monacotrainingguide_3 .20

Monaco Training Guide

Version 3.20

IMPAC Medical Systems, Inc. Document ID: LTGMON0320 Part Number: C#98961-EN Language: English

ii

Revision History

Revision Version Task Number Date Changes LTGMON0202 LTGMON0203 LTGMON0203 LTGMON0204 LTGMON0204 LTGMON0300 LTGMON0301 LTGMON0301 LTGMON0310 LTGMON0310 LTGMON0320 LTGMON0320

1.0 1.0 2.0 1.0 2.0 1.0 1.0 2.0 1.0 2.0 1.0 2.0

24701 24963

October 2009 March 2010 March 2010 August 2010 September 2010 January 2011 May 2011 June 2011 December 2011 January 2012 April 2012 May 2012

202 Updates for New Features Added the new Elekta CMS Software logo

to the footers Added the new template to the

presentations Added the new CE0086 to the cover of the

guide 203 Rev 1 Updates Support for VMAT 204 Rev 1 Updates Added New Beam Modeling 204 204 Updates Rev 2 300 Updates VMAT Varian Updates 301 Rev 1 Updates Miscellaneous changes 301 Rev 2 Updates Miscellaneous Updates 310 Rev 1 Updates

DICOM Export from multiple activities, support RT Image Export and Export of Multiple Beams

Support planning with Mixed Energies Bias Dose Support for Couchtop Inclusion Support for Max # of Arcs (Elekta) Paintbrush Enhancement Tools. Structure

Avoidance and Edge Detection MLC Geometry Parameters Creating an IMQA Phantom

310 Rev 2. Adding information regarding what Apex supports. See section 1. 0320 Rev 1.

Target Penalty Cost Function User Authorization Setup new appendix Revised General Operation and Navigation Ez Sketch Tool DVH Statistics: Display Tab, Heterogeneity Index, and Conformity Index Rescale Number of Fractions Approve a Calculated Plan Beam Spreadsheet for IMRT Plans VMAT Sequencing Parameters,- SSO

0320 Rev 2 Machine type used in exercise Plan information regarding APEX support Updated Plan information for CFS Added plan approval checkmark to workspace control and legend Added information regarding option to do VMAT w/ SSO for training course

Monaco iii

LTGMON0320

3.0

25342

June 2012

Added reference of neck to auto flash portion. Added at the end of the listed sections a sentence directing the user to the respecitve exercises in a particular section of the training guide Changed Min. Segment Area to Min Segment Width Added optional task to exercise Updated Foreword with Legal Entity information.

0320 Rev 3 Updated the headers and footers for Section 14.

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 2012 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. LTGMON0320 Part Number. C#98961-EN

Monaco v

Customer Course Content Outline Monaco 3.20.00

Day Course Activity TG

Section

1

Monaco Course Objectives Overall

Overview Day 1 Topics and Objectives

Discussion/Lecture: Before You Begin 1

Section Learning Objectives:General Operation & Navigation 2

Discussion/Lecture: General Operation & Navigation 2

Break

Practice Exercise: System Activities, Navigation, Plan Output 12.1

Check for Learning: Question & Answer (Q & A), or other means of assessement 2

Review if Section Objectives have been met: General Operation & Navigation 2

Section Learning Objectives:CT Simulation & Fusion 3 & 4

Discussion/Lecture: CT Simulation Activity 3

Lunch

Discussion/Lecture: Fusion Activity 4

Practice Exercise: Sim & Fusion 12.2

Check for Learning: Q & A, or other means of assessement 3 & 4

Review if Section Objectives have been met:Sim & Fusion 3 & 4

Section Learning Objectives:Monaco Workflow Introduction 6 -

front

Demonstration: Monaco Workflow 6 -

front

Break

Discussion/Lecture: Planning & Workflow Diagram, Terminology 6 -

front

Check for Learning: Q & A, or other means of assessement 6 -

front

Review if Section Objectives have been met:Monaco Workflow& Terminology 6 -

front

Review if Day's Objectives have been met: Day 1

vi

2

Discuss any questions or comments from Day 1 Overview Day 2 Topics and Objectives Section Learning Objectives: Contouring, Beam & Delivery Set-up 6 Discussion/Lecture: Contouring, Beam & Delivery Set-up 6 Check for Learning: Question and Answer (Q & A) or other means of assessment 6 Review if Section Objectives have been met: Contouring, Beam & Delivery Set-up 6 Section Learning Objectives: Calculation Parameters and Prescription Elements 7 Discussion/Lecture: Calculation Parameters 7 Break Discussion/Lecture: Prescription Elements: Structure, Cost Functions, & Other 7 Practice Exercise: Editing Prescription Elements 12.5 Practice Exercise: Adjustment to Serial Power Law (k) 12.7 Practice Exercise: Adjustment to Parallel Power Law (k) 12.8 Check for Learning: Q & A Calculation Parameters and Prescription Elements 7 Check for Learning: Quiz following Cost Function Prescription Elements 7 Review if Section Objectives have been met:Calculation Parameters & Prescription Elements 7 Lunch Section Learning Objectives: Plan Optimization & Sequence Parameters 8 Discussion/Lecture: Plan Optimization & Sequence Parameters 8 Practice Exercise: Optimization and Plan Evaluation 12.6 Check for Learning: Q & A or other means of assessment 8 Review if Section Objectives have been met: Plan Optimization & Sequence Parameters 8 Section Learning Objectives: Plan Analysis, Evaluation, & Review 9 Discussion/Lecture: Plan Analysis, Evaluation, & Review 9 Discussion: IMRT Planning Tools 5 Practice Exercise: Plan Review 12.4 Check for Learning: Q & A or other means of assessment 9 Review if Section Objectives have been met: Plan Analysis, Evaluation, & Review 9 Break Section Learning Objectives: IMRT QA 10 Discussion/Lecture: IMRT QA 10 Practice Exercise: IMRT QA 23 Check for Learning: Q&A or other means of assessment 10 Review if Section Objectives have been met: IMRT QA 10 Practice Exercise: Prostate IMRT (Step & Shoot or dMLC) 13 Check for Learning: Q&A Prostate IMRT Case 13

