Dosimetric Review Reference Guide

Dosimetric Review

Reference Guide

ARIA® Radiation Therapy Management

13485 P1020789-001-A APRIL 2017

Document ID P1020789-001-A
Document Title Dosimetric Review Reference Guide
Abstract This document provides reference information and procedures for using the Plan
Parameters and Editing Log workspaces, Version 15.5, software.
This publication is the English-language original.
Manufacturer Varian Medical Systems, Inc.

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Disclosure
WHO ICD-O codes and terms used by permission of WHO, from:

■ International Classification of Diseases for Oncology, (ICD-O) 3rd edition,
Geneva, World Health Organization, 2000.
2 Dosimetric Review Reference Guide

ICD-10 codes and terms used by permission of WHO, from:
■ International Statistical Classification of Diseases and Related Health Problems,
Tenth Revision (ICD-10). Vols 1–3, Geneva, World Health Organization, 1992.
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Copyright © 2011 - 2017 Varian Medical Systems, Inc.
All rights reserved. Produced in Finland.
3
Contents
CHAPTER 1 INTRODUCTION ...............................................................................................................7

Prerequisites ....................................................................................................................................................... 7
Visual Cues .......................................................................................................................................................... 7
Contact Varian Customer Support ............................................................................................................... 8
Related Publications ......................................................................................................................................... 8
What is New in Plan Parameters and Editing Log .................................................................................... 9
CHAPTER 2 SAFETY AND EMERGENCY ..........................................................................................10

Safety and Emergency Information for Plan Parameters ......................................................................10
CHAPTER 3 WORKING IN PLAN PARAMETERS WORKSPACE ....................................................12

Working in the Plan Parameters Workspace ............................................................................................ 12
Overview of the Plan Parameters Workspace .......................................................................................... 12
Open the Plan Parameters Workspace ............................................................................................... 14
Select the Window Layout ..................................................................................................................... 14
Activate or Deactivate the Advanced Feature Set ............................................................................14
Measuring Tools for Images ...................................................................................................................15
Measuring Accuracy .................................................................................................................................15
Image Processing Tools ...........................................................................................................................16
Drawing Tools for Images .......................................................................................................................17
Plan Revision Tools ................................................................................................................................... 18
Icons in the Scope and Focus Panes .....................................................................................................19
Show or Hide the Workspace Bar .........................................................................................................19
Show or Hide the Context Window .....................................................................................................19
CHAPTER 4 TREATMENT PLANNING IN PLAN PARAMETERS WORKSPACE ..........................20

Defining Treatment Parameters in Plan Parameters Workspace ....................................................... 20
Create a New Plan .................................................................................................................................... 21
Create a New Field ...................................................................................................................................22
Create a New Block ..................................................................................................................................22
Create a New MLC ....................................................................................................................................22
Create a New Setup Field ....................................................................................................................... 23
Create an Artificial Image ...................................................................................................................... 23
Editing MU and Reference Point Doses .............................................................................................. 23
Proton Plans in Plan Parameters ..........................................................................................................24
Change the Field Order .......................................................................................................................... 24
Delete a Field .............................................................................................................................................25
Edit Dosimetric Data—Before Treatment Approval ............................................................................... 25
Edit Dosimetric Data—After Treatment ................................................................................................... 26
Working with Reference Points ................................................................................................................... 27
Add a Reference Point to a New Patient Volume .............................................................................29
Add a Reference Point to an Existing Volume .................................................................................. 29
Change the Primary Reference Point ..................................................................................................30

Using RT Prescriptions in the Plan Parameters Workspace ..................................................................30
Create a Plan from an RT Prescription ................................................................................................ 32
Update a Plan with a New Revision of an RT Prescription .............................................................32
Update a Partially Treated Plan with New Revision of Prescription ............................................33
Validating Plans for Treatment .................................................................................................................... 33
Validate a Plan .......................................................................................................................................... 34
Approving Plans in Plan Parameters .......................................................................................................... 34
Planning Approve a Plan in Plan Parameters ....................................................................................35
Treatment Approve a Plan in Plan Parameters .................................................................................36
CHAPTER 5 MANAGING PLANS IN PLAN PARAMETERS WORKSPACE ................................... 37

Managing Plans and Plan Revisions ........................................................................................................... 37
Copy and Paste a Plan ............................................................................................................................. 37
Delete a Plan ............................................................................................................................................. 38
Create a New Plan Revision ...................................................................................................................38
Create a New Template from a Plan ................................................................................................... 38
Working with MLC Plans ............................................................................................................................... 38
Import MLC Plans .................................................................................................................................... 39
Export MLC Plans ..................................................................................................................................... 39
Edit MLC Leaves ........................................................................................................................................39
Lock the MLC ............................................................................................................................................. 39
Viewing the Patient Position in Treatment Unit Pane .......................................................................... 40
Change the Patient Position in the Treatment Unit Pane .............................................................40
Display the Digital Graticule ....................................................................................................................... 40
Images and Layers in Field Graphics Pane .................................................................................................41
Show an Image in Field Graphics Pane ............................................................................................... 41
Show or Hide a Layer in Field Graphics Pane .....................................................................................41
Expand the Image in Field Graphics Pane ..........................................................................................41
Create a Match Layer for Anatomy Matching ..........................................................................................42
Create a Field Aperture Contour ................................................................................................................. 42
About Changing Treatment Units .............................................................................................................. 43
Exchange the Treatment Unit to a DEM ............................................................................................ 43
Change the Treatment Unit ..................................................................................................................44
Clear a 3D Dose Distribution ........................................................................................................................44
Convert a HyperArc Plan to a Regular Plan .............................................................................................. 44
Determining the Couch Shifts for Patient Treatment ............................................................................45
Determine the Couch Shifts for Patient Treatment ........................................................................ 45
Closing Courses ...............................................................................................................................................46
Change Course Status to Completed ................................................................................................. 46
CHAPTER 6 EDITING LOG WORKSPACE ........................................................................................ 47

Editing Log Workspace Options ...................................................................................................................47
Open the Editing Log Workspace ............................................................................................................... 48
Check the Editing Log .................................................................................................................................... 48
APPENDIX A SUPPORT OF 3RD PARTY TREATMENT ..................................................................49

Third-Party Treatment Options ...................................................................................................................49
Assigning Reference Images to the Same Reference Coordinate System ........................................49
Configure the FOR Override ..................................................................................................................50
Contents 5
Import a Plan and Image ....................................................................................................................... 50
Set the DRR as a Reference Image .......................................................................................................50
Validate a Plan with the Validate Plan Tool ....................................................................................... 51
Export a Plan to 3rd Party OIS ................................................................................................................51
INDEX .........................................................................................................................................................52

Chapter 1 Introduction
Prerequisites
To work effectively with Plan Parameters and Editing Log workspaces, you should
have a basic understanding of computers and of working within a Windows
environment. In addition, you should be familiar with linear accelerators.
Visual Cues
This publication uses the following visual cues to help you find information:
WARNING: A warning describes actions or conditions that can result in serious injury or
death.
CAUTION: A caution describes hazardous actions or conditions that can result in minor or
moderate injury.
NOTICE: A notice describes actions or conditions that can result in damage to equipment
or loss of data.
Note: A note describes information that may pertain to only some conditions, readers, or sites.
Tip: A tip describes useful but optional information such as a shortcut, reminder, or suggestion,
to help get optimal performance from the equipment or software.
Chapter 1 Introduction 7
Contact Varian Customer Support
Varian Customer Support is available on the internet, by e-mail, and by telephone.
Support services are available without charge during the initial warranty period.
The MyVarian website provides contact information, product documentation, and
other resources for all Varian products.
1. Go to www.MyVarian.com.
2. Choose an option:
■ If you have an account, enter your User login information (email and
password).
■ If you do not have an account, click Create New Account and follow the
instructions. Establishing an account may take up to two working days.
3. Click Contact Us at the top of the window to display customer support and
training options, and international e-mail addresses and telephone numbers.
4. From the Contact Us page, choose an option:
■ Call Varian Medical Systems support using a phone support number for your
geographic area.
■ Complete the form corresponding to your request for use on a call with a live
Varian representative; then follow the instructions to complete the remote
connection.
You can order documents by phone, request product or applications support, and
report product-related issues. Links on the MyVarian website navigate to other
support resources for products, services, and education.
5. To find documents, click Product Documentation.
Online documents in PDF format include customer technical bulletins (CTBs),
manuals, and customer release notes (CRNs).
Related Publications
For additional information, refer to the following sources:
■ Acuity Reference Guide
■ ARIA OIS for RO Instructions for Use
■ Clinac Technical Reference Guide
■ DICOM Import and Export Reference Guide
■ Eclipse Photon and Electron Instructions for Use
■ Eclipse Photon and Electron Reference Guide
■ Eclipse Proton Instructions for Use

