Monaco 5.10 Training Guide

Monaco® Training Guide
IMPAC Medical Systems, Inc.

Document ID: LTGMON0510
Part Number: C#98961-EN
Language: English
Revision
History
Revision Version Date Changes
LTGMON0500 1.0 December 2013 New sections and content due to 3D planning
New section for Stereotactic Planning
New section for Siemens mARC
New sections for Physics course
Workflow and icons changed due to Ribbons
Merging of QA Activity
Planning process changes due to Prescription and Planning Control
LTGMON0510 1.0 April 2015 New MR Planning exercises and updates for Oblique MR images
New Frozen Dose content.
New Multiple Prescriptions exercise and updates.
New Forward Planning exercise and updates.
New Anatomical Sites content.
New DICOM Import content and DICOM Export updates.
New IMRT/VMAT planning improvement content.
LTGMON0510 2.0 September 2015 New content for Isodose Templates for the 5.1 patch.
New content for Rescale Doses and Physician’s Intent for the 5.1 patch.
Clarified Arc Rotation information after review of Version 1.0.
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All terms mentioned in this manual that are known trademarks, registered trademarks, or service marks have been appropriately labeled as
such. Other products, services, or terms that are referred to in this manual may be trademarks, registered trademarks, or service marks of
their respective owners. IMPAC Medical Systems, Inc. makes no claim to these trademarks. Use of a term in this manual should not be
regarded as affecting the validity of any trademark, registered trademark, or service mark.
XiO® is a registered trademark of IMPAC Medical Systems, Inc.
Monaco™ is a registered trademark of IMPAC Medical Systems, Inc.
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countries.
Microsoft®, Windows®, and Windows NT® are registered trademarks of Microsoft Corporation in the United States and other countries.
Copyright © 2015 by IMPAC Medical Systems, Inc. All rights reserved.

Performance characteristics given in this manual are for reference only and are not intended as guaranteed specifications.
Document Number. LTGMON0510

Part Number. C#98961-EN
ii ......
Table of Contents
Volume I of IV – Monaco Sim
Section 1. Overview
Monaco Products...................................................................................................................................... 1-1
Disclaimer .................................................................................................................................................. 1-2
System Activities ....................................................................................................................................... 1-2
Planning Activity ...................................................................................................................................... 1-3
Fusion Activity .......................................................................................................................................... 1-4
Plan Review Activity................................................................................................................................. 1-5
Conditions that Prevent Opening Studysets ......................................................................................... 1-5
Conditions that Prevent Plans from Being Available .......................................................................... 1-6
Entering and Editing the Monaco License ............................................................................................ 1-7
Online Help ............................................................................................................................................... 1-8
Keep the Online Help Window in an Open Status while Performing Functions....................... 1-9
User Authorization Database .................................................................................................................. 1-9
Other Training Resources ..................................................................................................................... 1-10
Section 2. General Operation and Navigation

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

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

Zoom and Pan T/S/C/O and 3D Images ............................................................................... 2-43
Zoom .......................................................................................................................................... 2-43
Zoom Continuously ........................................................................................................................ 2-43
Reset Zoom and Pan ....................................................................................................................... 2-43
Magnifying Glass ............................................................................................................................. 2-44
Zoom Area of Interest .................................................................................................................... 2-45
Pan.............................................................................................................................................. 2-46
Screen Layout ........................................................................................................................................ 2-47
Layouts .............................................................................................................................................. 2-47
Save Layout as Preset Option.................................................................................................. 2-47
Manage Layouts........................................................................................................................ 2-48
User Defaults ............................................................................................................................ 2-49
User Layouts ............................................................................................................................. 2-50
Global Layouts .......................................................................................................................... 2-51
Side-by-Side Layout ........................................................................................................................ 2-52
Side-by-Side: Planning Activity.............................................................................................. 2-53
Side-by-Side: Plan Review Activity ........................................................................................ 2-53
3D View ............................................................................................................................................ 2-54
3D Rotate ................................................................................................................................... 2-55
3D Translate.............................................................................................................................. 2-56
Reset 3D Image Navigation Functions ......................................................................................... 2-56
Reset 3D Functions .................................................................................................................. 2-56
4D Imaging Overview .......................................................................................................................... 2-57
4D Imaging....................................................................................................................................... 2-57
Import 4D Data ........................................................................................................................ 2-57
Multiple Structure Sets ............................................................................................................ 2-58
Create a Specialty Image.......................................................................................................... 2-58
Measurement Grid ................................................................................................................... 2-60
Use Grid to Measure Movement ............................................................................................ 2-60
4D Margin ................................................................................................................................. 2-63
Print 4D Auto Margin Report ................................................................................................ 2-64
Cine View .................................................................................................................................. 2-65
DRR Views ....................................................................................................................................... 2-66
Show MIP (Maximum Intensity Projection)........................................................................ 2-67
Show Grid (Reticule) ............................................................................................................... 2-68
Jaw Labels .................................................................................................................................. 2-68
DRR Volume of Interest Tool ................................................................................................ 2-69
Display Synth. CT............................................................................................................................ 2-70
Room’s Eye View ............................................................................................................................. 2-71
Room’s Eye View-Display Options........................................................................................ 2-72
Monaco® v ..
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Room’s Eye View-Menu.......................................................................................................... 2-72
Additional Navigation and Screen Customization Tools ............................................................... 2-74
Maximize and Restore a Window ................................................................................................. 2-74
Patient Orientation Icon ................................................................................................................ 2-74
Move Control Dialog Box .............................................................................................................. 2-75
Printing Options ................................................................................................................................... 2-77
Print/Export a Transverse, Sagittal, Coronal, Oblique, or 3D Image....................................... 2-77
Print or Export the Screen.............................................................................................................. 2-78
Print DRRs ....................................................................................................................................... 2-79
Select the Print Type ................................................................................................................ 2-80
Select Options and Copies ...................................................................................................... 2-81
Print or Export Monaco IMRT Plan Reports .............................................................................. 2-82
Print/Export Individual Reports ............................................................................................ 2-82
Print/Export Custom Reports ................................................................................................ 2-83
Additional IMRT Plan Report Options................................................................................. 2-85
Print DICOM Coordinates on reports instead of the proprietary system ....................... 2-85
Include Base Dose on Reports for Bias Dose plans ............................................................. 2-85
Print DICOM Plan Report ............................................................................................................. 2-85
Section 3. CT Simulation Options