*Instructor determines in advance if VMAT or Stereotactic, or both session(s)to be discussed, based on customer needs (see Day 3) Practice Exercise: VMAT Prostate 14

Monaco vii

Check for Learning: Q & A VMAT Prostate Case 14


3

Discuss any questions or comments from Day 2


Section Learning Objectives: Planning Suggestions 11

Discussion: Planning Suggestions 11

Practice Exercise: Couchtop Inclusion 21

Check for Learning: Question and Answer (Q & A) Couchtop Inclusion Case 21

Break

Practice Exercise: Head and Neck IMRT 15 Practice Exercise: VMAT or Dynamic Conformal ARC using Two Partial Arcs (Head & Neck) 17

Check for Learning: Q & A Head and Neck IMRT, VMAT Cases 15 &

17

Lunch

Practice Exercise: Bias Dose 20

Check for Learning: Q & A Bias Dose Case 20

Break

*Instructor determines in advance if VMAT or Stereotactic, or both session(s)to be discussed, based on customer needs (See Day 2)

Practice Exercise: Stereotactic Brain with Head Frame 19

Practice Exercise: Stereotactic Brain Case - Multiple Isocenters 18 Check for Learning: Q & A Stereotactic Brain Cases (head frame, multiple isocenters)

19 & 18

Review if Day's Objectives have been met: Day 3 4 Discuss any questions or comments from Day 3


*Note: You may work on Practice Exercises if not participating in Physics Lectures

Physics Presentations

Section Learning Objectives: Optimization Processes 24

Presentation/Discussion: Optimization Processess 24

Check for Learning: Question and Answer (Q & A) Optimization Processes 24

Review if Section Objectives have been met: Optimization Processes 24

Break

Section Learning Objectives: Cost Functions and Constraints 25

Presentation/Discussion: Cost Functions and Constraints 25

Check for Learning: Q & A Cost Functions and Constraints 25

Review if Section Objectives have been met: Cost Functions and Constraints 25

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Lunch

Section Learning Objectives: Monaco Algorithms 26

Presentation/Discussion: Monaco Algorithms 26

Check for Learning: Q & A Monaco Algorithms 26

Review if Section Objectives have been met: Monaco Algorithms 26

Break

Section Learning Objectives: Monaco Beam Modeling 27

Presentation/Discussion: Monaco Beam Modeling 27

Check for Learning: Q & A Monaco Beam Modeling 27

Review if Section Objectives have been met: Beam Modeling 27

Section Learning Objectives: Commissioning and QA 28

Presentation/Discussion: Commissioning and QA 28

Check for Learning: Q & A Commissioning and QA 28

Review if Section Objectives have been met: Commissioning and QA 28


4 & 5

Discuss any questions or comments from Day 4


Wrap-up: Evaluations, CE credits, etc.

Practice Exercise: Esophagus 22

Practice Exercise: Rectum 22

Practice Exercise: Breast 16

Practice Exercise: Head & Neck II 22

Review if Course Objectives have been met

Monaco ix

Monaco Course Syllabus

Monaco 3.20.00

Course Information Description

Instructor Tools Instructor Guidelines for Course Materials and Tools Course Name Monaco Audience Dosimetrists, Treatment Planners, Physicists Prerequisites Monaco Treatment Planning System installed at your clinic.

Course Objective

To Provide applications training in advanced radiobiology-based IMRT treatment planning. Ther course provides an understanding of the IMRT software enabling the user to efficiently create effective IMRT treatment plans.

Instructor Information Clinical Applications/Support Team Member Location / Environment Elekta Classroom & Computer Lab

Emergency Information Given during Welcome Presentation

Instructional Methods

Lecture Demonstration/Example Hands-on Practical Application / Exercise Discussion/Peer's Use in Clinic

Instructional Materials Training Guide - PDF Treatment Planning Computer with Training Data Supplemental Presentations

Course Content Outline Document includes schedule of course topics, associated training guide sections, instructional methods. Found in training guides, Elekta.com, Elekta intranet

Resources Technical References; Online Help Assessment Method Questions tied to each day's objectives

Wrap-up Continuing Education Credit

Customer Evaluations

Instructor Evaluations

Table of Contents Monaco Training Guide

Monaco xi

Section 1. Before You Begin

Overview.......................................................................................................................................... 1-1 Training Guide Organization ....................................................................................................... 1-1 Conditions that Prevent Opening Studysets ............................................................................... 1-2 Conditions that Prevent Plans from Being Available ................................................................ 1-2 Entering and Editing the Monaco License .................................................................................. 1-3 Online Help ..................................................................................................................................... 1-4

Keep the Online Help Window in an Open Status while Performing Functions............. 1-4 User Authorization Database........................................................................................................ 1-4 Other Monaco Resources .............................................................................................................. 1-5

Section 2. General Operation and Navigation Overview.......................................................................................................................................... 2-1 Patient Management ...................................................................................................................... 2-1

