beam doses.

9.

When you select RT Plan as a modality to export, the system activates the Map Machine feature. Click Map Machine to show the modeled machine names.

10.

Next to each modeled machine name, type a name that the receiving system recognizes.

11.

Select the Destination to where you want to export, such as the record and verify system. If you select File, the file is saved on your Monaco PC in a folder called DCMXprtFile.

12.

To export a plan and use an add-on micro-multileaf MLC, you have additional export options to select.

Figure E-4: RT Plan Options

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13.

To send the data to the Add-on TCS controller, select the SCP location in the Add-on TCS field. This information includes the complete plan that contains actual leaf and jaw positions.

14.

Select the special Accessory Tag for the Built-in MLC in the OIS Accessory field.

15.

You can edit the Patient ID, Patient Name, Block/Aperture ID, and Plan ID before you export it. Check the box next to Use Monaco Patient ID and Patient Name, if desired.

16.

Click the Export button to export the selected modalities.

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Patient Information Management General Functionality The topics reviewed in this section introduce additional information necessary when Monaco is used with XiO. You can import and evaluate calculated plans from XiO or other vendors in Monaco Plan Review.

Configuration of the Monaco and XiO Interface You must set up a data location and server so that XiO and Monaco can share data. See the Monaco Installation Guide for more information on Monaco preferences. When you use Monaco with XiO, you must use usernames and passwords for the systems to communicate. Valid usernames and passwords in XiO are valid on Monaco.

Send and Unget Overview The Send and Unget features are available for users to send patients to XiO for planning or calculation. Use Send to transfer the patient with all the contours and/or plan information. Use Unget to send the patient to XiO with none of the contours or plan information saved.

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Patient Information Management Send a Patient to XiO This section shows you how to send patients back to XiO with all the saved changes. 1.

Click Monaco Application button | Send Patient to show the Send dialog box.

Figure F-1: Send dialog box 2.

Check the box next to the patient you want to send to XiO.

3.

If you want to copy the patient data to the recycle bin when you send it to XiO, instead of it being removed completely from the PC, check the box next to the Copy Patient to Recycling Bin. It is important that you use this option to prevent lost of patient data. But, you need to empty your recycle bin periodically.

4.

Click the Send button to send the patient data to the clinic identified during the initial transfer of image data.

5.

In XiO, you can open the patient data file and select Permanent Plan to retrieve the saved plan. NOTE:

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XiO ignores all boli you add to the patient in Monaco.

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Patient Information Management Unget a Patient to XiO This section shows you how to send patients back to XiO without saving any changes made in Monaco. This option completely removes any changes made in Monaco. 1.

Click Monaco Application button | Unget Patient to show the Unget dialog box.

Figure F-2: Unget dialog box

Monaco®

2.

Check the box next to the patient you want to push back with no changes to XiO.

3.

If you want to copy the patient data to the recycle bin when you send it to XiO, instead of it being removed completely from the PC, check the box next to the Copy Patient to Recycling Bin. It is important that you use this option to prevent loss of patient data. However, you need to empty your recycle bin periodically.

4.

Click the Unget button to show a warning that all changes will be lost when you send this patient back to XiO.

5.

Click the Yes button to acknowledge the warning to send the patient data to the clinic identified during the initial transfer of image data.

6.

In XiO, you can open the patient data file and restore the patient with no changes.

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Patient Information Management Handling XiO Patients Opening a Remote XiO Patient in Monaco There are two ways to open a patient in Monaco that resides on XiO. You can push the data from XiO or while on Monaco, pull the data from XiO (described in the General Operation and Navigation section). Open Pushed data from XiO On XiO, there is an option on the main screen to Transfer data to Focal PC. Once you select and send the data from XiO, a blue folder under the Local Patient tab designates patients that have been pushed from XiO and are waiting to be opened in Monaco. While this patient is in use on Monaco, the patient is inaccessible in XiO until it is sent back.

Select a Batch of Patients to Import from XiO These instructions demonstrate how to select a batch of patients from XiO to bring into Monaco for planning or review. This function only applies to those using Monaco with XiO.

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1.

Click the Monaco Application button | Batch Get to open the Batch Get dialog box.

2.

Select the Installation and Clinic from the location where you would like to get these patients.

3.

Select as many patients from the list as you need by clicking on them to highlight them.

4.

(Optional) To de-select a patient name, click on it again to remove the highlight.

5.

(Optional) Place a checkmark in the Sort the Patients by Name box. When left unchecked, the system sorts the patients by patient ID.

6.

Click OK when you are done to download the selected patients.

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Patient Information Management Anatomical Groups Structures List You can create new structure names when you type the new name in the field. The structures list automatically contains a select few default structure names. If your system is connected to XiO and you would like to take advantage of the anatomical groups created on XiO, click the Contouring tab and select the Add Anatomical Groups option to show the Select Anatomy Group dialog box (Figure F-3).