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

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

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

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

Delete Anatomical Group .............................................................................................................. 5-49
Apply Anatomical Groups ............................................................................................................. 5-49
PET Tools .............................................................................................................................................. 5-50
SUV Calculation .............................................................................................................................. 5-50
DICOM Editor for SUV .......................................................................................................... 5-52
PET Threshold Contouring ........................................................................................................... 5-54
Click on RAW icon to select PET Image Type............................................................................ 5-57
Import Treatment Couchtop .............................................................................................................. 5-58
Prerequisites ..................................................................................................................................... 5-58
Generate Bolus ...................................................................................................................................... 5-62
Generate Bolus – Fill VOI .............................................................................................................. 5-65
Bolus – Editing Tools ...................................................................................................................... 5-66
Structure Planning Control ................................................................................................................. 5-66
Section 6. Planning Tools

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

Print a Beam Summary Report ...................................................................................................... 6-15
Feet First Sim Plans .............................................................................................................................. 6-16
Create a Feet First Sim Plan ........................................................................................................... 6-16
Change Treatment Orientation for Monaco IMRT Plan ................................................................ 6-17
Create a Feet First IMRT Plan ....................................................................................................... 6-17
Port Tools .............................................................................................................................................. 6-19
Auto Conform a Port ...................................................................................................................... 6-19
Draw a Port ...................................................................................................................................... 6-21
Edit a Port or MLC .......................................................................................................................... 6-21
Replace a Segment of the Port/MLC...................................................................................... 6-22
Resize the Port/MLC................................................................................................................ 6-23
Move the Port/MLC................................................................................................................. 6-24
Edit Individual MLC Leaves ................................................................................................... 6-24
Use the Leaf Table to edit the port ......................................................................................... 6-25
Edit the Close Leaf Position .................................................................................................... 6-26
Delete a Port.............................................................................................................................. 6-26
Maintain Field Borders ................................................................................................................... 6-27
Measure Tool......................................................................................................................................... 6-27
Use the Measure Tool .......................................................................................................................... 6-27
Remove the Measurement Rulers ....................................................................................................... 6-27
Interest Points and Markers ................................................................................................................ 6-28
Place Interest Points or Markers ................................................................................................... 6-28
Verify an Interest Point or Marker ............................................................................................... 6-30
Locate an Interest Point or Marker ............................................................................................... 6-30
Delete an Interest Point or Marker ............................................................................................... 6-31
Print the Interest Point and Marker Report ................................................................................ 6-31
Dose Reference Points (Plans from Monaco IMRT only) ......................................................... 6-31
Image Statistics...................................................................................................................................... 6-32
Section 7. Plan Review Activity

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

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

Practice Exercise 1. General Operation and Navigation ................................................................... 8-1
Practice Exercise 1. General Operation and Navigation .............................................................. 8-1
Practice Exercise 2. Fusion, Contouring, and Beam Manipulation ............................................ 8-2
Fusion .......................................................................................................................................... 8-2
Contouring .................................................................................................................................. 8-3
Beam Manipulation ................................................................................................................... 8-3
Miscellaneous.............................................................................................................................. 8-3
Practice Exercise 3. Plan Review ........................................................................................................... 8-4
Section 9.Treatment Couchtop Inclusion