Open the Monaco Application................................................................................................ 2-1

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 ........................................................................................................ 2-4 Open Treatment Couch Library ............................................................................. 2-4 Remove Couches from Treatment Couch Library............................................... 2-5

Import New Data....................................................................................................................... 2-6 Patient Workspace Control......................................................................................................2-11 Load a Patient/Plan from Patient Workspace Control ........................................................ 2-12 Load a Studyset .......................................................................................................................... 2-12 Load a Primary and Secondary Studyset................................................................................ 2-13 Load an Existing Plan ............................................................................................................... 2-14 Unload an Existing Studyset and/or Plan .............................................................................. 2-14 Activate a Loaded Studyset and/or Plan................................................................................. 2-14 Load an Existing Plan into a Specific Activity....................................................................... 2-15 New QA plan ............................................................................................................................. 2-15 New Bias Dose Plan .................................................................................................................. 2-15 Delete a Plan ...............................................................................................................................

Table of Contents

2-16


xii

Section 2. General Operation and Navigation(cont.)

Studyset Info .............................................................................................................................. 2-17 Patient Workspace Control Tooltip ....................................................................................... 2-18 Save a Plan................................................................................................................................ ..2-19 Save a Template ......................................................................................................................... 2-20 Autosave Contours.................................................................................................................... 2-21 Close a Patient ........................................................................................................................... 2-21 Delete a Patient.......................................................................................................................... 2-22

System Activities............................................................................................................................. 2-23 Image Navigation and View Types .............................................................................................. 2-23

Transverse, Sagittal and Coronal Views................................................................................. 2-23 Navigate Through T/S/C Images............................................................................ 2-24 Use the Color-coded T-bars ............................................................................ 2-24 Use the Scroll Wheel on the Mouse ................................................................ 2-25 Use the Quick Locator Method ....................................................................... 2-25 Use the Navigation Toolbar ............................................................................ 2-26 Use the Page Up/Page Down keys (Transverse Images Only) ....................... 2-27 Adjust Window and Level ....................................................................................... 2-27 Adjust Window and Level Using the Mouse .................................................. 2-27 Adjust Window and Level from the Window/Level Toolbar ......................... 2-28 Adjust Window and Level Using User-Definable Window Level Presets ..... 2-29Zoom and Pan T/S/C Images.................................................................................. 2-30 Zoom ............................................................................................................... 2-30 Pan................................................................................................................... 2-33 Pan and Zoom Reset........................................................................................ 2-34

Side-by-Side P/S View .............................................................................................................. 2-34 3D View ..................................................................................................................................2-35

3D Pan........................................................................................................................ 2-35 3D Zoom.................................................................................................................... 2-36 3D Magnifying Glass................................................................................................ 2-36 3D Zoom Area of Interest........................................................................................2-37 3D Rotate ................................................................................................................... 2-38 3D Translate .............................................................................................................. 2-38

Reset 3D Image Navigation Functions ................................................................................... 2-39 Reset All 3D Functions ............................................................................................ 2-39 Reset Individual 3D Functions ............................................................................... 2-39

Table of Contents


Monaco xiii

Section 2. General Operation and Navigation(cont.)

DRR Views ................................................................................................................................ .2-40 Show MIP .................................................................................................................. 2-41 Show Grid .................................................................................................................. 2-42 DRR Volume of Interest Tool................................................................................. 2-43

Rooms Eye View....................................................................................................................... 2-44 Additional Navigation and Screen Customization Tools ......................................................... 2-47

Maximize and Restore a Window........................................................................................... 2-47 Patient Orientation Icon .......................................................................................................... 2-47 Move Control Dialog Box ........................................................................................................ 2-48

Printing Options ............................................................................................................................. 2-50 Print/Export a Transverse, Sagittal, Coronal, or 3D Image................................................. 2-50 Print or Export the Screen........................................................................................................ 2-51 Print DRRs ................................................................................................................................ .2-51

Select the Print Type ................................................................................................ 2-52 Select Options and Copies....................................................................................... 2-53

Print or Export IMRT Plan Reports ....................................................................................... 2-54 Print/Export Individual Reports............................................................................. 2-54 Print/Export Custom Reports................................................................................. 2-55 Additional IMRT Plan Report Options ................................................................ .2-57 Print DICOM Coordinates on reports instead of the proprietary system coordinates ............................................................. 2-57 Include Base Dose on Reports for Bias Dose plans ........................................ 2-57

Print or Export QA Plan Reports ............................................................................................ 2-58 Print/Export Individual Reports............................................................................. 2-58 Print/Export Custom Reports................................................................................. 2-58 Additional QA Plan Report Option ....................................................................... 2-59

Print DICOM Plan Report....................................................................................................... 2-60

Section 3. CT Simulation Activity

Overview.......................................................................................................................................... 3-1 Contouring Tools ........................................................................................................................... 3-1

Draw Contour............................................................................................................................ 3-2 Replace (Contour Editing Tool).............................................................................................. 3-4 Contour Editing Tips................................................................................................................ 3-6

Guide Radius ............................................................................................................. 3-6 Reshape (Contour Editing Tool)............................................................................................. 3-8 Contour by Shapes .................................................................................................................... 3-8 Paintbrush ................................................................................................................................ ..3-9

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xiv

Section 3. CT Simulation Activity (cont.) Contour Using the Paintbrush Tool ...................................................................... 3-9 Smoothing Contours Using the Paintbrush Tool ................................................ 3-10 Change the Transparency of the Painted Area..................................................... 3-11 Erase the Painted Contour ...................................................................................... 3-12