Figure F-3: Select Anatomy Group dialog box Left-click the groups you want to add. Click OK to close the dialog box. The system shows the contours associated with the selected group(s) in the structures list.

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Patient Information Management Plan Review There are a few specific tools available in Plan Review to those who plan to review XiO plans on Monaco. These tools are View images from XiO, Plan Comments and Electronic Approval. Use of View images from XiO is outlined here.

View Images from XiO If you captured images in XiO and saved them with your XiO plan, you can view them in Plan Review. For more information on how to capture bitmap images in XiO, see the XiO Training Guide. 1.

Click Plan Options tab | Image Viewer to show the dialog box with images associated with the shown plan(s).

2.

Select a plan from the Plan column to show the thumbnail images available for the selected plan.

3.

Double-click on an image to select a single thumbnail image.

4.

Select multiple images. Hold down the Shift key on the keyboard and leftclick the first and last image of the set. Then, click the Open Images button. OR Hold down the Ctrl key on the keyboard and left-click on each image to select several images. Then, click the Open Images button.

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Appendix G Volume IV of IV Monaco Training Guide

Workflow Scenario for Margin Recipe Usage Creating and Customizing the Advanced Margin Template Introduction and Background Radiotherapy uses safety margins to account for the uncertainties associated with the complete (imaging -> delineation -> planning -> set-up -> delivery) treatment process. All margins are designed using some form of statistical method. As an example, to have 100% probability that the CTV for every patient receives at least 100% of the prescription dose, the PTV margins would have to be calculated from the maximum errors across all patients that will ever occur. However, this would clearly result in many of the patients being treated with unnecessarily large fields, which relates to larger than required volumes of high dose (and consequent normal tissue toxicity) A solution where the majority of patients are treated with appropriate margins at the expense of a potential under dose to the CTV for a few patients seems a better compromise. You can formally express this as: ‘The margin required to deliver at least X% of the prescription (Rx) dose to the CTV for Y% of the population.’ As an example, deliver at least 95% of the Rx dose to the CTV for 90% of the population. Monaco uses the formula below, which describes the isotropic margin in a single dimension from the GTV to the PTV:

M PTV , X %,Y % = α Y Σ + β X σ 2 + σ p2 − β X σ p

, Where: α Y = unitless, constant α Y relates to the percentage of the population, for which you desire the margin to apply, values of α Y (see Table 2) are shown below. Σ = the standard deviations in cm of the systematic errors (errors during preparation (planning, imaging)). β X = unitless, constant β X relates to the distance between the prescription isodose line and the 50% isodose line, values for β X (see Table 1) are below.

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Workflow Scenario for Margin Recipe Usage Creating and Customizing the Advanced Margin Template Introduction and Background (cont.)

σ = the standard deviations in cm of the random errors (errors during treatment

execution).

Σ≡

i

∑Σ n =1

2

Si

is the sum in quadrature over all systematic errors.

i

σ 2 ≡ ∑ σ 2 Ri is the sum of the squares of all the random errors. n =1

σ p = the penumbra width in cm modeled by a cumulative Gaussian. For prostate, the penumbra width used in the ‘classic van Herk’ margin recipe is 0.32 cm for an 8 MV beam in water. For lung (assumed homogeneous density of 0.25 g/cm3) a penumbra width of 0.64 cm for an 8MV beam is used. For simplicity, it is assumed that the tumor is the same density as the lung and there are no adjacent solid tissues.

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Workflow Scenario for Margin Recipe Usage Example: Lung SBRT Monaco includes the Advanced Margin Template Lung SBRT which is based on the following work1.

Figure G-1: Advanced Margin dialog box Caution: Values in the template have to be modified to represent data valid for your clinic. In order to determine the systematic and random components of localization uncertainty, many patients are scanned, shifted, and re-scanned. The difference between pre shift and post shift (pre treatment) are compared to arrive at the mean and the systematic and random components. To determine the systematic and random components of intra-fraction variability, the post-shift scan is then compared to a post-treatment scan for each patient in the group. Note that the assumption that differences between pre-treatment and post-treatment position increase linearly with the time. Therefore, divide the magnitude of the systematic component for infra-fraction stability by two when computing the margin1.

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Workflow Scenario for Margin Recipe Usage Example: Lung SBRT (cont.) All systematic and random components are specific to an institution and patient setup, treatment technique, and treatment time length (generally speaking, the longer the patient is in treatment position, the greater the intra-fraction variability). You should assess delineation uncertainty locally as well, via blind studies, as it may depend on imaging technique and physician training2. Tumor motion is the most easy to determine and is assessed by the use of 4-D scans for each patient. The Margin Recipe formula uses parameters α Y and β X which correspond to the Confidence Level (%) and the Prescription Line (%). The effect of treatment preparation (systematic) errors and execution (random) errors is fully separated. Therefore, a margin to account for the preparation errors (a margin to compensate for an unknown shift of the CTV) and a margin to account for execution variations (a margin to compensate for the blurring of the dose distribution due to day to day variation) are in separate tables. For the source of the α Y and β X (both unitless) tables3. Table 2: Values for βX (table 3 from Ref. 3) (Dosimetric part of the margin):