Task 1. Import a Treatment Couch Structure..................................................................................... 9-1
Task 2. Edit and Save a Treatment Couch........................................................................................... 9-2
Task 3. Add Couch to a Plan, a Studyset or a Phantom .................................................................... 9-3
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Volume II of IV – Planning
Section 1. 3D Planning
Features of 3D Plans ................................................................................................................................. 1-1
Create a 3D Treatment Plan .................................................................................................................... 1-1
Planning Control – Structures ................................................................................................................ 1-4
Planning Control – Prescription Tab:.................................................................................................... 1-4
Physician’s Intent ................................................................................................................................ 1-5
Rx ID .......................................................................................................................................................... 1-6
Add Rx ....................................................................................................................................................... 1-7
Delete Rx .................................................................................................................................................... 1-8
Rescale Dose .............................................................................................................................................. 1-8
Beam Weighting .................................................................................................................................. 1-9
Prescription: Segments Tab ............................................................................................................. 1-10
Segment Light Field Projection ....................................................................................................... 1-13
Planning Control – Dose Reference Points......................................................................................... 1-14
Planning Control – Beams Tab............................................................................................................. 1-14
Planning Control – Treatment Aids .................................................................................................... 1-15
Wedges................................................................................................................................................ 1-15
Port /MLC .......................................................................................................................................... 1-16
Applicator ID .............................................................................................................................. 1-16
Couch .................................................................................................................................................. 1-16
Bolus .................................................................................................................................................... 1-17
Section 2. Planning and Workflow: Workflow Diagram, Contouring,

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

Beam and Delivery Setup (cont.)
Planning Ribbon – Beam Tools ....................................................................................................... 2-14
Beam Control .......................................................................................................................................... 2-16
Add/Edit/Delete Beams in Beam Control ...................................................................................... 2-18
Copy a Beam/Sequence .................................................................................................................... 2-18
Beam Control for IMRT Plans – General Tab .................................................................................... 2-19
Delete a Beam/Sequence................................................................................................................... 2-19
Renumber Beams/Sequences ........................................................................................................... 2-19
Reorder Beams/Sequences ............................................................................................................... 2-19
Number Beams/Sequences Consecutively ..................................................................................... 2-19
Link Machine ID and/or Isocenter Location ................................................................................. 2-20
Beam Control | Geometry Tab.............................................................................................................. 2-22
Split Beams ......................................................................................................................................... 2-23
Fixed Jaws ........................................................................................................................................... 2-25
Beam Control |Treatment Aids Tab..................................................................................................... 2-27
Planning Control – Treatment Aids ............................................................................................... 2-27
Wedges ........................................................................................................................................ 2-28
Port ............................................................................................................................................... 2-28
MLC ............................................................................................................................................. 2-28
Applicator ID .............................................................................................................................. 2-29
Bolus............................................................................................................................................. 2-29
Couch ........................................................................................................................................... 2-30
Add Bolus to Beams ................................................................................................................... 2-30
Beam Control | Setup Beams Tab ......................................................................................................... 2-31
Edit Beam Options Using Mouse ......................................................................................................... 2-31
Print a Beam Control Report ........................................................................................................... 2-32
Definition of Terms as They Apply to Arc Planning ......................................................................... 2-33
Sequence ............................................................................................................................................. 2-33
Direction............................................................................................................................................. 2-33
Gantry ................................................................................................................................................. 2-34
Arc ....................................................................................................................................................... 2-34
Collimator .......................................................................................................................................... 2-34
Increment ........................................................................................................................................... 2-35
Sector................................................................................................................................................... 2-36
Sweep Sequencer ............................................................................................................................... 2-38
Control Point (VMAT only) ............................................................................................................ 2-39
Arc Segment (VMAT only).............................................................................................................. 2-39
Dynamic Segments with Static Gantry (VMAT only) ................................................................. 2-41
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Section 3. 3D Lung Case

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

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

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

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

Task 10. Add Right Lateral Beam .................................................................................................... 5-11
Task 11. Create Right Lateral Port .................................................................................................. 5-12
Task 12. Duplicate and Oppose Right Lateral Beam .................................................................... 5-13
Task 13. (Optional) Edit a Port ....................................................................................................... 5-14
Task 15. Force Electron Density ...................................................................................................... 5-16
Task 21. Create 6 Field Boost Plan .................................................................................................. 5-19
Task 22. Add/Edit Additional Beams ............................................................................................. 5-20
Task 23. Create Ports ........................................................................................................................ 5-20
Task 26. Force Electron Density ...................................................................................................... 5-21
Task 31. Create Plan Summation .................................................................................................... 5-23
Task 32. Plan Summation Review ................................................................................................... 5-23
Task 33. Save the Plan Summation ................................................................................................. 5-23
Section 6. IMRT Tools

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

Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans........................ 6-11
Fluence Analysis and Visualization Tools ..................................................................................... 6-13
Planning Tab | Grid Volume Panel................................................................................................. 6-14
Volume Cursor ........................................................................................................................... 6-14
Studyset and Grid Slider Bar..................................................................................................... 6-15
Plan Options Tab .................................................................................................................................... 6-16
Optional Panel ................................................................................................................................... 6-16
Fluence Statistics ........................................................................................................................ 6-16
Show Dose Extents ..................................................................................................................... 6-17
DVH Panel ......................................................................................................................................... 6-17
Dose Normalization Panel ............................................................................................................... 6-18
Tools Tab ................................................................................................................................................. 6-19
Interest Points and Markers............................................................................................................. 6-19
Editing Interest Points and Markers........................................................................................ 6-19
Additional Interest Point and Marker Functionality ............................................................ 6-20
Measure Tool ..................................................................................................................................... 6-20
Additional IMRT Tools ......................................................................................................................... 6-21
Progress Meter ................................................................................................................................... 6-21
Beam Visibility Control .................................................................................................................... 6-22
Section 7. Planning and Workflow: Calculation Parameters and IMRT