■ Eclipse Proton Reference Guide
■ RT Summary Reference Guide
■ Treatment Delivery Instructions for Use
■ Treatment Preparation Reference Guide
■ TrueBeam Technical Reference Guide
What is New in Plan Parameters and Editing Log

Plan Parameters and Editing Log contain the following new features:
■ You can change the order of fields with the new Field Order command. Fields are
grouped by their isocenter, and you can move several fields at a time as an
isocenter group, or you can move a single field within an isocenter group.
Chapter 1 Introduction 9
Chapter 2 Safety and Emergency
Safety and Emergency Information for Plan Parameters

Safety Considerations
Where applicable, hardware, and software are designed to meet current international
technical and safety standards, for example, IEC, for the protection of operators and
patients.
Since hazards can be encountered, and risks cannot be ruled out completely,
instructions and procedures in the manuals must be followed to guarantee safety of
operators and patients.
Any use of the system and software which does not comply with the agreed use
described in this manual or other related Varian manuals is prohibited.
NOTICE: Regional Settings in the Windows operating system using commas as the
decimal separator are not recognized by the application. For example, the entry “1,23”
will not be recognized as “1.23”. The decimal point “.” should always be used regardless
of the Regional Settings.
Care Required
Careless handling or operating can result in poor performance, equipment and
environmental damage, potential fire hazards, and personal injury or death.
The equipment must be handled with care and kept in a good and safe condition as
described in the system manuals.
WARNING: Incorrect use of a radiotherapy linear accelerator can cause serious injury or
death. Only trained personnel under the supervision of a licensed physician should be
authorized by the hospital or owner to operate a clinical accelerator. The emergency and
safety procedures are described in the related Instructions for Use.
Responsibility
All persons who handle, use, or operate the system must read and understand the
chapters dealing with safety regulations and emergency procedures.
Only qualified and trained personnel are permitted to operate and maintain the
system and its parts.

The hospital management shall establish emergency and safety procedures before
operating the system and all personnel must be trained in such procedures.
The system must only be operated with its original and unmodified fittings and
parts.
No modifications to the system, its parts, or the software are permitted without prior
review and approval from Varian.
Varian cannot be held responsible for personal injury or equipment damage if:
■ Changes are carried out that are not in accordance with the instructions contained
in any Varian manual for the system, or if standards, and procedures not
authorized in writing by Varian are used.
■ Warning messages are ignored.
■ Updates, modification or repair instructions occasionally issued by Varian are not
complied with.
■ The equipment is used for purposes other than those intended.
■ The periodic inspection and maintenance instructions are not complied with and
records not kept.
■ Operation or maintenance work is performed by unqualified persons.
■ The instructions and safety regulations are not complied with by the operators,
maintenance staff, or guests.
■ Local laws and regulations have not been complied with.
■ Anomalies during operation and maintenance are not reported to Varian
immediately.
■ Legal or government regulations are not complied with.
Further Regulations
These instructions do not render any further hospital or local, state or country
regulations or laws invalid. Such regulations must be complied with at all times.
Chapter 2 Safety and Emergency 11

Chapter 3 Working in Plan Parameters Workspace
Working in the Plan Parameters Workspace

The Plan Parameters workspace is intended for creating new simple plans, and
implementing simple dosimetric edits.
Treatment fields are used for treating the patient. Setup fields are not used for
treatment delivery, but may be useful for setting up non-treatment angles for initial
positioning of the patient, or for imaging. Setup fields do not accumulate dose, thus
any dose from possible imaging is ignored.
CAUTION: All changes made to plans, including dosimetric and geometrical settings, are
used for patient treatment and may override data from other sources. Make all changes
with the utmost care, and verify the modified plans thoroughly before using them for
patient treatment. Incorrect data may result in a mistreatment.
Overview of the Plan Parameters Workspace

The Plan Parameters workspace contains the parts shown in the figure.

1 2 3 4 5 6 7 8 9 10
1. Scope pane: Right-click to select tasks 6. Plan Parameters pane.

from a drop-down list. 7. View pane, displays field parameter
2. Plan Parameters workspace tab. overview.
3. Menu functions. 8. Toolbar.
4. Plan Revision Filter toolbar. 9. Field Graphics pane.
5. Focus pane, outline view of fields and 10. Treatment Unit pane, indicates the gantry
images. position.
Figure 1 Plan Parameters Workspace
You can toggle the Field Graphics pane by selecting or clearing the Field Graphics
check box in the Plan Parameters pane.
You can toggle the Treatment Unit pane by selecting or clearing the Treatment Unit
check box in the Plan Parameters pane. A second DRR, simulation image or portal
image can be displayed instead of the Treatment Unit pane.
Tip: The Scope pane and the Focus pane are only shown if you are displaying the Context
Window (Window > Context Window).
Chapter 3 Working in Plan Parameters Workspace 13

Open the Plan Parameters Workspace
■ Click Plan Parameters workspace tab or choose QuickLinks > Treatment
Management > Plan Parameters.
Select the Window Layout

1. Choose Window > Arrange.
2. Select the layout and click OK.
Activate or Deactivate the Advanced Feature Set

Activating the Advanced Feature Set makes certain features available. For instance,
you can set images as reference images, create and edit layers, modify non-dosimetric
data, and define the tolerance table for fields.
Tip: You have to restart the application to activate the Advanced Feature Set.
1. Choose Tools > Task Configuration.

2. Turn the Advanced Feature Set on or off.
3. Restart the application.

Measuring Tools for Images
Table 1 Measuring Tools
Icon Description
Pixel/CT Number. Measures pixel intensity in the image and displays the number
in Hounsfield units.
Measure Distance. Measures the distance between two points. Click a start and
finish point and the distance is displayed in a label.
Measure Angle. Measures the angle between two lines. Click the first and second
points to create the reference axis on the image, then click a third point and the an-
gular information is displayed in a label.
Histogram. Creates a histogram of the Region of Interest (ROI). You can adjust the
histogram by entering values or selecting pre-set values from the drop-down lists.
Line Profile. Creates a line profile displaying pixel values measured along a line.
Measuring Accuracy
Measurement Accuracy in Images
The following formula expresses the measuring accuracy in images:
Max 0.1mm± 2 screen pixel size mm + image pixel size mm
This results in a measurement accuracy of about 4 mm for equipment with low
imager resolution and low screen resolution.
The accuracy with newer equipment is in the range of 1 mm.
Measurement Accuracy in Contours

The following formula expresses the accuracy for measuring contours:
Max 0.1mm± 2 screen pixel size mm
This results in a measurement accuracy of about 0.5 mm to 0.6 mm.

Note: The accuracy of the image position and isocenter position is not included in this
calculation. It is dependent upon the image that the image position and isocenter position is
accurate. However, image and isocenter accuracies are completely independent of the accuracy
of the measurement tools.
Image Processing Tools

Table 2 Image Processing Tools
Icon Description
Invert. Inverts the currently displayed treatment image.
ROI. Allows you to mark and adjust a ROI in which all image tools apply.
Window/Level. Displays the Window and Level control bars. To manually adjust
brightness and contrast of images.
Mouse Window/Level. Displays the Window and Level control bars. To manually
adjust brightness and contrast of images.
■ To adjust the brightness, press and hold left mouse button and move the mouse
up or down.
■ To adjust the contrast, press and hold left mouse button an move the mouse left
or right.
Auto Window/Level. Automatically adjusts brightness and contrast of images.
Digital Graticule. Displays/hides the digital graticule in displayed images.
Zoom In. Provides an area which can freely be chosen and sized with the mouse
pointer. The chosen area is magnified to the size of the entire window pane.
Zoom Out. Decreases magnification of the currently selected image.
Pan. Enables you to move image in the view by using the mouse, for example, if an
image has been zoomed in and is not entirely visible, you can pan the image for the
optimal view.
Rotate All. Enables you to rotate the entire image, including layers and MLC, to
any angle while pressing the left mouse button. Plan Parameters workspace dis-
plays the angle as you rotate the image.

Icon Description
Flip Left/Right. Mirrors the image and all its related overlays along its y-axis.
Flip Up/Down. Mirrors the image and all its related overlays along its x-axis.
Reset All. Resets the image display in respect to all manipulations (geometrical and
non-geometrical). Window/Level and Image Processing are not affected by this
function.
Reset Geometry. Resets the image display in respect to geometrical manipulations.
Grid. Displays and hides the image grid in displayed images. A scale indicator ap-
pears at the bottom right of the display.
Drawing Tools for Images

Which drawing tools you can use depends on what is currently selected in the Focus
pane.
■ When a contour is selected, all of the tools described in the table below are
available.
■ When an image is selected, only the Point, Rectangle, Ellipse, Freehand and
Annotation tools are available.
Table 3 Drawing Tools
Icon Description
Select. Selects or manipulates, that is, moving or resizing, contours and labels.
Rotate. Rotates selected contours by clicking and dragging anchor points.
Mirrors selected contours L/R (left/right). Mirrors the drawings along its y-axis
vertically.
Mirrors selected contours U/D (up/down). Mirrors the drawings along its x-axis.
Point. Places points that can be used for anatomy matching, or user-defined la-
beling. Using this tool when an image is selected, automatically creates and selects a
new contour if no contours exist previously.

