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. Select Patient and Open Studyset

Task 2. Start an IMRT Plan
Task 3. Add Beams in Planning Activity
Task 4. Enter the Prescription
Task 5. Enter the IMRT Constraints
Task 6. Edit Calculation Parameters
Task 7. Edit Sequencing Parameters
Task 8. Save an IMRT Template
Task 9. Optimize Fluence (Stage 1)
Task 10. Evaluate Optimized Fluence and Dose
Task 11. Re-Optimize and Evaluate (Optional)
Task 12. Optimize Segment Shapes/Calculate Dose (Stage 2)
Task 13. Evaluate Final Plan
Task 14. Save Plan
Task 15. Print the Plan
Task 16. Create/Calculate a QA Plan
Task 17. Edit QA Plan Beam Weights
Task 18. Save the QA Plan
Task 19. Export the Dose Planes
Task 20. Print the QA plan

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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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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. Click on 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 8-1).

Figure 8-1: New Monaco Plan dialog box

3. Type in a plan name and description.

4. Select dMLC or Step and Shoot IMRT for the Delivery.

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Practice Exercise

Task 2. Start an IMRT Plan (cont.)

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.

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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 <click to add a new beam> 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 8-2: Prescription Control

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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.

• 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.

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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.

- 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.

NOTE: 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.

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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. 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.

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Practice Exercise

Task 5. Enter the IMRT Constraints (cont.)

5. Review the plan scoring criteria.

Target Structures
PTV 95% is at or above 73.80 Gy
and
Max dose < or = 81.18 Gy (110%)

Organs at Risk (OAR)

BLADDER 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 no more than 5% > 45 Gy
Lt Femur no more than 5% > 45 Gy

Figure 8-3: Planning Score Criteria example

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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. Click the Calculation Properties button on the

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: 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.

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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 8-4: IMRT Parameters button

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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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 button on the

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.

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.

1. Click the Monaco Application Menu and select the Save Template As
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.

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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. Click the Start Optimization button located on the Planning tab, to start
stage one of the optimization processes.

NOTE: 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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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 button. Understand that this
action does not result in fully optimized fluence.

OR

(Optional) If you would like to stop the optimization and go back to the start of
stage one, click the Skip Back button. This action removes the current
display of fluence and lets you start the optimization again at stage one.

5. Once stage one of the optimization completes, the system shows a dialog box
with the message “Full Fluence Modulation Complete”. Click OK to
acknowledge.

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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 8-5: 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 button. For more information, refer to the IMRT Tools
section in this guide.

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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

button on the toolbar changes from to . If so, the changes you made require
re-optimization. Evaluate again. Use the tools described in task 10. You may re-
optimize 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.

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.

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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 button. Understand that this
action does not result in a fully optimized plan.

OR

(Optional) If you would like to pause stage 2 of the optimization, click the Skip
Back button. This action removes the current display of fluence and lets
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.

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Practice Exercise (cont.)

Task 15. Save Plan

Save the plan when satisfied that it meets the prescribed goals.

NOTE: You can save optimized plans after stage 1, but optimized dose is not
preserved.

1. 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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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 on the preview window to print the image
shown.

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.

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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.

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.

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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.

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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 . Select New QA
Plan.

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.

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.

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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.

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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.

1. Select the Output tab.

2. Select Print Views on the Reports panel.

3. Select the necessary view to print.

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