Constraints
Calculation Properties.............................................................................................................................. 7-1
Calculation Parameters....................................................................................................................... 7-2
Algorithm ............................................................................................................................................. 7-2
Grid Spacing......................................................................................................................................... 7-2
Calculate Dose Deposition to: ........................................................................................................... 7-3
Statistical Uncertainty (%) ................................................................................................................. 7-3
Statistical Uncertainty Per Control Point (CP) ............................................................................... 7-4
Statistical Uncertainty Per Calculation............................................................................................. 7-5
IMRT Constraints: Structure .................................................................................................................. 7-7
Introduction ......................................................................................................................................... 7-7
Structure ............................................................................................................................................... 7-9
Structure Mismatch............................................................................................................................. 7-9
Structure Layering ............................................................................................................................... 7-9
Structure Optimization Properties and IMRT Prescription Parameters ................................... 7-11
Clear all Voxels below the Minimum CT number ................................................................ 7-13
Clear and Fill Example: ............................................................................................................. 7-13
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Constraints (cont.)
Display Total Volume DVH ..................................................................................................... 7-15
Auto Flash ................................................................................................................................... 7-15
Do Not Store Dose ..................................................................................................................... 7-16
Avoidance.................................................................................................................................... 7-17
Surface Margin – IMRT Prescription Parameter ................................................................... 7-17
Beamlet Width – IMRT Prescription Parameter ................................................................... 7-17
Target Margin – IMRT Prescription Parameter .................................................................... 7-18
Avoidance Margin- IMRT Prescription Parameter............................................................... 7-18
IMRT Constraints: Cost Functions ...................................................................................................... 7-19
Cost Function Overview ................................................................................................................... 7-19
Objective ............................................................................................................................................. 7-19
Constraint........................................................................................................................................... 7-19
EUD (Equivalent Uniform Dose) ................................................................................................... 7-19
Application of Objectives and Constraints .................................................................................... 7-20
Required Cost Function Parameters ............................................................................................... 7-21
Target Penalty ............................................................................................................................. 7-21
Target EUD ................................................................................................................................. 7-22
Serial............................................................................................................................................. 7-24
Parallel ......................................................................................................................................... 7-28
Conformality............................................................................................................................... 7-34
Quadratic Overdose ................................................................................................................... 7-36
Calculating a Root Mean Square for Dose Excess ................................................................... 7-37
Quadratic Underdose ....................................................................................................................... 7-38
Maximum Dose .......................................................................................................................... 7-41
Overdose DVH ........................................................................................................................... 7-42
Underdose DVH ........................................................................................................................ 7-44
Optional Parameters ......................................................................................................................... 7-45
Shrink Margin............................................................................................................................. 7-45
Surface Margin ........................................................................................................................... 7-48
Optimize Over All Voxels in Volume ..................................................................................... 7-53
Multicriterial ...................................................................................................................................... 7-54
IMRT Constraints: Other ...................................................................................................................... 7-57
Rescale Dose ....................................................................................................................................... 7-57
Enabled ............................................................................................................................................... 7-58
Bias Dose (only shows for Bias Dose Plans) .................................................................................. 7-58
Status ................................................................................................................................................... 7-60
Manual Weighting ............................................................................................................................ 7-60
Isoeffect ............................................................................................................................................... 7-61
Isoconstraint ...................................................................................................................................... 7-61
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Constraints (cont.)
Reference Dose .................................................................................................................................. 7-61
Multicriterial ...................................................................................................................................... 7-62
Relative Impact .................................................................................................................................. 7-63
Optimization Modes ......................................................................................................................... 7-63
Constrained Optimization Mode ............................................................................................. 7-63
Pareto Optimization Mode ....................................................................................................... 7-64
Exercises ................................................................................................................................................... 7-64
Section 8. Planning and Workflow: Optimization and Sequence

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

Parameters (cont.)
Park Closed Leaf Gaps Under Jaw .................................................................................................. 8-23
Max Sweep Efficiency ....................................................................................................................... 8-23
Allow Move Only Segments (dMLC Only): .................................................................................. 8-24
Constant Dose Rate ........................................................................................................................... 8-24
Min. MU per Dynamic CP ............................................................................................................... 8-24
Exercises ................................................................................................................................................... 8-25
Section 9. Planning and Workflow: Plan Analysis and Evaluation

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

Optimized DVH ......................................................................................................................... 9-16
Optimized Total DVH (Bias Dose Plans only) ...................................................................... 9-16
Evaluating Intensity Maps and Monitor Units ............................................................................. 9-17
Review Segments and Monitor Units per Segment ...................................................................... 9-17
Using the Fluence Statistics.............................................................................................................. 9-18
Section 10. Monaco Planning Suggestions