Paintbrush Enhancement Tools .............................................................................................. 3-13 Edge Detection Tool................................................................................................ .3-13 Structure Avoidance Tool........................................................................................ 3-13 Edge Detection Sensitivity....................................................................................... 3-13 Considerations When Using Paintbrush Enhancement Tools .......................... 3-14 Desirable Image Characteristics of Structures: ..................................................... 3-14 Less Desirable Image Characteristics of Structures:............................................. 3-15 Using Structure Avoidance with Paintbrush Tool ............................................... 3-15

Using Structure Avoidance with Edge Detection ................................................................ .3-18 EZ Sketch Tool.......................................................................................................... 3-21 EZ Sketch-Initial Execution .................................................................................... 3-21 EZ Sketch Edit Mode- Refine Contour................................................................ ..3-23 EZ Sketch Edit Mode- Global Edit ......................................................................... 3-25 EZ Sketch-Quick Scheme ........................................................................................ 3-25 Using Other Editing Tools ...................................................................................... 3-25

Draw a 3D Contour (Transverse, Sagittal, and Coronal).....................................................3-26 Import Treatment Couchtop................................................................................................ ...3-28

Prerequisites: ............................................................................................................. 3-28 Copy Structure........................................................................................................................... 3-30 Copy Superior/Inferior, Anterior/Posterior or Right/Left .................................................. 3-32

Transverse View........................................................................................................ 3-32 Sagittal View.............................................................................................................. 3-32 Coronal View ............................................................................................................ 3-33

Interpolation .............................................................................................................................. 3-34 Auto Threshold.......................................................................................................................... 3-35 Auto Segmentation ................................................................................................................... 3-37 Auto Margin............................................................................................................................... 3-38 Common Margin Templates ................................................................................................ ...3-43

Save a Template ........................................................................................................ 3-43 Apply a Template...................................................................................................... 3-43

Using Advanced Margins......................................................................................................... 3-45 Create an Advanced Margin ................................................................................................ ....3-46 Save an Advanced Margin Template ...................................................................................... 3-49

Apply an Advanced Margin Template................................................................ ...3-49

Table of Contents


Monaco xv

Section 3. CT Simulation Activity (cont.) Print a Margin Report............................................................................................................... 3-50 Structure Control ...................................................................................................................... 3-52

Toggle Structure On and Off...................................................................................3-53 Toggle 2D Transparencies On and Off................................................................ ..3-53 Transparency Toolbar.............................................................................................. 3-54

Selecting and Grouping Contours and Structures ................................................................ 3-56 Delete Contours or Structures ................................................................................................ .3-57

Anatomical Groups ................................................................................................ ..3-58 CT-to-ED File Creation and Assignment ................................................................................... 3-59

Create and Edit a CT-to-ED File............................................................................................. 3-59 Create and Edit a CT-to-ED File (Monaco with XiO Users) .............................................. 3-59

Create and Save a New CT-to-ED file................................................................ ....3-60 Delete Contours or Structures ................................................................................ 3-60 Edit an Existing CT-to-ED File to Create a New CT-to-ED File ....................... 3-61 Assign CT-to-ED to Studyset.................................................................................. 3-62

Beam Tools ...................................................................................................................................... 3-63 Beam Toolbar............................................................................................................................. 3-63 Manipulate Beams..................................................................................................................... 3-64 Enter/Edit values in the Beam Control Fields ....................................................................... 3-65 Beam Visibility........................................................................................................................... 3-66 Move the Beam Isocenter......................................................................................................... 3-67

Move a Single Beam ................................................................................................ .2-67 Move Multiple Beams as a Group .......................................................................... 3-67

Change the Gantry or Collimator Using the Mouse ............................................................ 3-68 Rotate the Gantry or Collimator Using the Mouse.............................................. 3-68 Move the Field Borders Using the Mouse ............................................................. 3-69 Enter Values on the Beam Spreadsheet ................................................................ .3-69 Print a Beam Summary Report ............................................................................... 3-70

Multi-activity Tools........................................................................................................................ 3-71 Measure Tool ............................................................................................................................. 3-71

Use the Measure Tool .............................................................................................. 3-71 Remove the Measurement Rulers........................................................................... 3-71

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xvi

Section 3. CT Simulation Activity (cont.) Interest Points and Markers................................................................................................ .....3-72

Place Interest Points or Markers............................................................................. 3-73 Verify an Interest Point or Marker......................................................................... 3-74 Locate an Interest Point or Marker ........................................................................ 3-75 Delete an Interest Point or Marker ........................................................................ 3-76 Print the Interest Point and Marker Report.......................................................... 3-76

Dose Reference Points .............................................................................................................. 3-76 References ........................................................................................................................................ 3-77

Section 4. Fusion Activity

Overview.......................................................................................................................................... 4-1 Open a Primary and Secondary Studyset .................................................................................... 4-1 Masking Options (Optional)......................................................................................................... 4-2

Patient Contours ....................................................................................................................... 4-2 Shape/Intensity Model.............................................................................................................. 4-2 RE Segmentation ....................................................................................................................... 4-3 No Mask (default) ..................................................................................................................... 4-3

Create a Registration ...................................................................................................................... 4-4 Create a Registration Manually ............................................................................................... 4-4 Create a Registration using Auto Registration ...................................................................... 4-5

Use the VOI Masking Tool ..................................................................................... 4-6 Verify the Results of the Alignment ....................................................................... 4-7

