3D Prostate Case

Volume II of IV Monaco Training Guide

3D Prostate Case

Practice Exercise

When you complete the first two interactive treatment plans in this series, you
should be familiar with most of the procedures required to contour critical
structures. Therefore, this plan will have the contours already drawn. This
exercise gives you the opportunity to practice with the fusion tools, review the
general process of planning a 3D prostate patient in Monaco, as well as create a
bias dose plan. There are many ways to complete a plan in Monaco. This is just
one suggested method of treatment planning. This exercise and the information
provided is subject to the disclaimer included in the Overview section of Volume
1, Section 1.This exercise includes these tasks:

Task 1. Select Patient and Open CT and MRI Studysets

Task 2. Fuse Studysets
Task 3. Import Treatment Couch
Task 4. Create Shift Origin
Task 5. Start a 3D Plan
Task 6. Add Beams
Task 7. Create DRRs
Task 8. Enter Prescription
Task 9. Calculate plan
Task 10. Save a Template
Task 11. Evaluate Dose
Task 12. Edit Beam Weights
Task 13. Save Plan
Task 14. Print the Plan
Task 15. Export the Plan

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Practice Exercise (cont.)

Task 1. Select Patient and Open Studysets

This task walks you through the steps to select a patient and open a studyset.

1. Open the Monaco software to automatically show the Open Patient

Selection dialog box.

2. Select the patient Fusion Prostate using one of these methods:

Double-click on the patient name.

OR

Click the name once. Click the OK button.

The system loads the patient information into the Patient Workspace
Control.

3. Select the CT studyset CT1. Use one of these methods:

Double-click on the studyset name.

OR

Click the studyset name once, and then select the Load button at the
bottom of the Workspace.

4. Click the MRI studyset MR1 once, and then right-click to select the Load /
Set As Secondary button.

The patient appears in the Planning activity.

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Practice Exercise (cont.)

Task 2. (Optional) Fuse Studysets

This task lets you practice with the fusion tools available in Monaco.

1. Select the Image Fusion Workspace.

2. Create a registration manually. Use the translate (move) and rotate

tools to adjust the position of the secondary studyset.

3. Click the Save button on the toolbar to save the registration.

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Practice Exercise (cont.)

Task 3. (Optional) Import Treatment Couch

1. Select the Planning Workspace.

2. Click the Plan Options tab.

3. Click the Import Positioning Device button.

4. Highlight a Sample Couch to import into your plan as an example.

5. Click the OK button.

6. Adjust the Treatment Couch Position, you can pan or move the couch
position with your mouse or edit the shifts in the Treatment Couch
Position dialog box (Figure 5-1).

Figure 5-1: Treatment Couch Position dialog box

7. Click Done on the Treatment Couch Position dialog box.

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Practice Exercise (cont.)

Task 4. Define the Scan Reference Point

You can use the Scan and Setup Reference tool to replace the original patient
origin with a new (0,0,0) location. Monaco calculates the offset shift between the
setup reference point and the scan reference point.

1. Click the Plan Options ribbon.

2. Click the Scan and Setup Reference button. The Setup Reference
dialog box opens (Figure 5-2).

Figure 5-2: Setup Reference dialog box

3. Designate the Scan Reference point’s position with either of these methods.

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Practice Exercise

Task 4. Define the Scan Reference Point (cont.)

4. Type the X, Y, and Z values in the Setup Reference dialog box.

OR

Use the mouse to reposition the cross hairs in the transverse view.

5. Select the Patient orientation when scanned: Head-in/Supine.

6. Select the Setup Reference Point location, Center of GTV.

7. Check the Lock Shift option in the Setup Reference dialog box. With the
shift locked, no further interaction with the point is allowed unless you
explicitly unlock it.

8. Close the Setup Reference dialog box.

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Practice Exercise (cont.)

Task 5. Create a New Monaco Plan from Template

This task walks you through the steps to select a template to import.

1. Click the Planning tab.

2. Click the drop-down arrow next to the New Plan button and select
New Monaco Plan in the drop-down list. This opens the New Monaco Plan
dialog box (Figure 5-3).

3. Type in a Plan Name and Description.

4. Select 3D for the Delivery.

5. Select All for the Anatomical Site.

6. Place a checkmark by the template named DEFAULT3D1beam (Rx Site ,

Rx Dose: 2.0Gy , Total Beams: 1).

7. Select Head First for the Treatment Orientation.

8. Select a treatment unit used in your clinic, labeled as Demo.

9. Select the Collapsed Cone Algorithm.

10. Select the Photon Energy to be used in the plan.

11. Select the Isocenter Location: Center of GTV.

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Task 5. Create a New Monaco Plan from Template (cont.)

12. Select OK to load the template and open the patient in Planning Control.

Figure 5-3: New Monaco Plan dialog box

Task 6. Edit DRR

1. Right-click in the DRR window, select Maximize from the menu.

2. Right-click in the DRR window, toggle Show MLC to turn the MLC display
on the DRR on and off.

3. Right-click in the DRR window, click Filters from the menu.

4. Select Sim Film from the DRR filters menu.

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Practice Exercise (cont.)