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

Pilot Beamlets .................................................................................................................................. 10-17
QA Plan .................................................................................................................................................. 10-18
Multiple QA Plans ........................................................................................................................... 10-18
Show Coronal Slice at Measured Depth ....................................................................................... 10-18
Section 11. Prostate IMRT Case

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

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

General Planning Instructions ........................................................................................................ 13-2
Example Prescription........................................................................................................................ 13-3
Section 14. Breast Case

General Planning Instructions .............................................................................................................. 14-2
Breast Plan Scoring Criteria ............................................................................................................. 14-2
Left Breast Practice Exercise.................................................................................................................. 14-3
Prescription A .................................................................................................................................... 14-4
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Section 15. Brain Case – Two Partial Arcs

Task 2. Start a Dynamic Conformal Arc or VMAT Plan ............................................................. 15-2
Task 4. Enter/Update the Prescription ........................................................................................... 15-4
Task 5. Edit Calculation Properties................................................................................................. 15-5
Task 6. Edit IMRT Parameters ........................................................................................................ 15-5
Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) ................................................ 15-6
Task 8. Optimize Fluence and Calculate Dose .............................................................................. 15-6
Task 9. Evaluate Plan ........................................................................................................................ 15-7
Task 10. Re-Optimize and Evaluate (Optional) ............................................................................ 15-8
Task 11. Save Plan ............................................................................................................................. 15-9
Section 16. mARC Brain Case

Task 2. Start an mARC Plan ............................................................................................................ 16-2
Task 4. Enter/Update the Prescription ........................................................................................... 16-4
Task 5. Edit Calculation Properties................................................................................................. 16-5
Task 6. Edit IMRT Parameters ........................................................................................................ 16-5
Task 7. Enter/Edit Sequencing Parameters (VMAT Plans only) ................................................ 16-6
Task 8. Optimize Fluence and Calculate Dose .............................................................................. 16-7
Task 9. Evaluate Plan ........................................................................................................................ 16-8
Task 10. Re-Optimize and Evaluate (Optional) ............................................................................ 16-9
Task 11. Save Plan ........................................................................................................................... 16-10
Section 17. Multiple Prescription

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

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

Bias Dose – Head and Neck Exercise ................................................................................................... 18-1
Prescription Goals ............................................................................................................................. 18-1
Task 1. Fuse Base Plan CT with Bias Dose Plan CT ..................................................................... 18-2
Task 2. Review the Base Plan ........................................................................................................... 18-2
Task 3. Create a Bias Dose Plan from a Base Plan ........................................................................ 18-3
Task 4. Enter the Bias Dose Prescription ....................................................................................... 18-3
Task 5. Start the Optimization and Dose Calculation .................................................................. 18-4
Section 19. MR Planning

Oblique MR Planning ............................................................................................................................ 19-1
Import the New Patient .................................................................................................................... 19-2
RTOG 1115 – Plan Scoring Criteria ........................................................................................ 19-5
Section 20. Additional Cases

Esophageal Case ...................................................................................................................................... 20-2
Rectal Case ............................................................................................................................................... 20-3
RTOG 0822 – Plan Scoring Criteria ........................................................................................ 20-3
Head and Neck Case II........................................................................................................................... 20-4
Practice Exercise 1. IMRT and QA....................................................................................................... 20-5
Create an IMRT Plan ........................................................................................................................ 20-5
Create a QA Plan ............................................................................................................................... 20-6
Practice Exercise 2. Plan Review ........................................................................................................... 20-7
Practice Exercise 3. Editing IMRT Prescription Elements ................................................................ 20-8
Practice Exercise 4. Optimization and Plan Evaluation .................................................................... 20-9
Practice Exercise 5. Serial Power Law (k) .......................................................................................... 20-10
Task 1. Select Patient and Open Studyset .................................................................................... 20-10
Task 2. Enter/Adjust Power Law and Optimize IMRT Plans.................................................... 20-10
Task 3. Plan Review......................................................................................................................... 20-13
Practice Exercise 6: Parallel Power Law (k)....................................................................................... 20-14
Task 1. Select Patient and Open Studyset .................................................................................... 20-14
Task 2. Load IMRT Template ........................................................................................................ 20-14
Task 4. Enter the IMRT Constraints............................................................................................. 20-16
Task 5. Enter Calculation Properties ............................................................................................ 20-18
Task 6. Enter IMRT Parameters .................................................................................................... 20-18
Task 7. Adjust Power Law (k) and Optimize IMRT Plans ........................................................ 20-19
Task 8. Plan Review......................................................................................................................... 20-20
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Section 21. QA Tools