Fusion Display Options ................................................................................................................. 4-8 Blended Display......................................................................................................................... 4-9

Studyset Volume Toolbar........................................................................................ 4-9 Fusion Display Options ................................................................................................................. 4-10

Transition between Primary and Secondary Images ........................................... 4-10 Change the Appearance of the Secondary Studyset............................................. 4-10

Horizontal, Vertical and Checkerboard Display................................................................ ...4-11 Pan/Reset Fusion Display Options ......................................................................................... 4-12

View/Edit the Transformation Matrix......................................................................................... 4-13 (Optional) Registering Multiple Studysets.................................................................................. 4-15

Table of Contents


Monaco xvii

Table of Contents

Section 5. IMRT Planning Activity

Overview.......................................................................................................................................... 5-1 IMRT Toolbar ................................................................................................................................ .5-1

Fluence Toolbar for IMRT Plans ............................................................................................ 5-4 Fluence Toolbar Blended Display ........................................................................................... 5-6

Fluence Toolbar for VMAT and Dynamic Conformal Arc Plans ..................... 5-6 Fluence Toolbar for VMAT Plans........................................................................................... 5-7

Volume Cursor and Grid Volume Toolbar ................................................................................ 5-8 Volume Cursor .......................................................................................................................... 5-8

Grid Volume Toolbar...............................................................................................5-8 Studyset and Grid Slider Bar................................................................................................ ....5-9

Show Dose Extents ......................................................................................................................... 5-9 Dose Reference Points....................................................................................................................5-10

Editing Dose Reference Points ................................................................................................ 5-10 Dose Reference Points....................................................................................................................5-11

Use the mouse to move a Dose Reference Point .................................................. 5-11 Reset All Dose Reference Points to Isocenter........................................................................ 5-11

Additional Plan Analysis Tools ................................................................................................ ....5-12 Progress Meter........................................................................................................................... 5-12 Fluence Statistics ....................................................................................................................... 5-13 Dose-Volume Histogram ......................................................................................................... 5-13 Normalization Tools................................................................................................................. 5-14 Beam Visibility Control............................................................................................................ 5-14 Measure and Interest Point Tools ........................................................................................... 5-16

Additional Interest Point and Marker Functionality........................................... 5-16

Section 6. Planning and Workflow: Workflow Diagram, Contouring,

Beam and Delivery Setup Overview.......................................................................................................................................... 6-1 Monaco Workflow..........................................................................................................................6-3 Contouring and Beam Manipulation........................................................................................... 6-4

Contour all Targets and Organs at Risk (OARs) ................................................................ ..6-4 3D Auto-Margin Generation .................................................................................. 6-4 Consideration of Contours outside the Patient.................................................... 6-4

Beam Manipulation Tools........................................................................................................ 6-5


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Table of Contents

Section 6. Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup (cont.)

Using IMRT Templates ................................................................................................................. 6-6 Start a Plan Using a Template................................................................................................ ..6-6

Select Template ......................................................................................................... 6-7 Number of Beams..................................................................................................... 6-7 Select Isocenter.......................................................................................................... 6-7 Use Common Isocenter ........................................................................................... 6-8 Machine ..................................................................................................................... 6-8 Delivery Mode........................................................................................................... 6-8 VMAT ........................................................................................................................ 6-9 Dynamic Conformal Arcs ....................................................................................... 6-9

Creating a Customized Template............................................................................................ 6-10 Deleting a Template .................................................................................................................. 6-11

Beam Tools ...................................................................................................................................... 6-12 IMRT Beam Toolbar................................................................................................................. 6-13

Beam Spreadsheet for IMRT Plans............................................................................................... 6-14 Add/Edit/Delete Beams in Beam Spreadsheet.......................................................................6-16 Copy a Beam/Sequence ............................................................................................................ 6-16 Delete a Beam/Sequence........................................................................................................... 6-17 Renumber Beams/Sequences ................................................................................................ ...6-17 Reorder Beams/Sequences ....................................................................................................... 6-17 Number Beams/Sequences Consecutively ............................................................................. 6-17 Link Machine ID and/or Isocenter Location......................................................................... 6-18

Beam Spreadsheet for IMRT Plans-Geometry Tab................................................................ ....6-20 Split Beams ................................................................................................................................ .6-21 Fixed Jaws ................................................................................................................................ ..6-23

Beam Spreadsheet for IMRT Plans-Setup Beams Tab............................................................... 6-25 Edit Beam Options Using Mouse ................................................................................................ .6-26

Print a Beam Spreadsheet Report............................................................................................ 6-26 Definition of Terms as They Apply to Arc Planning................................................................ .6-27

Sequence ................................................................................................................................ ..6-27 Gantry ................................................................................................................................ ..6-28 Collimator ................................................................................................................................ ..6-28 Arc ................................................................................................................................ ..6-29


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Table of Contents

Section 6. Planning and Workflow: Workflow Diagram,

Contouring, Beam and Delivery Setup (cont.) Direction ................................................................................................................................ ..6-29 Sector ................................................................................................................................ ..6-30 Increment ................................................................................................................................ ..6-32 Sweep Sequencer ....................................................................................................................... 6-32 Control Point (VMAT only)................................................................................................ ....6-33 Arc Segment (VMAT only)......................................................................................................6-33 Dynamic Segments with Static Gantry (VMAT only) ......................................................... 6-35

Section 7. Planning and Workflow: Calculation Parameters and

Prescription Element IMRT Calculation Properties........................................................................................................ 7-1