Icon Description
Rectangle. Draws a rectangle that can be stretched and adjusted. Using this tool
when an image is selected, automatically creates and selects a new contour if no
contours exist previously.
Ellipse. Draws a circle or oval that can be stretched and adjusted. Using this tool
Freehand. To draw on the selected contour with the mouse. Using this tool when an
image is selected, automatically creates and selects a new contour if no contours
exist previously.
Annotation. To type a text label that appears at the point you click. Using this tool
Rubber Band / Modify the contour points. Automatically creates points along a se-
lected outline. To change the outline of the shape, pull on the points by using the
mouse.
Correction. To modify existing contours. To draw freehand, hold down the mouse
button. To draw straight lines click end points for the line. Finish the correction by
right-clicking in the context menu, and choose Correct, Remove Larger or Cancel.
Auto Margin. To automatically draw a margin of a designated size around a se-

lected contours.
Plan Revision Tools

With the Plan Revision Filter toolbar you select the type of plan information for
display. These modes are available from the drop-down list:
■ Planning View: Plan revisions in any state are displayed when this mode is
selected. If a new plan or plan revision is created, the display switches to the
Planning View mode automatically.
■ Review View: Only Planning Approved and Treatment Approved plan revisions are
displayed. This mode is used by dosimetrists to prepare 3D treatment plans. This
mode may be used for follow-up of treatments and dose accumulations.
Additional buttons toggle the display of retired and rejected plans:
■
Display Rejected Plan : Shows or hides plans with status Rejected.
■
Display Retired Plan : Shows or hides plans with status Retired.

Icons in the Scope and Focus Panes
■
—Plan
■
—Course
■
—Dose Matrix
■
—Setup Field
■
—Treatment Field
■
—Image
■
—MLC Plan
■
—Dose Dynamic MLC
■
—Contours/Layers
Show or Hide the Workspace Bar

■ Choose Window > Workspace Bar.
Show or Hide the Context Window

The Scope pane and the Focus pane are only shown if you have chosen Context
Window option.
■ Choose Window > Context Window or click in the toolbar.

Chapter 4 Treatment Planning in Plan Parameters
Workspace
Defining Treatment Parameters in Plan Parameters

Workspace
Plan Parameters is used for creating treatment plans, treatment and setup fields and
the necessary parameters, for adding reference images and reference points, and for
checking and modifying plans created in Eclipse.
CAUTION: All definition and planning actions, including dose planning and geometrical
settings, are used for treatment and can override possible data from other sources, such
as Eclipse or a 3rd party treatment planning system. Perform all planning actions with
the utmost care verifying the planned data thoroughly before releasing it for treatment.
Incorrect data can result in a mistreatment.
If the treatment is planned with Eclipse, all relevant fields, dose and image
information are automatically available in the Plan Parameters workspace.
Treatment fields and other data must be created for a plan in following cases:
■ Treatment planning was not made with Eclipse. All dose, target volume and
fractionation planning data is calculated externally and may be entered using the
Plan Parameters workspace.
■ Treatment planning was made with 3rd party planning system and transferred to
the Varian system server using DICOM RT.
■ The treatment was simulated (with Acuity or Ximatron) and geometrical
treatment field parameters were acquired there. Dosimetric parameters can be
entered in Plan Parameters for the plan.
■ If no image data is available, an artificial image needs to be created prior to using
the graphical tools for defining field size or shape, see Create an Artificial Image
on page 23.
Note: The Gantry/Source Rtn value represents the position of the active beam, corresponding
to the gantry position for treatment fields, or the kV source position for setup fields.

Create a New Plan
Note: A course is created automatically during plan creation if the patient has no course
available.
1. Choose Insert > New Plan.

2. If prompted to do so, select an RT prescription for the plan. To review the RT
prescription, click Preview.
3. Define the plan details:
■ Define an ID and Name for the plan, or use the default ID.
■ In the Intent list, select the purpose of the treatment.
■ Define the Dose per Fraction and Number of Fractions.
4. Select the primary reference point for the plan, or create a new one.
The patient volume selected for the primary reference point is automatically
defined as the target volume of the plan.
5. Select the treatment unit for the plan.
6. Select the patient position during the treatment.
7. Click Finish.
The new plan is shown in the Scope pane and in the View pane.
8. Complete all mandatory text boxes. For treatment fields, all additional
parameters must be defined.
To use 2D/2D matching with kV imaging, you have to create two orthogonal
setup fields. For CBCT, you need 3D image data of the patient.
Related Topics
Create a Plan from an RT Prescription on page 32
Chapter 4 Treatment Planning in Plan Parameters Workspace 21

Create a New Field
1. In the Plan Parameters pane, choose Field > New Treatment Field, or press F9.
To use 2D/2D matching with kV imaging, you have to create two orthogonal
setup fields. For CBCT, you need 3D image data of the patient.
The new field is listed in the Scope pane for the respective plan and in the View
pane. If the plan already contained a field, the new field will use the same
treatment unit as the previous treatment field.
2. Define the parameters for the field.
Note: For imager positions to be transferred correctly to the treatment console, you need to
define all imager position parameters for the field. Default values can be specified in the
operating limits of the treatment unit in RT Administration.
Tip: To be able to select the tolerance table for the field, you need to activate the Advanced
Feature Set.
Create a New Block

You can add a block to a plan if there is no dose in the plan.
1. In Focus pane, right-click Field and choose New Block from the context menu.
2. Click OK.
3. Create a block contour using drawing tools, for example Freehand.
Create a New MLC

You can add an MLC to a plan when there is no dose in the plan.
1. In Focus pane, right-click Field and select New MLC from the context menu.
2. Click OK.
3. Edit the MLC as necessary.

Create a New Setup Field
Setup fields are used for moving the treatment unit to the correct treatment position
or for aligning the patient correctly for treatment. The dose distribution is not
calculated for setup fields and they cannot be used for patient treatment.
Note: When using setup fields in HyperArc plans, note that the field order cannot be changed
in them. A setup field can only be the first or the last field in the plan.
1. Do one of the following:

■ In the Plan Parameters pane, choose Field > New Setup Field.
■ In Focus pane, right-click a field and choose New Setup Field from Selected
Treatment Field.
2. Define the parameters for the field.
Note: For imager positions to be transferred correctly to the treatment console, you need to
define all imager position parameters for the field. Default values can be specified in the
operating limits of the treatment unit in RT Administration.
Create an Artificial Image

If a treatment field does not contain a reference image (simulator image or DRR), you
can create an artificial reference image for the field. The artificial image must be
created before you can add a layer, block, or MLC. The Advanced Feature Set must
be selected.
1. In the Focus pane, right-click a field without a reference image and then choose
Create Artificial Image.
2. Click OK.
3. Add the desired structures using the drawing tools, for example Freehand.
Editing MU and Reference Point Doses

MU and reference point doses are editable for plans without 3D dose distribution.
Reference points without a location are editable also in plans with 3D dose
distribution.

If the MU Dose Scaling option is selected, and you edit the MU value in a photon or
electron field, the reference point doses (shown in the Dose to <Reference point ID>
cells) are scaled accordingly. The values that will be scaled are indicated by an arrow
icon , and the edited and scaled values are shown in bold in the View pane (until
you save the plan). If the MU Dose Scaling option is not selected, the reference point
doses are not scaled. In both cases, if you edit the dose from the field to the any of the
reference points (Dose to <Reference point ID>), the MU values are not scaled.
Editing of MU values is available also for calculated proton plans for which the MU
values have not been calculated by the planning system. If you have a calculated
proton plan without MU values defined, you can edit the MU value, but the reference
point doses will not be scaled.
Proton Plans in Plan Parameters

Most proton plan parameters and proton field parameters are read-only in Plan
Parameters. The following actions are allowed:
■ Assigning and editing virtual trays (Accessory parameters).
■ Editing the maximum treatment time (Max. Tx Time).
■ Editing of MU values (available for calculated proton plans for which the MU
values have not been calculated by the planning system).
■ Changing the field order.
■ Changing the plan status.
■ Changing the treatment unit of all fields to a dosimetrically equivalent machine.
■ Creating a plan revision.
■ Editing, deleting and adding field images.
Note: It is not possible to delete the 3D dose of a proton plan in Plan Parameters.
Change the Field Order

Note: Field order of HyperArc treatment fields cannot be changed. You can move the setup
field as the first or the last field in the plan.
1. In the Plan Parameters pane, choose Field > Field Order.