Overview .................................................................................................................................................. 21-1
Dose Calculation Tools .......................................................................................................................... 21-1
Beam Tools ......................................................................................................................................... 21-2
Fluence Toolbar ...................................................................................................................................... 21-3
Beam and Dose Visibility Control .................................................................................................. 21-4
Dose Plane Output ................................................................................................................................. 21-5
Show Dose Extents ............................................................................................................................ 21-6
Measure and Interest Point Tools ........................................................................................................ 21-6
Dose Reference Points............................................................................................................................ 21-6
Create a QA Plan .................................................................................................................................... 21-7
Edit Dose Calculation Properties ....................................................................................................... 21-10
Edit Assigned Electron Densities........................................................................................................ 21-11
Save the QA Plan .................................................................................................................................. 21-11
Export the QA Plan .............................................................................................................................. 21-12
Tips When Creating a QA Phantom .................................................................................................. 21-13
Exercise .................................................................................................................................................. 21-13
Section 22. QA Exercise

Creating an IMRT QA Phantom .......................................................................................................... 22-1
Add a Couchtop to an Existing Studyset........................................................................................ 22-3
Create an IMRT QA Plan ...................................................................................................................... 22-5
Create QA Verification Beams.............................................................................................................. 22-8
Section 23. Stereotactic Planning with Monaco

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

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

Task 6. Set Calculation Properties, IMRT Parameters and Sequencing Parameters.............. 23-57
Task 8. Calculate Fluence – Optimization Phase 1 ..................................................................... 23-61
Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate ................. 23-61
Task 10. Calculate Segments – Optimization Phase 2 ................................................................ 23-63
Task 11. Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-optimize ......... 23-63
References......................................................................................................................................... 23-64
xxx ......
Table of Contents
Volume III of IV – Physics
Section 1. Monaco Patient Model (Presentation)
Section 2. Dose to Medium / Dose to Water Considerations

(Presentation)
Section 3. MU Workflow in Monaco (Presentation)
Section 4. Monaco Optimization Dose Calculation Algorithms

(Presentation)
Section 5. Electron Monte Carlo Algorithm (Presentation)
Section 6. Head Model and Collapsed Cone Photon Algorithm for 3D

Calculations (Presentation)
Section 7. Monaco Optimization Processes (Presentation)
Section 8. Setting the Couch Densities

Open the Full Beams Package ................................................................................................................. 8-1
Save the Plan as a Template..................................................................................................................... 8-3
Create the Dummy Plan .......................................................................................................................... 8-4
Remove All Unnecessary Beams............................................................................................................. 8-9
Edit the Couch Densities ....................................................................................................................... 8-11
Section 9. Post Modeling Adjust of MLC Parameters

Open the Test Beams Package ................................................................................................................ 9-3
Save the Plan as a Template..................................................................................................................... 9-5
Evaluate the First Beam ......................................................................................................................... 9-10
Tune the MLC Offset ............................................................................................................................. 9-12
Step 1. Check MLC Calibration ....................................................................................................... 9-12
Editing the MLC Offset in Monaco ......................................................................................... 9-13
Monaco® xxxi
Table of Contents
Section 9. Post Modeling Adjust of MLC Parameters (cont.)

Evaluate the 20x20, 10x10 and DMCL1 beams from the Express QA Package ............................. 9-16
Evaluate Plans 7SegA and FOURL for MLC Offset and Leaf Transmission .................................. 9-22
Evaluate the FOURL Field................................................................................................................ 9-24
Evaluate the field of “7SegA” ........................................................................................................... 9-28
Evaluate the field of “7SegA” ........................................................................................................... 9-29
Editing the Leaf Transmission and Leaf Groove Width (mm) in Monaco ........................ 9-29
The Effect of MLC Leaf Offset on Test Beams Dose .......................................................................... 9-32
Evaluate the fields of “HIMRT” and “HDMLC” ................................................................................ 9-35
Interest Points at Different Dose Levels in a Typical HN Case ........................................................ 9-38
Section 10. Folder Structure (Presentation)
Section 11. Monaco Beam Modeling (Presentation)
xxxii ......
Table of Contents
Volume IV of IV – Appendices
Appendix A. User Authorization Setup for Plan Approval

User Authorization.................................................................................................................................. A-1
Create Users and Permissions in User Authorization................................................................... A-1
Create a New User .............................................................................................................................. A-2
Create a New Group .......................................................................................................................... A-4
Edit Group’s Permissions and Users ............................................................................................... A-5
Appendix B. Machine Configuration and Jaw Labeling (Standalone

Users)
Edit Machine Configuration .................................................................................................................. B-1
Copy to Create a New Machine ............................................................................................................. B-2
Customize the Jaw Labels ....................................................................................................................... B-3
Appendix C. Settings
General Information ............................................................................................................................... C-2
Graphical Preferences ............................................................................................................................. C-4
Tolerance Tables ...................................................................................................................................... C-5
Rx Sites ...................................................................................................................................................... C-6
Ports and Materials.................................................................................................................................. C-7
DICOM Machine Mapping .................................................................................................................... C-8
Parameters ................................................................................................................................................ C-9
MLC Dynamic Parameters................................................................................................................ C-9
MLC Geometric Parameters ........................................................................................................... C-11
MLC Leakage ............................................................................................................................. C-16
Wedge Parameters ........................................................................................................................... C-18
Stereotactic Cone Parameters .............................................................................................................. C-21
Treatment Units..................................................................................................................................... C-23
Treatment Unit Storing ................................................................................................................... C-23
Adding Treatment Units ................................................................................................................. C-23
Treatment Unit Mapping ................................................................................................................ C-25
Appendix D. MLC Geometry Definitions