Calculation Parameters............................................................................................................. 7-1 Grid Spacing.............................................................................................................. 7-1 Number of Fractions ................................................................................................ 7-2 Prescription ............................................................................................................... 7-3 Secondary Algorithm ............................................................................................... 7-3 Calculate Dose to Medium or Water ..................................................................... 7-4 Monte Carlo Standard Deviation (%)................................................................ ....7-4

Prescription Elements: Structure................................................................................................ ..7-7 Introduction............................................................................................................................... 7-7 Structure ................................................................................................................................ ..7-9 Structure Mismatch................................................................................................................... 7-9 Structure Layering..................................................................................................................... 7-9 Structure Optimization Properties and Global Parameters.................................................7-11

Density Overrides ................................................................................................ .....7-13 None ........................................................................................................................... 7-13 Fill Structure with Minimum Electron Density.................................................... 7-13 Clear all Voxels below the Minimum CT number............................................... 7-14 Display Total Volume DVH.................................................................................... 7-16 Auto Flash.................................................................................................................. 7-16 Do Not Store Dose................................................................................................ ....7-17 Avoidance .................................................................................................................. 7-18


xx


Prescription Element Surface Margin Global Parameter....................................................................... 7-18 Beamlet Width Global Parameter ....................................................................... 7-18 Target Margin- Global Parameter .......................................................................... 7-19 Avoidance Margin- Global Parameter................................................................ ...7-19

Prescription Elements: Cost Functions ....................................................................................... 7-20 Cost Function Overview........................................................................................................... 7-20 Objective ................................................................................................................................ ..7-20 Constraint ................................................................................................................................ ..7-20 EUD (Equivalent Uniform Dose) ........................................................................................... 7-20 Application of Objectives and Constraints ............................................................................ 7-21 Required Cost Function Parameters....................................................................................... 7-22

Target Penalty ........................................................................................................... 7-22 Target EUD................................................................................................................7-23

Required Cost Function Parameters....................................................................................... 7-24 Serial ........................................................................................................................... 7-25 Parallel........................................................................................................................ 7-29 Quadratic Overdose ................................................................................................ .7-35

Quadratic Underdose ............................................................................................................... 7-37 Maximum Dose ........................................................................................................ 7-40 Overdose DVH ......................................................................................................... 7-41 Underdose DVH....................................................................................................... 7-43

Optional Parameters ................................................................................................................. 7-44 Shrink Margin ........................................................................................................... 7-44 Surface Margin.......................................................................................................... 7-47 Optimize Over All Voxels in Volume................................................................ ....7-52

Multicriterial .............................................................................................................................. 7-53 Monaco Cost Functions Quick Reference....................................................... 7-56

Pop Quiz-Questions.................................................................................................................. 7-57 Pop Quiz-Answers .................................................................................................................... 7-58

Prescription Elements: Other........................................................................................................ 7-59 Rescale Dose............................................................................................................................... 7-59 Enabled ..................................................................................................................................

7-60

Table of Contents


Monaco xxi


Prescription Element Bias Dose (only shows for Bias Dose Plans) .......................................................................... 7-60 Status .................................................................................................................................. 7-61 Manual Weighting .................................................................................................................... 7-61 Isoeffect ..................................................................................................................................7-62 Isoconstraint .............................................................................................................................. 7-62 Reference Dose .......................................................................................................................... 7-62 Multicriterial .............................................................................................................................. 7-63 Relative Impact .......................................................................................................................... 7-64 Optimization Modes ................................................................................................................. 7-64

Constrained Optimization Mode ........................................................................... 7-64 Pareto Optimization Mode......................................................................................7-65

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.............................................................................................................. 8-11 Stage One- Fluence Optimization .......................................................................... 8-11 Stage Two- Aperture Optimization and Dose Calculation................................ .8-12

Dynamic Conformal Arc Delivery Mode............................................................................... 8-12 Fluence Modulation, Aperture Optimization and Dose Calculation ................ 8-12

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Section 8. Planning and Workflow: Optimization and Sequence

Parameters (cont.) Editing the Sequencing Parameters.............................................................................................. 8-14

Segment Shape Optimization ................................................................................................ ..8-16 Min. Segment Width (cm) ....................................................................................................... 8-17 Min. Change Between Consecutive Segments (cm2 ............................................................) 8-17 Max Number of Arcs (Elekta and Varian machines) ........................................................... 8-17 Max # Control Points/Beam ................................................................................................ ....8-17 Max # Control Points/Arc........................................................................................................ 8-17

Elekta Specific information: .................................................................................... 8-17 Varian Specific Information:................................................................................... 8-18

Target Dose Rate ....................................................................................................................... 8-18 Elekta Specific Information:.................................................................................... 8-18 Varian Specific Information:................................................................................... 8-19

Min. Segment Width (cm) ....................................................................................................... 8-19 Fluence Smoothing ................................................................................................................... 8-19 Min. MU/Segment .................................................................................................................... 8-20 Park Closed Leaf Gaps Under Jaw .......................................................................................... 8-20 Max Sweep Efficiency ............................................................................................................... 8-20 Allow Move Only Segments (dMLC Only): .......................................................................... 8-21 Constant Dose Rate................................................................................................................... 8-21

Section 9. Planning and Workflow: Plan Analysis, Evaluation,

and Review 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


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and Review (cont.) 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 When you select this option, the percent of 3D voxel occupancy for the selected Volume of Interest (VOI) is shown. ..... 9-11CF (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...................................................... 9-16 Total Volume DVH................................................................................................ ..9-16 Optimized DVH ....................................................................................................... 9-17 Optimized Total DVH (Bias Dose Plans only)..................................................... 9-17