If the Lock isocenter groups check box is selected, all fields within an isocenter
group will be treated in sequence. If you clear the check box, a field in the list can

be moved freely, which may disrupt the treatment order within the isocenter
group.
2. To change the field order, do one of the following:
■ Sort the fields within an isocenter group by clicking Sort by Gantry CW or
Sort by Gantry CCW. You cannot sort the fields by gantry rotation if one or
more of the fields is an arc field.
■ Select a field in the Fields list and move it within the isocenter group by
clicking Field Order Up or Field Order Down.
■ To move all fields within an isocenter group up or down, click Group Order
Up or Group Order Down. The isocenter groups are renamed according to
the new treatment order.
3. Click OK to apply the new field order.
Delete a Field
You can delete a Treatment field if the plan is in Unapproved state.
■ Right-click the field column to be deleted, then select Delete.
■ Right-click the field to be deleted in Scope or Focus pane, and select Delete.
2. Click Yes.
Edit Dosimetric Data—Before Treatment Approval

Follow this procedure to review, complete, or change dosimetric data in a plan that
already exists but is not Planning Approved or Treatment Approved.
You have reviewed the possible validation errors and warnings either in the
Treatment Preparation or Plan Parameters workspace.
1. In the Scope pane, do one of the following:
■ If the plan contains a 3D dose distribution, right-click the plan and choose
Clear 3D Dose Distribution from the context menu.
■ Right-click on the dose and choose Delete from the context menu.
The system prompts you to select how to handle the existing MU and dose
distribution:
■ Keep the MU and reset the dose distribution,
■ or reset the MU and dose distribution.
2. To cancel edits or stop the procedure, select Cancel.

3. Edit the dosimetric data.
If the MU Dose Scaling option is selected, the reference point doses are scaled
accordingly. If the MU Dose Scaling option is not selected, the reference point
doses are not scaled. In both cases, if you edit the dose from the field to the any of
the reference points, the MU values are not scaled.
4. Save your data.
ARIA RTM validates whether the data you entered is in the allowed range, saves
the edits, and updates validation errors or warnings.
5. If you have reset the distribution, recalculate the dose per fraction after editing
the dose.
You can now validate the plan again in the Treatment Preparation or Plan
Parameters workspace.
Edit Dosimetric Data—After Treatment

Follow this procedure to edit dosimetric parameters in a plan that is Treatment
Approved and has been treated at least once.
1. In the Scope pane, right-click the plan and then choose Create Plan Revision.
■ In case of a 3D dose calculated plan, right-click the plan and then choose
Clear 3D Dose Distribution.
■ Right-click the dose and then choose Delete.
3. The system prompts you to select how to handle the existing MU and dose
distribution:
■ Keep the MU and reset the dose distribution or
■ Reset the MU and dose distribution.
If the MU Dose Scaling option is selected, the reference point doses are scaled
accordingly. If the MU Dose Scaling option is not selected, the reference point
doses are not scaled. In both cases, if you edit the dose from the field to the any of
the reference points, the MU values are not scaled.
5. Do one of the following at the prompt to approve the selection:
■ Enter your user name and password to approve the selection.
■ To edit the plan in the Treatment Planning System (Eclipse) or in a third-party
TPS that originated the plan, go to that system or workspace.
7. Save your data.
ARIA RTM validates whether the data you entered is in the allowed range and
saves the edits.

■ In the plan revision you created in the Scope pane, select another set of
dosimetric parameters and follow this procedure to revise them.
■ Approve the plan from state Planning Approved to Treatment Approved.
Working with Reference Points

A reference point is a point in the body into which dose may be accumulated during
treatment, for example, the tumor region or other locations of interest for dose
delivery. A reference point is related to a patient volume, and several reference points
can be defined within a patient volume. Before you can create a reference point, the
related patient volume must be defined.
The primary reference point is used for defining the field dose contribution
parameters for the plan. In ARIA RTM, it is beneficial to have a primary reference
point without location to track the dose prescription values from the treatment
planning regardless how the plan has been normalized. Other reference points may
be defined at secondary points of interest; these may also be critical structures that
you wish to track dose values.
Reference points can be managed in the Plan Parameters workspace. You can:
■ Create, delete, and modify reference points.
■ Assign reference point to plans and set a reference point as the primary reference
point with the Reference Point Organizer. The primary reference point is marked
by .
Note: In Reference Point Organizer, reference points with geometrical location are
indicated with the label [3D] after the reference point ID.
■ Check, define, and modify the Session Dose Limit, Daily Dose Limit and Total
Dose Limit for each reference point in the Reference Point Properties.
Reference points can also be assigned to multiple plans, and you can define dose
limits and breakpoints for each reference point of one or multiple plans. Editing dose
limits and breakpoints is possible as long as the status of at least one plan
contributing to the reference point is not Treatment Approved, Retired, or
Completed.

2 3
1. Primary reference point.

2. Dose to primary reference point from all fields in the plan during one fraction.
3. Dose to primary reference point from one field during one fraction.
4. Other reference points in the plan with doses from all fields and from each field during one fraction
shown.
Figure 2 Reference Point Information in Plan Parameters
You can filter out the secondary reference point information from the View pane by
going to the Plan Parameters pane and clearing the Secondary Reference Points
check box.
Reference points may be deleted as long as there is no dose contribution from earlier
treatments.
Note: For proton plans, manually enter the MU value for each planned field. These values are
determined by water phantom measurements based on the corresponding verification fields.
You can further modify reference point information in Plan Scheduling. You can do
the following:
■ Define dose limits for reference points.
■ Define and modify breakpoints for reference points.
■ Add secondary reference points without location after Planning Approval.
■ Define field dose to the secondary reference points after Planning Approval.

Add a Reference Point to a New Patient Volume
■ In the Plan Parameters pane, click the Add Reference Point button and then
choose New.
■ Right-click the Reference Points folder in the Context Window, select
Reference Point Organizer from the context menu, and then click New.
2. In the Reference Point Properties dialog box, type an identification and name for
the reference point.
3. In the Patient Volume group box, click New.
4. In the Patient Volume Properties dialog box, type an identification and name for
the new patient volume.
5. Select the Volume Type from the drop-down list.
6. To define a volume code for the patient volume, click Search to display the Select
Code dialog box, containing a list of all available codes.
7. Select the appropriate code and click OK.
8. Click OK.
9. Define the ID and the dose limits for the reference point.
Tip: You can also define the dose limits in Plan Scheduling, where you can see an overview of
the dose per reference point.
10. Click OK.

The reference point is automatically included in the open plan. If the patient has
more than one plan, use the Reference Point Organizer to include the reference
points to the desired plans.
Add a Reference Point to an Existing Volume

■ In the Plan Parameters pane, click the Add Reference Point button and then
choose New.
■ Right-click the Reference Points folder in the Context Window, select
Reference Point Organizer from the context menu, and then click New.
2. In the Reference Point Properties dialog box, type an identification and name for
the reference point.
3. Select a patient volume that the point will represent.

4. Define the dose limits.
Tip: You can also define the dose limits in Plan Scheduling, where you can see an overview of
the dose per reference point.
5. Click OK.
6. Click Close to close the Reference Point Organizer.
The reference point is automatically included in the open plan. If the patient has
more than one plan, use the Reference Point Organizer to include the reference
points to the desired plans.
Change the Primary Reference Point

Changing the primary reference point for a plan clears the MU values. The dose to
the primary reference point and the MU value must be defined if you want to
treatment approve a plan.
Note: The primary reference point cannot be changed for a plan that has 3D dose calculated in
Eclipse.
1. Select the required plan.

2. Right-click the Reference Points folder in the Context Window and select
Reference Point Organizer from the context menu.
3. Select the point in the Plan Reference Points list box and click Set Primary.
Note: In ARIA RTM, it is beneficial to have a primary reference point without location to
track the prescription dose regardless of which volume the plan is prescribed to. This way the
dose adds up with a round number in the Treatment Preparation workspace, for instance,
180 cGy instead of 181.2 cGy, as treatments are accumulated.
Using RT Prescriptions in the Plan Parameters Workspace

An RT prescription is a way of communicating dose prescription and treatment
management information between Workflow Management components and other
applications. Using an RT prescription allows the definition of the dose prescription
for the target, for instance, by the oncologist in the Prescribe Treatment workspace
before starting treatment planning. The dose prescription can be defined for a
volume, depth, isocenter or isodose line.