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

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

Creating and Customizing the Advanced Margin Template ............................................................. G-1
Introduction and Background .......................................................................................................... G-1
Example: Lung SBRT .............................................................................................................................. G-3
How to Establish Margin Recipe Input Data for Your Clinic ........................................................... G-6
References ................................................................................................................................................. G-7
xxxiv ......
Overview
Volume I of IV Monaco Training Guide
Overview
Monaco Products
Congratulations on your purchase of Monaco. The Monaco products run on a PC

workstation and may be used in conjunction with XiO or other Treatment Planning
System (TPS). Before you begin, it may be useful to understand the functionality
available with the licenses you purchased. Consult with your internal purchasing
agent, Sales Representative, or Customer Support Representative if you are not sure
which features are available to you. The following is a list of possible features:
Simulation includes 4D support, Contouring Tools, Fusion, beam placement,

block/port definitions, and real-time DRRs. Multiple customizable views ensure
efficient access to all required images and planning perspectives. Plans may be sent to
XiO or another treatment planning system for dose calculation and optimization.
DICOM Import/Export is a purchasable option for Monaco and is required if you plan
to use this product with any other TPS besides XiO.
3D Planning utilizes a Collapsed Cone algorithm which lets you add treatment aids
and calculate isodose distributions. You calculate isodose distributions for an electron
plan using the Electron Monte Carlo algorithm. You can use a Photon Monte Carlo
dose calculation engine for plans which contain MLCs.
IMRT/VMAT Planning uses segment shape optimization and a Photon Monte Carlo
dose calculation engine for accurate results. A biological optimization ensures superior
treatment plans.
Stereotactic Planning is full MLC-based planning that includes Apex micro-MLC

support. It also includes Contouring, CT Simulation, Plan Review, and DICOM
import/export capabilities. You calculate the isodose distribution using the Photon
Monte Carlo algorithm.
Plan Review is an application that offers an array of review tools and rapid off-line
access for plan analysis and approval.
Monaco® 1-1
Overview
Overview
Monaco Products (cont.)
You can view the Intended Use Statement for this product in the Monaco
User’s Guide. The Monaco guide is divided into two sections. The first section
covers the Settings, General Operation and Navigation and Sim Planning. The
second section covers treatment planning, calculation algorithms and QA
tools. There are planning exercises you can use throughout the training, an
appendix, and useful IMRT references. Detailed discussions of the planning
process and cost functions are in the Monaco guide. Refer to the table of
contents for a more detailed outline.
Disclaimer
The examples and exercises used throughout this training guide are for
illustrative purposes only, and are in no way to be construed as Elekta acting
in any way to provide medical direction or advice. The information included
in this training guide is not intended to replace or to be a substitute for the
knowledge, expertise, skill, and judgment of a qualified healthcare
professional. The professional duty to the patient in providing healthcare
services lies solely with the healthcare professional providing patient care
services. Full responsibility for the use of information provided in this training
guide resides with the healthcare professional providing patient care services.
System Activities
Figure 1-1: Patient Workspace Control - System Activities
The major sets of features are separated into activities you can access from the Patient
Workspace Control. Click on the activity button on the Patient Workspace Control.
Monaco activities include:
• Fusion Activity - Manual and Auto Registration of CT, MRI and/or Pet Images
• Planning Activity - Contouring, Plan Creation, Beam Manipulation
• Plan Review Activity - Plan Evaluation and Comparison
1-2
Overview
Overview
Planning Activity
The Planning activity is available to all users. However, if you purchased Monaco Sim,
the features are limited. The system has a dedicated set of CT Simulation tools tailored
to these tasks:
• Image import
• Target and organ contouring
• Beam placement
• Port designing
• DRR generation
You can import images straight into Monaco, fuse images from CT, MR, or PET (that
is, if you purchased Fusion), and prepare new patients for dose calculation later on
XiO.
You can use the Planning Activity tools to contour, edit and create XiO plans, or it can
be used by any 3rd party vendor strictly as a CT Simulation tool. This training guide
does not teach CT simulation. It teaches you how to use this software.
You can send CT simulation shift information to Gammex or LAP laser marking
systems. For information on Gammex and LAP Laser Marking Systems, see the
Monaco Installation Instructions guide.
Monaco® 1-3
Overview
Overview
Fusion Activity
The Fusion activity is only available to those who purchased this feature. Fusion is a
process that lets you to register datasets for the purpose of contouring from either
dataset or both datasets.
Fusion lets you to combine patient data collected from multiple diagnostic imaging
methods for a single patient's anatomy. The fusion of a primary studyset with a
secondary studyset lets you combine important anatomical data garnered from each
method. The system offers two methods for aligning the studysets:
(1) Use the first method, Auto Registration, to automate the alignment process. The
software computes the geometric transformation that best registers corresponding
anatomic details in two 3D studysets of the same patient's anatomy. The alignment
criterion is mutual information that is a measure of the statistical similarity of the
overlapping data.
(2) Use the second method (Interactive Registration) to manually align the studysets.
However, you must first adjust the display of the images to better see the
individual structures, then manually translate and rotate the secondary studyset
until you achieve the desired alignment.
The image sets are considered fused when the resulting registration is accepted. You
can now show the primary and secondary studysets together in the Planning and Plan
Review activity.
The system lets you use studysets comprised of CT, MRI, and PET images.
1-4
Overview
Overview
Plan Review Activity
This activity is available to all system users. Plan Review lets a physician, physicist, or
dosimetrist review and compare treatment plans in real time.
Plan Review gives a visual display of the following:
• Dose distributions superimposed on volumetric CT data in colorwash or isodose