Evaluating Intensity Maps and Monitor Units ................................................................ .....9-18 Review Segments and Monitor Units per Segment .............................................................. 9-19 Using the Fluence Statistics...................................................................................................... 9-20

Plan Review Activity.......................................................................................................................9-21 Overview ................................................................................................................................ ..9-21 Open Plan(s) into Plan Review................................................................................................ 9-21 Change the Isodose Display ................................................................................................ .....9-23 Change the Transparency of the Dose Display ................................................................ .....9-25 (Optional) Transition between Two Studysets......................................................................9-26 Beam Visibility Control............................................................................................................ 9-27 Beam Summary..........................................................................................................................9-28 Structure Control ...................................................................................................................... 9-28

Toggle Structure On and Off...................................................................................9-28 Toggle 2D Transparencies On and Off................................................................ ..9-29


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and Review (cont.) Change the DVH Display Properties...................................................................................... 9-30 DVH Statistics-Statistics Tab................................................................................................ ...9-30

Edit the Reference Doses and % Volumes on the DVH Statistics Dialog......... 9-30 Edit the Reference Doses and % Volumes on the DVH Graph.......................... 9-32

DVH Statistics-Display Tab................................................................................................ .....9-34 Heterogeneity Index................................................................................................ .9-34 Conformity Index ................................................................................................ .....9-35

Print/Export the DVH Statistics.............................................................................................. 9-36 DVH Color Setup...................................................................................................................... 9-37 Change the DVH Display Properties...................................................................................... 9-38

DVH Properties Setup ............................................................................................. 9-38 Change the DVH Display Properties...................................................................................... 9-39

DVH Properties Setup ............................................................................................. 9-39 Create Structure Combinations for the DVH ....................................................................... 9-41

Add Structures .......................................................................................................... 9-41 Export the DVH Values........................................................................................... 9-42 Print or Export the DVH View............................................................................... 9-43 Measure Dose Intensity at a Point.......................................................................... 9-43

Set the Normalization Parameters .......................................................................................... 9-45 Show Dose Extents .................................................................................................................... 9-46 Measure and Interest Points Tools ......................................................................................... 9-46 Dose Reference Points .............................................................................................................. 9-46 Single Plan Display and Multiple Plan Display................................................................ .....9-46 Switch from Single Plan Mode to Multiple Plan Mode........................................................ 9-47 Navigation Tools in Multiple Plan Mode...............................................................................9-48 Show the Dose Difference or Dose Summation between Plans.......................................... 9-48 Modify the Dose Difference or Dose Summation Display .................................................. 9-49

Dose Summation ...................................................................................................... 9-50 Dose Difference ......................................................................................................................... 9-51 Save the Summation or Difference Plan.................................................................................9-52 Review the Patient in 3D .......................................................................................................... 9-53 Rescale Number of Fractions................................................................................................ ...9-54 Approve a Calculated Plan....................................................................................................... 9-55 Approve a Calculated Plan....................................................................................................... 9-56 Save Current Settings (available for non-Monaco plans only) ........................................... 9-57


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Section 10. IMRT QA Activity

Overview.......................................................................................................................................... 10-1 IMRT QA Tools.............................................................................................................................. 10-1

Dose Calculation Tools............................................................................................................. 10-1 QA Tools.................................................................................................................... 10-1

Fluence Toolbar .............................................................................................................................. 10-5 Beam and Dose Visibility Control................................................................................................ 10-5 Beam Summary............................................................................................................................... 10-6 Show Dose Extents ......................................................................................................................... 10-6 Measure and Interest Point Tools ................................................................................................ 10-7 Grid Volume Toolbar.....................................................................................................................10-7 Create an IMRT QA Plan .............................................................................................................. 10-7 Edit Dose Calculation Properties ................................................................................................ .10-11 Edit Assigned Electron Densities................................................................................................ ..10-12 Save the IMRT QA Plan................................................................................................................. 10-12 Export Dose Profiles....................................................................................................................... 10-13 Tips When Creating an IMRT QA Phantom.............................................................................. 10-14

Section 11. Monaco Planning Suggestions

Workflow......................................................................................................................................... 11-1 Bolus ................................................................................................................................................. 11-3 Templates......................................................................................................................................... 11-9 Machine Energy .............................................................................................................................. 11-9 Standardize Planning ..................................................................................................................... 11-10 Status Messages............................................................................................................................... 11-10 DVH & Statistics Resolution......................................................................................................... 11-10 Setup Beams for Portal Imaging ................................................................................................ ...11-10 Calculation Region Volume .......................................................................................................... 11-11 Applying Structure Optimization Properties to a Non-Optimized Structure........................ 11-11 Target Coverage.............................................................................................................................. 11-11 IMRT Beam Arrangement............................................................................................................. 11-12 Prescription ................................................................................................................................ .....11-12

General Suggestions .................................................................................................................. 11-12 Tips When Creating Target Volume Prescriptions .............................................................. 11-13 Tips When Creating Organ at Risk Prescriptions ................................................................ 11-14 Avoid Hot Spots in Unspecified Tissue.................................................................................. 11-15


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Section 11. Monaco Planning Suggestions (cont.)