You can use RT prescriptions in your treatment plans in the Plan Parameters
workspace by linking the appropriate RT prescription to the plan. The RT
prescription must be found in the same course as the plan, and it must be in draft,
reviewed,or approved status. It is also possible to base multiple plans on one single
RT prescription. An RT prescription may also contain dose prescriptions for several
targets, and you can create a separate plan for each of them.
In Plan Parameters, RT prescriptions defined for a patient are displayed under the
course they belong to in the Scope pane. Plans linked to an RT prescription are
displayed under the RT prescription in question in the Scope pane. The statuses of
the RT prescription are indicated by icons.
■ —Draft RT prescription
■ —Reviewed RT prescription
■ —Approved RT prescription
■ —An old revision of an RT prescription. This icon is shown only when a newer
revision of the RT prescription exists, but a plan is still linked to an old revision.
■
—An RT prescription that has been errored out. This icon is shown only if
there are plans that are still linked to the RT prescription.
Details of the RT prescription are shown in RT prescription properties, from where
you can also open the prescription in read-only mode in the Prescribe Treatment
workspace. If the RT prescription contains constraints that have been defined in the
Prescribe Treatment workspace, they are shown on the Constraints tab in
Prescription Properties.
If the course in which you are creating a plan contains an RT prescription, you can
link the plan to the RT prescription during the plan creation. You can also create a
photon plan by right-clicking the RT Prescription icon in the Context pane in Plan
Parameters. You can update the link from the plan to an RT prescription, exchange
the link to another RT prescription or remove the link after creating the plan.
RT prescriptions are versioned in the Prescribe Treatment workspace. If an approved
RT prescription that is linked to a plan is modified, the new revision is shown in the
Plan Properties. The revision number is displayed after the name of the RT
Prescription in the Scope pane and Prescription Properties. To copy the dose values
from the new revision to the plan, you need to update the plan manually by clicking
Update Plan. If necessary, you can also view the original and the new revision of the
prescription.

Create a Plan from an RT Prescription
This information applies to creating photon and electron plans in Plan Parameters
workspace.
1. In Plan Parameters, right-click the prescription in the Scope pane, and do one of
the following:
■ To create a plan for one target, select Create plan for.
■ To create separate plans for all targets that have an RT prescription defined,
select Create One Plan Per Prescribed Target.
2. In the Plan Properties dialog box, select the RT Prescription tab.
3. In the Treatment Prescription group box, verify the details of the RT prescription
and click OK.
Update a Plan with a New Revision of an RT Prescription

When updating a plan with a new revision of an RT prescription in the Plan
Parameters workspace, you can select whether to update the dose prescription
related data.
1. In the Scope pane, right-click the plan and choose Properties.
2. Click the RT Prescription tab. If there is a new revision of the RT prescription,
you can see an icon and a help text about the new RT prescription revision.
3. To view the new revision, click Latest Revision Properties. To view the current
RT prescription, click Linked Revision Properties.
Tip: To view the details of the RT prescription in Prescribe Treatment workspace in read-only
mode, click Open in the Prescription Properties.
4. To update the current plan with the dose prescription values from the new
revision, click Update Plan.
5. In the Update Plan dialog box, you can compare the current dose prescription
values in the plan and the new values from the new revision.
6. To apply the new values to the plan, select the corresponding check box and click
Update.
The plan is linked to the new revision of the RT prescription, and the new values
are copied to the Dose tab.
7. In the Plan Properties dialog box, click Apply or OK.
The new values are copied to the plan.

Update a Partially Treated Plan with New Revision of Prescription
If the prescription linked to a plan is modified during the treatment, you need to
manually link the new revision of the prescription to the plan. Since the plan is
Treatment Approved, you first create a new revision of the plan.
1. To create a new revision of the partially treated plan, in the Context Window,
right-click the plan and then choose Create Plan Revision.
2. In the message that informs you about the new revision of the prescription, click
OK to link the new revision of the prescription to the new revision of the plan.
3. To apply the new prescription values to the plan, select the corresponding check
box and click Update.
4. In the Linking Plan to Prescription dialog box, choose the option how to process
the fractions that have been treated and then click OK. Depending on option, the
plan MU values and doses are scaled according to the new revision of the
prescription. The scale is shown in the dialog box.
The new plan revision appears below the new revision of the prescription in the
Context Window.
Validating Plans for Treatment

Before approving plans for treatment, they can be validated for treatment by using
the Validate Plan for Treatment tool, which checks the plan and informs you about
possible invalid or missing parameters. This allows you to correct the data in order to
have the plan ready for Treatment Approval.
Note: The Validate for Treatment function checks on the basic validity of plan data for
Treatment Approval. It cannot check whether you have accidentally entered inappropriate
values that are still within the maximum or minimum range, for example, if you enter an
incorrect gantry angle or field size.

Validate a Plan
Note: The Validate for Treatment function checks on the basic validity of plan data for
Treatment Approval. It cannot check whether you have accidentally entered inappropriate
values that are still within the maximum or minimum range, for example, if you enter an
incorrect gantry angle or field size.
1. Do one of the following.

■ In the Plan Parameters pane, click Validate for Treatment.
■ In the Scope pane, right-click the plan to be validated and then select Validate
Plan for Treatment.
The plan is now proofed and the Validate Plan for Treatment dialog box lists all
existing plan-level or field-level conflicts. The issues are categorized into errors
and warnings.
■ You must correct the errors listed before approval.
■ If there are only warnings listed, you can approve the plan but the warnings
will be logged in the system log file. It is recommended to solve the issues
causing the warnings before the plan is approved for treatment.
2. Correct all possible invalid data.
3. Repeat until a message box confirms the plan is ready for Treatment Approval.
Approving Plans in Plan Parameters

Plan approval statuses for external beam plans are changed using the Planning
Approval wizard. The wizard first validates the plan and notifies about
inconsistencies in the plan.
You can give the following approval statuses to plans in Plan Parameters:
■ Planning Approval.
■ Treatment Approval.

Planning Approve a Plan in Plan Parameters
Before approving a plan, review it and ensure that it belongs to the intended patient.
Note: If you have linked an RT prescription to a plan, check that the RT prescription has not
changed before approving the plan. Right-click the plan in the Scope window, and select
Properties > RT Prescription. If the prescription has changed, you can see a warning icon
and a notification text on the tab. If you want to update the new dose values to the current
plan, click Update Plan.
1. In the Scope window, right-click the plan to be approved and select Plan
Approval > Planning Approved.
If the system has been configured to allow it, the structures belonging to the
structure set to which the plan references are approved simultaneously.
2. Review the messages shown, and, if appropriate, click Next to proceed.
3. Review the dose prescription and 3D dose statistics for the plan target volume
and, if appropriate, click Next to proceed.
Note: If you are approving a plan created from an RT prescription, the wizard page also
shows whether there are other plans created from the same RT prescription.
4. In the wizard pages that follow, review the information shown and choose from
the following options:
Choice Description
Use values Uses the calculated delta couch shift values. To clear the
calculated from couch shift values, click Clear.
user origin
Planned SSD Defines the planned SSD for the fields. Click OK to accept
the SSD value suggested. To use some other value, type the
desired value to the Planned box and then select OK.
Calculate Calculates the treatment time for the fields. Define the
Treatment Times treatment time factor in the Multiply with Factor box. The
range of the factor is 1.00 to 5.00.
5. Click Finish.
6. To grant the plan Planning Approval, type your user authentication information
and click Approve.

Treatment Approve a Plan in Plan Parameters
The plan must be Planning Approved and scheduled. If the plan is linked to a
prescription, the prescription must be approved before the plan can be Treatment
Approved.
1. In the Scope window, right-click the plan to be approved and select Plan
Approval > Treatment Approved.
2. To grant the plan Treatment Approval, type your user authentication information
and click Approve.