Task 7. Create Anterior Port

1. Select the Create and Edit Ports button.

2. In the Create/Edit Ports dialog box, select MLC as the Port.

3. Click to place a check mark in the Snap Jaws to Port box.

4. Use the mouse cursor to draw a whole pelvis port.

Superior: SI Joint
Inferior: Ischial tuberosities
Lateral: 2 cm lateral to the pelvic rim

5. Close the Create/Edit Ports dialog box.

6. Right-click in the DRR window, toggle Show MLC to turn the MLC display
on the DRR on and off.

Figure 5-4: AP DRR and Port

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Practice Exercise (cont.)

Task 8. Duplicate and Oppose Anterior Beam

1. Click the New Beam drop-down menu.

2. Create a posterior beam Select the Duplicate and Oppose

button.

Task 9. Edit Beams in Planning Activity

This task is only required when you need to add beams to or modify beam
arrangements from a template. This task should be less frequently used once you
create and save your own clinical templates.

1. In the Planning Control spreadsheet, click the Beams tab.

2. Select the General tab to modify Treatment Unit, energy, Isocenter location.

3. Select the Geometry tab to edit the Jaw parameters.

4. Label the Field ID for the applicable beam(s). Refer to the Planning Tools
section of this training guide for additional information.

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Practice Exercise (cont.)

Task 10. Add Right Lateral Beam

1. In the Planning Control spreadsheet, click the Beams tab.

2. Select the <click to add a new beam> option.

OR

Select the New Beam button.

3. Click the Geometry tab in the Planning Control spreadsheet.

4. Edit the Gantry angle to that of a Right Lateral.

5. Edit additional beam information. Use the steps in task 9.

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Practice Exercise (cont.)

Task 11. Create Right Lateral Port

1. Select the Create and Edit Ports button.

2. In the Create/Edit Ports dialog box, select MLC as the Port.

3. Click to place a check mark in the Snap Jaws to Port box.

4. Use the mouse cursor to draw a whole pelvis port.

Superior: SI Joint
Inferior: Ischial tuberosities
Posterior: S3
Anterior: Pubic symphysis

5. Close the Create/Edit Ports dialog box.

6. Right-click in the DRR window, toggle Show MLC to turn the MLC display
on the DRR on and off.

Figure 5-5: Right Lateral DRR and Port

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Practice Exercise (cont.)

Task 12. Duplicate and Oppose Right Lateral Beam

1. Click the New Beam drop-down menu.

2. Create a posterior beam Select the Duplicate and Oppose

button.

3. Edit beam information. Use the steps in task 9.

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Practice Exercise (cont.)

Task 13. (Optional) Edit a Port

The port editing tools enables you to reshape the MLCs of a port or to replace the
port. Follow these instructions if you want to manually make edits to your port.

Verify the active port before editing.

1. Click the Create and Edit Ports button.

2. Click the Replace editing tool radio button on the Create and Edit Ports
dialog box.

3. Left-click on the area of the port you want to edit. Hold and drag your
mouse to draw the new portal segment. The mouse cursor for editing a port
is a .

4. Click and drag the yellow edit box around the port to resize the port shape.

5. Click the Reshape editing tool radio button on the Create and Edit Ports
dialog box.

6. The selected MLC for editing is shown in red. The mouse cursor you use to
edit a port is . Click and drag a MLC leaf to the new location.

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Practice Exercise (cont.)

Task 14. Enter the Prescription

This task is only required when you need to edit the prescription from a template.
This task should be less frequently used once you create and save your own
clinical templates.

1. Select the Prescription tab on the Planning Control (Figure 5-6).

2. Type Whole Pelvis for RX Site.

3. Select Plan Isocenter in the Prescribe to Column.

4. Type 45 in the Rx Dose (Gy) column.

5. Type 25 in the Number of Fractions column. The Fractional Dose (Gy)

column automatically updates with 1.8 as the value.

6. Click Equal Weights to distribute the weight of the beams

equally.

Figure 5-6: Prescription Control

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Practice Exercise (cont.)

Task 15. Force Electron Density

This task is only required if there is an object in the treatment that needs to
maintain a constant mass density. In this studyset, the bladder structure contains
contrast.

1. Click the Structures tab on the Planning Control.

2. Check the Force ED box on the Bladder row of the spreadsheet.

3. The Relative ED for the bladder is now 1.0.

Task 16. Calculate Dose

1. Select the Calculate button, on the planning ribbon.

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Practice Exercise (cont.)