Controlling Mean Dose in OARs............................................................................................ 11-16 Controlling Maximum Dose................................................................................................ ....11-16 Using Biological Cost Functions to Control Dose................................................................ 11-17 Bias Dose ................................................................................................................................ ..11-18

Optimization ................................................................................................................................ ...11-19 DVH Statistics............................................................................................................................11-19 Sensitivity Analysis.................................................................................................................... 11-19 Multicriterial .............................................................................................................................. 11-19 Troubleshooting Optimization Failures................................................................................. 11-20

Plan Analysis ................................................................................................................................ ...11-21 Fluence Statistics ....................................................................................................................... 11-21

Auto Flash ON ................................................................................................................................ 11-21 Fluence Statistics....................................................................................................... 11-21

Performance ................................................................................................................................ ....11-23 Grid Spacing............................................................................................................................... 11-23 Monte Carlo Standard Deviation per Plan vs. per Control Point....................................... 11-23

QA Plan............................................................................................................................................ 11-23 External Contour Name ........................................................................................................... 11-23 Multiple QA Plans..................................................................................................................... 11-24 Show Coronal Slice at Measured Depth................................................................................. 11-24

Section 12. Practice Exercises

Practice Exercise 1. General Operation and Navigation ........................................................... 12-1 Practice Exercise 2. Fusion, Contouring, and Beam Manipulation ......................................... 12-3

Fusion ................................................................................................................................ ..12-3 Contouring................................................................................................................................ .12-3

Practice Exercise 2. Fusion, Contouring, and Beam Manipulation ......................................... 12-4 Beam Manipulation...................................................................................................................12-4 Miscellaneous............................................................................................................................. 12-4

Practice Exercise 3. IMRT and QA............................................................................................... 12-5 Create an IMRT Plan ................................................................................................................ 12-5 Create a QA Plan ....................................................................................................................... 12-6

Practice Exercise 4. Plan Review................................................................................................ ...12-7 Practice Exercise 5. Editing IMRT Prescription Elements........................................................ 12-8 Practice Exercise 6. Optimization and Plan Evaluation ............................................................ 12-9


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Section 12. Practice Exercises (cont.)

Practice Exercise 7. Serial Power Law (k)................................................................................... 12-10 Task 1. Select Patient and Open Studyset .............................................................................. 12-10 Task 2. Enter/Adjust Power Law and Optimize IMRT Plans............................................. 12-10 Task 3. Plan Review.................................................................................................................. 12-13

Practice Exercise 8: Parallel Power Law (k)................................................................................. 12-14 Task 1. Select Patient and Open Studyset .............................................................................. 12-14 Task 2. Load IMRT Template................................................................................................ .12-14 Task 3. Enter the Prescription ................................................................................................ 12-15

Prescription Information:........................................................................................ 12-15 Task 4. Enter Calculation Properties ..................................................................................... 12-16 Task 5. Adjust Power Law (k) and Optimize IMRT Plans ................................................. 12-17 Task 6. Plan Review.................................................................................................................. 12-18

Section 13. Prostate IMRT Case Practice Exercise ............................................................................................................................. 13-1

Task 1. Select Patient and Open Studyset .............................................................................. 13-2 Task 2. Start an IMRT Plan...................................................................................................... 13-2 Task 3. Add Beams in CT Simulation Activity or IMRT Planning Activity ..................... 13-3 Task 4. Enter/Update the Prescription................................................................................... 13-4

Target Structures ............................................................................................. 13-7 Organs at Risk (OAR)..................................................................................... 13-7

Task 5. Edit Calculation Parameters....................................................................................... 13-8 Task 6: Edit Sequencing Parameters ..................................................................................... 13-8 Task 7: Save an IMRT Template............................................................................................ 13-9 Task 8: Optimize Fluence (Stage 1)....................................................................................... 13-9 Task 9: Evaluate Optimized Fluence and Dose ................................................................ ...13-10 Task 10: Re-Optimize and Evaluate (Optional) ................................................................ ....13-11 Task 11: Optimize Segment Shapes/Calculate Dose (Stage 2) ............................................ 13-11 Task 12: Evaluate Final Plan ................................................................................................ ....13-12 Task 13: Save Plan ..................................................................................................................... 13-12 Task 14: Print the Plan.............................................................................................................. 13-13

Subtask 1: Print or Export IMRT Reports ............................................................. 13-13 Subtask 2: Print Single Plane View, 3D Image or DVH Graph.......................... 13-14 Subtask 3: Print DRR/BEV...................................................................................... 13-14

Task 15: Create/Calculate a QA Plan...................................................................................... 13-15


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Section 13. Prostate IMRT Case (cont.)

Task 16: Edit QA Plan Beam Weights (Optional) ................................................................ 13-16 Task 17: Save the QA Plan ....................................................................................................... 13-16 Task 18: Export the Dose Profiles ........................................................................................... 13-16 Task 19: Print the QA plan....................................................................................................... 13-17

Subtask 1: Print QA Plan Reports .......................................................................... 13-17 Subtask 2: Print QA Plan Images............................................................................ 13-17

Section 14. Prostate VMAT Case Practice Exercise ............................................................................................................................. 14-1

Task 1. Select Patient and Open Studyset .............................................................................. 14-2 Task 2. Start a VMAT Plan using a Template ....................................................................... 14-2 Task 3. Add VMAT Sequences in IMRT Planning Activity................................................ 14-3 Task 4. Enter/Update the Prescription................................................................................... 14-3

Target Structures ...................................................................................................... 14-6 Organs at Risk (OAR) .............................................................................................. 14-6

Task 5. Edit Calculation Parameters....................................................................................... 14-7 Task 6: Edit Sequenc

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