Chapter 5 Managing Plans in Plan Parameters
Workspace
Managing Plans and Plan Revisions

A patient can have multiple plans within one course. A plan chain consists of one
active plan and one or more retired plans.
If the treatment has already started, the parameters of the plan are locked and no
more modifications can be made to a plan. By setting the treated plan status to
Planning Approved, the positioning and imaging parameters become editable. Setup
fields can be also editable in some specific cases. A new plan revision or a plan copy
has to be created in order to modify dose related data.
If the plan has a gating protocol defined, creating a plan revision clears the gating
protocol. You can reselect the gating protocol in Treatment Preparation.
Plan revisions are visible in the Scope pane. The fields of the new plan revision are
displayed normally in the View pane.
Toggle the display of retired plans by clicking the Display Retired Plans button
( ) in the Plan Revision Filter toolbar.
Copy and Paste a Plan

Instead of creating a new plan, you can copy a plan of the patient and paste it to the
same or another course of the same patient. A copied plan can be modified as
required for the next stage of treatment, for example, reducing field sizes for a Phase
2 treatment.
Tip: Defining multiple fractionations for a plan is no longer supported. Instead of including
multiple fractionations in a single plan, you can create a copy of a plan, modify the number of
fractions or dose per fraction in the plan copy, and optionally, create a plan sum of the plans in
External Beam Planning.
1. In the Scope pane, right-click the plan and choose Copy Plan.
2. In the Course list, select the course into which you wish to paste the plan.
3. In the Scope pane, right-click the course and do one of the following:
■ Paste > Plan
■ Paste > Plan with Reference Images
Chapter 5 Managing Plans in Plan Parameters Workspace 37

■ Paste > Plan as Verification Plan
The Plan Properties dialog box opens, suggesting a default plan ID.
4. Change the plan ID and modify the plan parameters if desired.
5. Click OK.
Delete a Plan
A plan can only be deleted if the plan status is Unapproved or Rejected. The plan
cannot be deleted if it has treatment history.
1. In the Scope pane, right-click the plan and choose Delete.
2. Click OK.
Create a New Plan Revision

A plan revision can only be created on a plan that has treatment history.
■ In the Scope pane, right-click the plan and choose Create Plan Revision.
A new plan is automatically added to the plan chain, and the plan and field
information is copied.
The plan ID is generated automatically. The existing plan ID is appended with a
sequence number to identify the revision.
Create a New Template from a Plan

Treatment prescriptions can be created by using existing plan templates. Usually, a
new template is based on a previously defined plan.
1. In the Scope pane, right-click the plan to be stored as a template and then choose
Create Template From Plan.
2. In the Create Plan Template - Identify the new Plan Template dialog box, check
or modify the template ID and enter additional parameters.
3. Click Next.
4. In the Create Plan Template - Select Plan Template Contents dialog box, select
the items to be included, then click Next.
5. In the Create Plan Template - Review Plan Item Placement dialog box, check or
modify the placement parameters and click Finish to store the template.
Working with MLC Plans

You can open an MLC plan in the Field Graphics pane and view it as an overlay
superimposed on a reference image.

Import MLC Plans
1. In the Focus Window, select the field to import the MLC into.
2. Choose File > Import > MLC Plan in Varian MLC Format.
3. Select the appropriate MLC type and click OK.
4. Locate the import directory.
5. Select the MLC file to be imported.
6. Click Open to add the MLC to the plan.
7. Edit the MLC leaves if necessary.
Export MLC Plans

1. If not selected, select the Field Graphics check box in the Plan Parameters pane.
2. In the Focus pane, right-click the MLC plan.
3. From the drop-down list, select Export MLC plan in Varian MLC format.
4. Follow the prompts to export the MLC plan to the desired file.
Edit MLC Leaves

You can edit individual MLC leaves or groups of leaves in the Field Graphics pane.
1. In the Focus pane, select the MLC.
2. To expand the MLC view, click Maximize on the title bar of the Field Graphics
pane.
3. Right-click in the Field Graphics pane and then choose Deselect All.
Leaves turn blue.
■ To move one leaf, click and drag the leaf to a new location.
■ To select multiple leaves, hold the Ctrl key, click the leaves you wish to select,
and then drag them to a new location.
5. To view numbered labels for individual MLC leaves, click the Leaf Labels
On/Off tool on the toolbar.
Lock the MLC

You can lock the MLC to prevent accidental editing of the MLC.
1. In the Focus pane, click the MLC for the field.
2. Click the Lock/Unlock toolbar button ( ).

Viewing the Patient Position in Treatment Unit Pane
The patient position on the couch, plus the position of the gantry for each field are
shown in the Treatment Unit pane so you can view an approximation of the field
setup. If the plan has been created on 3D images, the treatment unit pane is
automatically available.
Figure 3 Treatment Unit Pane
CAUTION: The Treatment Unit pane is not designed as a collision detection system and
should not be used in place of dry run collision checks. Before delivering treatments,
always perform a dry run to make sure there are no collisions between the patient and
the treatment unit equipment.
Change the Patient Position in the Treatment Unit Pane

1. In the Plan Parameters pane, select the Treatment Unit check box.
2. In the Scope pane, right-click the plan and then choose Properties.
3. In the Plan Properties dialog box, choose the General tab.
4. In the Patient Orientation drop-down list, select a patient orientation.
5. Click OK.
Display the Digital Graticule

You can view an image with a digital graticule superimposed.
■ On the View menu, select Shows/Hides Digital Graticule.
The digital graticule appears over the image in the Field Graphics pane.

Images and Layers in Field Graphics Pane
You can view images in the Field Graphics pane. You can change the shape of
outlines, draw ROI, mark points for anatomy matching, and create user-defined
contours.
Show an Image in Field Graphics Pane

■ Do one of the following:
■ Click the Field icon in the Scope pane.
■ If the Treatment Unit check box is not selected the Plan Parameters pane,
select the image and drag it into Treatment Unit pane.
Show or Hide a Layer in Field Graphics Pane

■ Select or clear the visibility check box next to the icons for the field elements, such
as layers and MLC plan, in the Focus pane.
Expand the Image in Field Graphics Pane

■ Click Maximize on the title bar of the Field Graphics pane.

Create a Match Layer for Anatomy Matching
Note: To be able to create a match layer for anatomy matching, you need to turn on the
Advanced Feature Set.
To perform anatomy matching, you can create an additional image layer and define
the match structures on this layer.
1. Right-click the Image icon in the Focus pane.
2. Select New Layer.
3. Define the type as Match Anatomy.
4. Click OK.
5. Add the desired structures using drawing tools, for example Freehand.
Create a Field Aperture Contour

To be able to create a field aperture contour, you need to turn on the Advanced
Feature Set. The field must have a reference image, the plan must be Planning
Approved, Reviewed or 3rd Party Approved.
Note: The Field Aperture Contour is automatically created by the Treatment Daemon when
loading the plan on the console, if configured in the Treatment Daemon configuration.
Note: Field aperture contours cannot be created for dynamic or conformal arc fields.
1. To show the Field Graphics pane, select the Field Graphics check box in the Plan
Parameters pane.
2. In the Focus pane, right-click the Field icon and select Create Field Aperture
Contour.
The Field Aperture icon appears in the Focus pane.
3. Add the desired contour using drawing tools, for example Freehand.
4. Choose File > Save All.

About Changing Treatment Units
Sometimes it is necessary to exchange the treatment unit in a plan without otherwise
changing the plan. The treatment unit to be used in the actual patient treatment may
not be known when the planning process is started. It might also be necessary to start
using a different treatment unit in the course of a treatment without recalculation.
ARIA RTM allows exchanging the treatment unit for a Dosimetrically Equivalent
Machine (DEM). DEM are treatment units having the same or equivalent
configuration with each other. You can freely transfer a treatment from one DEM to
another without changing the original plan. This is possible in Plan Parameters
workspace. You can define which treatment units are interchangeable in treatment by
creating Dosimetrically Equivalent Machine Groups in RT Administration. For
more information on managing these groups, refer to RT Administration Reference
Guide.
Changing the treatment unit to a DEM creates a new plan revision of the original
plan (the original plan is set to the Retired status). The revision is an exact copy of the
original plan, and it will retain the original dose and approval status. Any scheduled
treatment sessions are also retained.
The following preconditions apply to the plan and are checked by Plan Parameters
workspace when you exchange the treatment unit to a DEM.
■ The plan is calculated or approved. If the plan is unapproved and does not have a
calculated dose, the Change Treatment Units function is used.
■ The treatment unit for all fields is the same. However, the fields can use multiple
energies within the same treatment unit.
■ The original treatment unit and the equivalent machine belong to the same group
of equivalent machines and use the same beam data. The equivalent machine
must be in Active state.
■ The equivalent machine contains dosimetric equivalents for all accessories, and
the accessories are in Active state.
■ The dose rate in the equivalent machine supports the primary fluence and energy
mode combinations used in the plan.
Exchange the Treatment Unit to a DEM

To be able to exchange the treatment unit to a DEM, a DEM group must be
configured, and the machines in the DEM group must share the same beam data.
1. Choose Parameters > Change to Dosimetrically Equivalent Machine.
2. From the list of DEMs, select the one you want to use. You can view remarks,
errors and warnings regarding the checks performed in the message log box.