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Prescription Line % 80%

βX 0.84

85% 90% 95% 99%

1.03 1.28 1.64 2.34

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Workflow Scenario for Margin Recipe Usage Example: Lung SBRT (cont.) Note that (from Ref. 3), the value of αY is related to the percentage of the population for which you desire the margin to be applicable. Table 3: Values of α Y (from table 2 from Ref. 2) are listed below:3 Confidence Level (% of patients) 80% 85% 90% 95% 99%

α Y 3D 2.16 2.31 2.50 2.79 3.36

As an example, the equation which relates the margin from the GTV to the PTV necessary to deliver at least 95% of the Rx dose to the CTV for 90% of the population is:

M PTV ,95%,90% = 2.5Σ + 1.64 σ 2 + σ p2 − 1.64σ p

. You can input values for the Confidence Level (%) and the Prescription Line (%).

The system calculates and shows the corresponding α Y and βX values based on the alpha and beta tables above. You can edit and save these tables with new data. For example, in the default Confidence Level dependency table, perfect conformation in 3D is assumed. Because, in reality this is not always true, you can use a different values for α Y which corresponds to 2D conformation (for example when using opposed block fields). Notice that it is impossible to reach 100% confidence level, as this would require infinite margins (example: total body irradiation).

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Workflow Scenario for Margin Recipe Usage Example: Lung SBRT (cont.) The advanced margin template (when used to calculate the required margin) can be saved with empty cells (example, Respiratory Motion of the tumor in each direction) for the patient-specific component.

How to Establish Margin Recipe Input Data for Your Clinic An end-to-end test of the entire patient imaging -> delineation -> treatment planning -> set-up -> delivery treatment process using an anthropomorphic (patient-like) phantom, can assist to establish the possible uncertainties in each process activity. Using the standard image acquisition protocol, the possible geometric errors and Hounsfield Unit reproducibility can be established using this system. In order to store values and trend results over time, you could use MOSAIQ (example: MOSAIQ supplies multiple default assessment views that you can use). Refer to MOSAIQ User Guide for more information on Clinical Assessments. You can also use the same approach for MR image studies. Monaco 4D supports both the multi-observer input and display/comparison of different structure sets based upon a single CT study (image series). If Monaco is used, then instead of separate structure sets, different clinician users may draw different structures for the same structure set, and display/compare them on a single CT study. Although a user can establish a 3D set-up error using orthogonal or stereoscopic MV portal images and bony (landmark) anatomy, image guided radiotherapy practice using cone beam CT (CBCT) and the Elekta XVI application in 3D is expected. XVI R4.5 supports a dual-registration technique in which a user can register the reference CT study to the pre-treatment CBCT using bony landmark anatomy, hence establishing the set-up error, followed by registration to the GTV itself (the tumor or organ motion). The values of calculated translations are the data required for margin recipe input. Conversion of rotations to translations and applying them as patient (couch) shifts, or applying the calculated rotations using the Hexapod patient support system, is not accounted for.

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Workflow Scenario for Margin Recipe Usage How to Establish Margin Recipe Input Data for Your Clinic (cont.) MOSAIQ captures the applied shifts from the XVI application. However, with a shrinking action level protocol, there may be sessions in which the XVI calculated data is not actually applied, and hence this data would be missing when the session (treatment fraction) should be included in margin calculations.

References 1. Sonke JJ, Rossi C, et al. ‘Frameless stereotactic body radiotherapy for lung cancer using four-dimensional cone beam CT guidance’, Int. J. Radiat. Oncol. 74(2), 567-574 (2009). 2. Remeijer P, Rash C, Lebesque JV et al. A general methodology for threedimensional analysis of variation in target volume delineation, Med Phys. 1999; 26:931-940). 3. van Herk M, Remeijer P, et al, The probability of correct target dosage: Dose-population histograms for deriving treatment margins in radiotherapy, IJROBP, 2000; 47:1121-1135.

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Manufacturer Elekta Business Area Software Systems

IMPAC Medical Systems, Inc. 13723 Riverport Drive Suite 100 Maryland Heights, MO 63043 USA Phone: +1.800.878.4267 Fax: +1 314 812 4491

European Union Authorized Representative Elekta Limited Linac House, Fleming Way Crawley, West Sussex RH10 9RR, United Kingdom Phone: +44 129 365 4242 Fax: +44 1293 471347 Email: [email protected]

Monaco

www.elekta.com

Human Care Makes the Future Possible

Corporate Head Office:

Regional Sales, Marketing and Service:

Elekta AB (publ) Box 7593, SE-103 93 Stockholm, Sweden Tel +46 8 587 254 00 Fax +46 8 587 255 00 [email protected]

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