Task 17. Evaluate Isodoses and DVH

1. Open the Isodoses Control (Figure 5-7).

Figure 5-7: Isodoses

2. Adjust the Isodose display for your plan.

3. Review the isodoses on T/S/C and 3D views.

4. Right-click on the DVH window and select Statistics from the menu.

5. Review your plan. Use the DVH and DVH Statistics.

Task 18. Edit Beam Weights

1. Select the Prescription tab on the Planning Control.

2. Use the slider bar or numerical entry box to adjust

the beam weight in percentage.

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Task 19. (Optional) Rescale Dose

If your plan already has calculated dose, you can adjust the dose from within the
Planning activity.

1. Select the Prescription tab on the Planning Control.

2. Use the Rescale Dose dialog box drop down menus to rescale the dose.

Table 5-1: Rescale Dose

Name Description

to cover % and Structure field appears

to min dose of structure Structure field appears

to mean dose of Structure field appears

structure

to max dose of Structure field appears

structure

to dose at point All available points appear

to relative isoline You can type a value for the % isoline

in the number field that appears

to absolute isoline You can type a value for the cGy or Gy

isoline in the number field that appears

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Practice Exercise (cont.)

Task 20. Save the Plan

1. Click the Save button.

OR

Type (Ctrl + S) on your keyboard.

Task 21. Create 6 Field Boost Plan

1. Click on the drop-down arrow next to the New Plan button and select
New Monaco Plan in the drop-down list.

2. Type in a Plan Name and Description.

3. Select 3D for the Delivery.

4. Select All for the Anatomical Site.

5. Place a checkmark by the template named DEFAULT3D1beam (Rx Site ,

Rx Dose: 2.0Gy , Total Beams: 1).

6. Select Head First for the Treatment Orientation.

7. Select a treatment unit used in your clinic, labeled as Demo.

8. Select the Collapsed Cone Algorithm.

9. Select the Photon Energy to be used in the plan.

10. Select the Isocenter Location: Center of GTV.

11. Click OK to load the template and open the patient in Planning Control.

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Practice Exercise (cont.)

Task 22. Add/Edit Additional Beams

1. Click the Beams tab in the planning control.

2. Click <click to add a new beam> to create five additional beams.

3. On the Geometry tab, edit Gantry angles to generate a 6 field beam

arrangement.

4. On the General tab, edit the Beam Description and Field ID.

Task 23. Create Ports

1. Select the Create and Edit Ports button.

2. In the Create/Edit Ports dialog box, select MLC as the Port.

3. Auto Conform to Structure: PTV.

4. Type 1.0 (cm) for the Auto Conform Margin.

5. Click to place a check mark in the Snap Jaws to Port box.

6. Activate each beam and create a por. Use these steps.

7. Close the Create / Edit Ports dialog box.

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Practice Exercise (cont.)

Task 24. Enter the Prescription

1. Select the Prescription tab on the Planning Control.

2. Type Prostate Boost for RX Site.

3. Select Plan Isocenter in the Prescribe to Column.

4. Type 21.6 in the Rx Dose (Gy) column.

5. Type 12 in the Number of Fractions column. The Fractional Dose (Gy)

column automatically updates with 1.8 as the value.

Task 25. Edit Beam Weights

1. Use the slider bar or numerical entry box to

adjust the beam weight in percentage.

Task 26. Force Electron Density

1. Click the Structures tab on the Planning Control.

2. Check the Force ED box on the Bladder row of the spreadsheet.

3. The Relative ED for the bladder is now 1.0.

Task 27. Calculate Dose

1. Select the Calculate button, on the planning ribbon.

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Task 28. Evaluate Isodoses and DVH

1. Open the Isodoses Control.

2. Adjust the Isodose display for your plan.

3. Review the isodoses on T/S/C and 3D views.

4. Right-click on the DVH window and select Statistics from the menu.

5. Review your plan. Use the DVH and DVH Statistics to evaluate whether
95% of the PTV receives the prescribed dose and the example constraints
shown below:

Table 5-2: Planning Score Criteria example

Less Than … Receives…

Bladder 40% 66.6 Gy or higher

60% 50.0 Gy or higher

Rectum 25% 66.6 Gy or higher

50% 50.0 Gy or higher

Task 29. (Optional) Rescale Dose

1. Select the Prescription tab on the Planning Control.

2. Use the Rescale Dose dialog box drop down menus to rescale the dose.

Task 30. Save the Plan

1. Click the Save button.

OR

Type (Ctrl + S) on your keyboard.

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Task 31. Create Plan Summation

Monaco enables you to combine plans regardless of dose calculation matrix
variations. Monaco creates a new, independent dose matrix for plan summation.

1. In the workspace control, left-click to highlight the first plan you created.

2. Hold down the Control key and left-click on the second plan you created.

3. Right-click and select Sum Plans from the menu.

Task 32. Plan Summation Review

1. Use the Multiplan Navigation control and the slice mode indicator to reveal
the area of interest.

2. Adjust the color ranges in the isodose control.

3. Review the DVH.

Task 33. Save the Plan Summation

1. Click the Save button.

OR

Type (Ctrl + S) on your keyboard.

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