3. Click Convert.
4. Confirm the creation of a new plan revision from the original plan.
Change the Treatment Unit

The treatment unit can be changed in Field Properties if the plan is unapproved and
does not have a calculated dose.
1. In the Focus pane, right-click the required field and choose Edit > Properties.
2. In Field Properties choose the General tab.
3. In the Machine drop-down list, select the treatment unit.
4. Click OK.
Clear a 3D Dose Distribution

If you want to add or edit a parameter that impacts the dose distribution you have to
clear the 3D dose distribution previously.
1. In the Scope pane, do one of the following:
a. Right-click the dose and select Delete.
b. Right-click the plan and select Clear 3D dose distribution.
2. In the open dialog, select or clear the check box Do not clear MUs and reference
point doses.
3. Click OK.
Convert a HyperArc Plan to a Regular Plan

You can convert a HyperArc plan to a regular plan by removing the automatic beam
delivery support from the plan. This performs the following changes in the plan: The
field setup technique is set to Isocentric, and the links from the fields in the plan to
fixation devices are removed.
1. In the Context Window, right-click the HyperArc plan and then choose Remove
Automation.
2. Confirm the removal by clicking Yes.

Determining the Couch Shifts for Patient Treatment
To facilitate correct patient setup during treatment, you can use Eclipse to
automatically determine the couch shifts required in the treatment room. The shifts
are calculated from the DICOM origin or the user origin defined in the image
referenced by the plan. The user origin can be used to mark a reference setup point in
the patient, such as the simulation isocenter (from the CT scanner or a conventional
simulator).
Tip: For more information on user origin, refer to Eclipse user documentation.
If the field isocenters do not coincide with the user origin, Plan Parameters
workspace can calculate the relative couch shifts, or the delta couch shifts, from the
user origin to the treatment isocenter(s).
Whether the calculated couch shifts are to be used in the treatment, is communicated
to the treatment using the Delta Couch Shift Editor. The couch shift values and
directions are printed on treatment reports, and will be shown in Treatment
Preparation and the console. The values are also shown in the Field Properties
dialog box. You can also modify and clear the automatically calculated couch shift
values using the Delta Couch Shift Editor.
You can open the Delta Couch Shift Editor separately to determine the shifts, or use
the editor in connection with planning approval. Delta couch shift values are
included in DICOM import, and DICOM export of planning approved plans (if the
delta couch shift values are consistent for each field) and treatment approved plans.
Determine the Couch Shifts for Patient Treatment

1. In the Scope pane, right-click the plan and select Delta Couch Shift Editor from
the context menu.
■ The Delta Couch Shift Editor also opens after choosing Edit > Plan
Approval > Planning Approved. Make sure that you have the Show Delta
Couch Shift upon Plan Approval setting selected in RT Administration.
2. To define the couch shifts manually, type the desired values for each isocenter
group in the cells in the table.
Note: Editing is not possible if you are in the Plan Approval wizard.

3. To use the couch shifts calculated from the user origin, click Use values
calculated from user origin.
4. To clear the calculated delta couch shift values, click Clear.
5. Click OK.
Closing Courses
Courses can have two statuses: Active or Completed. When the patient treatments
have been completed or if a treatment course is discontinued, you can change the
status of a course to Completed in Plan Parameters or Treatment Preparation. After
the course status has been changed into Completed, all modifications to the plans,
structures and images that belong to the course are prevented. It is recommended
that the statuses of completed courses be changed to prevent accidental modifications
and accidental use of the plan.
Change Course Status to Completed

1. In the Scope Window, select the course.
2. Choose Edit > Properties.
3. In the Status drop-down list, select Completed.
4. Click OK.
5. Type the correct user name and password and click OK.

Chapter 6 Editing Log Workspace
Editing Log Workspace Options

The Editing Log workspace displays all relevant actions performed on the plan.
When the filtering system is enabled, you can restrict the view of records based on
filter selections. The filters allow the selection of records to determine what action
was performed and by whom. When the action took place and in which workspace
the action was performed is also shown.
The figure shows an example of the Editing Log workspace.
1 2 3
1. Menu functions
2. Actions filter
3. Workspace bar, Editing Log is selected
Figure 4 Editing Log Workspace
Chapter 6 Editing Log Workspace 47

Tip: You can show or hide the workspace bar.
Open the Editing Log Workspace

■ Click Editing Log workspace tab or choose Quicklinks > Treatment
Management > Editing Log.
Check the Editing Log

1. Select the required patient using Patient Explorer.
The view lists the entire log file of all relevant actions performed on the active or
retired plans in this course.
2. Select Enable Filter.
3. Choose one or more of the following options:
If you want to Select
■ Filter the actions based on type In the What group box select the type of
of modification. modification from the Event list.
■ Filter the actions based on who In the Who group box select the user from
performed the modification. the Operator list.
■ Filter the actions based on the In the Who group box select the workspace
workspace where the from the Workspace list.
modification was performed.
■ Filter the actions based on the In the Date group box select the start date
date when the modification was and the end date from the list. If no ending
performed. date is specified, the list shows all records
up to date.
4. To update the list according to the selected criteria, click Refresh.

Appendix A Support of 3rd Party Treatment
Third-Party Treatment Options

Normally, DRRs are exported by treatment planning systems as true DICOM-RT
images. However, some treatment planning systems export the DRRs as DICOM
secondary capture images or as bitmaps.
The secondary capture and bitmap images do not include any
■ Field geometry information
■ Information about the Frame of Reference (FOR) in DICOM, that is reference
coordinate system or reference conditions where they were created or acquired.
Thus, these images need to be scaled and aligned in Plan Parameters workspace
before they can be used as reference images.
Because the reference conditions of the reference images are unknown to ARIA RTM,
ARIA RTM assigns artificially created reference coordinate system information (FOR)
to each imported secondary capture or bitmap image by default.
kV imaging requires that the reference images used for image matching share the
same FOR, that is, are available in the same coordinate system or created in the same
reference conditions. Otherwise kV imaging does not allow storing the match results
in the information system. Thus, the Offline Review application is not able to display
the acquired images as paired images.
With ARIA RTM, users can assign the reference images to the same reference
coordinate system (FOR) at the same time as deciding which DRR is to be the
reference image for a particular field in Dosimetric Review. This assignment needs to
be done only once during the treatment plan preparation phase. After doing so, the
Offline Review application displays kV imaging radiographs as paired images.
Assigning Reference Images to the Same Reference

Coordinate System
Note: The following steps are NOT required if you are using the Eclipse treatment planning
system, or if your planning system is able to export DRRs as true DICOM RT images.
Appendix A Support of 3rd Party Treatment 49

Configure the FOR Override
1. Choose Quicklinks > Administration > RT Administration.
2. Select System Properties.
3. Select Allow FOR override when assigning ref. images, for more information
refer to the RT Administration Reference Guide.
Import a Plan and Image

1. Go to the Plan Parameters workspace.
2. Choose File > Import.
3. Use the DICOM Import Export application, for more information refer to the
DICOM Import and Export Reference Guide.
Set the DRR as a Reference Image

Tip: This procedure applies to DRRs and acquired images.
1. Go to the Plan Parameters workspace.

2. Select the patient and the plan you want to prepare.
3. Select a DRR under the first setup field.
4. Right-click the mouse and select Set as Reference Image to set this DRR as a
reference image for the selected field.
If the imported DRRs do not share the same reference coordinate system (FOR), a
dialog box opens in which you can create a copy of the image with the same FOR
UID.
5. Click the down arrow from the Image which has been acquired at the same time
drop-down list.
6. Select the DRR of the second field.
7. Click OK if you want to proceed.
■ After clicking OK, the program copies the original DRR of the first setup field
and assigns this new image to the same reference coordinate system (FOR) as
the DRR of the second setup field. The new image is set also as a reference
image for the first field. Now the DRRs of both setup fields share the same
reference coordinate system (FOR).
■ The program proceeds to the alignment and scaling process if needed.
8. Select a DRR under the second field.

9. Right-click the mouse and select Set as Reference Image to set this DRR as a
reference image for the second field.
The program proceeds to the alignment and scaling process if needed.
10. The treatment plan has been prepared for IGRT process, including paired image
for Offline Review application.
Validate a Plan with the Validate Plan Tool

1. After you have prepared the plan for treatment, it is always a good practice to
validate the plan. This option checks the following:
■ The validity of the plan.
■ That the reference images have been prepared correctly.
If the reference images of different fields do not have the same reference
coordinate system identification (FOR UID), the program displays a warning.
2. To correct the situation, proceed to set the DRR as a reference image.
Export a Plan to 3rd Party OIS

If you are using a 3rd party OIS, you have to export the files via this export function
in the Plan Parameters workspace.
1. Right-click the required plan in the Focus pane.
2. From the drop-down list, select Export to 3rd Party OIS.
An Export Wizard: DICOM Storage Filter dialog box opens.
3. Use the DICOM Import Export application, for more information refer to the
DICOM Import and Export Reference Guide.
4. Follow the prompts to export the plan.
Appendix A Support of 3rd Party Treatment 51

Index
3D dose distribution customer support 8
clear 44
3rd party OIS
export plan 51
D
3rd party plan daily dose limit
validate 51 reference point 27
3rd party treatment DEM (dosimetrically equivalent machine)
assign reference coordinate system 49 checks in plan when changing 43
bitmap 49 overview 43
DICOM secondary capture image 49 transfering plan to 43
DRRs 49 DICOM (Digital Imaging and
Communications in Medicine) 45
DICOM RT (extension of DICOM-3) 20, 49
A see also DICOM
accuracy of measurements 15 DICOM secondary capture image
Advanced Feature Set assign reference coordinate system 49
activate 14 bitmap 49
deactivate 14 DRR 49
anatomy matching FOR 49
create match layer 42 digital graticule
approving plans 34 showing in Field Graphics pane 40
Planning Approval 35 Digital Imaging and Communications in
Treatment Approval 36 Medicine
artificial image see DICOM
create 23 Digitally Reconstructed Radiograph
when needed 20 see DRR
dose
clear 3D dose 44
B primary reference point 23
block scaling after MU editing 23
create new 22 dosimetric data
breakpoint edit after treatment 26
create in Plan Scheduling 27 edit before treatment approval 25
dosimetrically equivalent machine
see DEM
C drawing tools 17
DRR (Digitally Reconstructed Radiograph) 23,
Context Window
49
hide 19
assign reference coordinate system 49
show 19
bitmap 49
couch shifts for patient treatment 45
DICOM secondary capture image 49
course
set as reference image 50
Active status
changing status
closing E
Completed status
completing editing log
check 48

filtering information in 48 expand in Field Graphics pane 41
Editing Log Field Graphics pane 41
new features 9 import 50
open the workspace 48 measuring tools 15
workspace 47 processing tools 16
emailing Varian customer support 8 show in Field Graphics pane 41
export showing graticule 40
DICOM 45 import
MLC plan 39 image 50
plan to 3rd party OIS 51 MLC plan 39
plan 50
F
field K
change order 24 kV imaging
creating 22 FOR 49
delete 25 using bitmaps 49
field aperture contour using DICOM secondary capture image
create 42 49
Field Graphics pane
expand image in 41
image 41 L
layer 41 layer
MLC 41 Field Graphics pane 41
overview 12 hide in Field Graphics pane 41
show image 41 match layer 42
showing graticule 40 show in Field Graphics pane 41
Focus pane
icons 19
overview 12 M
FOR (frame of reference) match layer
assign reference coordinate system 49 create for anatomy matching 42
bitmap 49 measurement accuracy 15
configure 50 measuring tools 15
DICOM secondary capture image 49 MLC (Multileaf Collimator)
DRR 50 create new 22
kV imaging 49 edit leaves 39
frame of reference hide outline in Field Graphics pane 41
see FOR lock 39
show outline in Field Graphics pane 41
MLC plan
H export 39
HyperArc plan import 39
convert to regular plan 44 work with 38
Monitor Unit
see MU
I MU 30
image MU (Monitor Unit)
create artificial image 23 editing 23, 25, 26
DICOM RT 49 Multileaf Collimator
drawing tools 17 see MLC
Index 53
MyVarian 8 treatment parameters 20
workspace 12
Plan Parameters pane 12
N plan revision
new features 9 create new 38
display rejected plan 18
display retired plan 18
O Planning View 18
online customer support 8 Review View 18
ordering product documents by phone 8 tools 18
Planning Approval 34, 35
prescription
P create a plan from 32
patient position updating revision in plan 32
changing 40 updating revision in treated plan 33
position 40 primary reference point
patient volume change 30
add reference point 29 dose 23
plan dose scaling 23
3rd party plan 51 proton plan
3rd party system 20 modifying in Plan Parameters 24
Acuity 20
chain 37 R
change treatment unit 44
convert HyperArc to regular 44 reference coordinate system
copy 37 assign images to 49
create from prescription 32 reference image
create new revision 38 assign to coordinate system 49
create template from 38 configure FOR override 50
creating 21 DICOM RT 49
creating in Plan Parameters 20 DRR 49, 50
delete 38 FOR override 49
Eclipse 20 reference point
export MLC plan 39 add to existing volume 29
export to 3rd party OIS 51 add to new patient volume 29
import 50 breakpoint 27
import MLC plan 39 change primary 30
paste 37 daily dose limit 27
retired 37 definition 27
revisions 37 dose 23
RT prescription 30 editing dose 23
validate for treatment 33, 34 overview 27
Ximatron 20 session dose limit 27
Plan Parameters total dose limit 27
artificial image 20 RT prescription 30
creating plans 20 see prescription
new features 9
open workspace 14
overview of GUI 12
S
proton plans 24 safety
select window layout 14 care required 10

emergency 10 workspace
further regulations 10 Editing Log 47
responsibility 10 Plan Parameters 12
verify planned data before treatment 20 workspace bar
Scope pane hide 19
icons 19 show 19
overview 12
session dose limit
reference point 27
setup field
create new 23
stereotactic plan
HyperArc 44
support e-mail addresses 8
T
technical support 8
template
create from a plan 38
tools
drawing tools 17
image processing 16
measuring tools 15
plan revision 18
total dose limit
reference point 27
Treatment Approval 34, 36
validating plan for 33, 34
treatment unit
change in a plan 44
DEM 43
DEM (dosimetrically equivalent machine)
43
Treatment Unit pane 40
overview 12
showing patient 40
V
validation
Treatment Approval 33, 34
validate plan 33, 34
Varian customer support 8
View pane 12
visual cues 7
W
window layout
select 14
Index 55

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Dosimetric Review

ARIA® Radiation Therapy Management

13485 P1020789-001-A APRIL 2017

Document Title Dosimetric Review Reference Guide

Manufacturer Varian Medical Systems, Inc.

Authorized Varian Medical Systems Nederland B.V.

WHO ICD-O codes and terms used by permission of WHO, from:

2 Dosimetric Review Reference Guide

CAUTION: US Federal law restricts this device to sale by or on the

Copyright © 2011 - 2017 Varian Medical Systems, Inc.

All rights reserved. Produced in Finland.

CHAPTER 1 INTRODUCTION ...............................................................................................................7

CHAPTER 2 SAFETY AND EMERGENCY ..........................................................................................10

CHAPTER 3 WORKING IN PLAN PARAMETERS WORKSPACE ....................................................12

CHAPTER 4 TREATMENT PLANNING IN PLAN PARAMETERS WORKSPACE ..........................20

4 Dosimetric Review Reference Guide

CHAPTER 5 MANAGING PLANS IN PLAN PARAMETERS WORKSPACE ................................... 37

CHAPTER 6 EDITING LOG WORKSPACE ........................................................................................ 47

APPENDIX A SUPPORT OF 3RD PARTY TREATMENT ..................................................................49

6 Dosimetric Review Reference Guide

8 Dosimetric Review Reference Guide

What is New in Plan Parameters and Editing Log

Safety and Emergency Information for Plan Parameters

10 Dosimetric Review Reference Guide

Chapter 2 Safety and Emergency 11

Working in the Plan Parameters Workspace

Overview of the Plan Parameters Workspace

12 Dosimetric Review Reference Guide

1. Scope pane: Right-click to select tasks 6. Plan Parameters pane.

Figure 1 Plan Parameters Workspace

Chapter 3 Working in Plan Parameters Workspace 13

Select the Window Layout

Activate or Deactivate the Advanced Feature Set

1. Choose Tools > Task Configuration.

14 Dosimetric Review Reference Guide

Measurement Accuracy in Contours

Chapter 3 Working in Plan Parameters Workspace 15

Image Processing Tools

Invert. Inverts the currently displayed treatment image.

Auto Window/Level. Automatically adjusts brightness and contrast of images.

Digital Graticule. Displays/hides the digital graticule in displayed images.

Zoom Out. Decreases magnification of the currently selected image.

16 Dosimetric Review Reference Guide

Reset Geometry. Resets the image display in respect to geometrical manipulations.

Drawing Tools for Images

Table 3 Drawing Tools

Rotate. Rotates selected contours by clicking and dragging anchor points.

Chapter 3 Working in Plan Parameters Workspace 17

Auto Margin. To automatically draw a margin of a designated size around a se-

Plan Revision Tools

18 Dosimetric Review Reference Guide

Show or Hide the Workspace Bar

Show or Hide the Context Window

Chapter 3 Working in Plan Parameters Workspace 19

Defining Treatment Parameters in Plan Parameters

20 Dosimetric Review Reference Guide

1. Choose Insert > New Plan.

Chapter 4 Treatment Planning in Plan Parameters Workspace 21

Create a New Block

Create a New MLC