line
• Dose distribution on a 3D image
• Dose distribution on secondary studyset
• Dose volume histograms (DVHs)
• Beam arrangements
Plan Review lets you to do these functions:
• Review multiple plans for the same patient

• Manipulate the images with basic tools like window/level, dose transparency,
zoom, and pan
• Adjust the isodose levels for display
• Review the beam arrangements for a given plan
• Review the dose volume histogram
• Provide organ-based DVH summaries
• Review a dose comparison display to determine the differences between two plans
• Review Plan Summation results and Plan Summation DVH.
• Make NOTEs about individual patient plans and store these NOTEs for the
dosimetrist or planner
• Select and mark a plan for approval
Conditions that Prevent Opening Studysets
• The studyset contains fewer than five cross-sections (2D plans).

• The studyset contains no CT, MRI, or PET images (non-image based plans).
• The studyset is a CT or PET studyset defined with a roll angle other than 0 or 180
(prone or supine).
Monaco® 1-5
Overview
Overview
Conditions that Prevent Plans from Being Available
The plan types below sent proprietarily from XiO are not supported.
 Brachytherapy plans
 Plans with rotational beams
 Stereotactic plans
 Relative dose plans without a valid prescription
NOTE: Plan Review supports plans with rotational beams and stereotactic plans
imported through DICOM.
Plan Review also supports rotational plans from Monaco.
1-6
Overview
Overview
Entering and Editing the Monaco License
Once Monaco is loaded, it must be licensed for the features you purchased. If your
system was set up by support personnel, the system may already be licensed. However,
if you need to verify features or make edits, you can do so on the Edit License dialog
box. If you think that an edit is needed, please contact customer support to verify your
features and get a new activation code, if necessary.
1. Click Start | All Programs | Elekta | Edit License to show the Edit License dialog
box Figure 1-2.
Figure 1-2: Edit License dialog box
2. Your System ID and the software Version fields automatically populate.
3. The Site ID is listed on the activation code generated by applications support.
Monaco® 1-7
Overview
Overview
Entering and Editing the Monaco License (cont.)
4. All features on your activation code must have a checkmark beside them on the
Edit License dialog box for the activation code to be correct.
5. Click Check License to verify that the activation code and feature combinations
are correct.
6. You can print the information on this dialog box by clicking the Print button.
7. Click the Save and Exit button when you are finished or the Cancel button if
you do not want to accept any edits you made.
Online Help
The online help includes an Index function where you can search for a topic when you
use the Index tab and type a key word. The Find function lets you to search for a topic
when you use the Find tab and type a single character or an entire word. The system
does the search for you.
1-8
Overview
Overview
Online Help (cont.)
Keep the Online Help Window in an Open Status while Performing

Functions
To keep the online help procedures for a task in view while you complete a task,
follow these steps:
1. Click Monaco Application button followed by the Help menu item.

The Help window remains open until you either minimize the window or close it.
2. To minimize the help window while you do a task, click the box in the upper
right corner of the help window. (This feature works identically to other
Windows applications.)
3. To bring the help window back into view, right-click the Online Help session
identifier on the Start taskbar at the bottom of your
computer screen.
4. To close the help window, click the box in the upper right-hand corner of the
help window. (This feature works identically to other Windows applications.)
User Authorization Database
Before you set up your clinic, it is important for the administrator to create users and
assign the users to the appropriate group based on the group’s permissions in the User
Authorization database. This is done so that they can do certain functions, such as,
Plan Approval. We give the user a username and password so they can login with the
specific rights and information assigned to them.
Monaco® 1-9
Overview
Overview
Other Training Resources
If you have additional questions about the functions that are not described in the
online help or in the training practice exercises, refer to any of these resources:
• Monaco User Guide

• Monaco Upgrade Instructions
• Customer Support (supply phone and technical resources around the world)
1-10
General Operation and Navigation
Overview
This section provides information related to the general operation and navigation
tools available. When applicable, tools that are activity-specific will be labeled as such.
TERMINOLOGY NOTE: Monaco uses the term Studyset to represent the set of
images that make up one complete patient scan. You
can also refer to a studyset as an image set. The term
Study refers to a set of studysets or image sets relating
to one patient.
Open the Monaco Application and Log In

Once you configure the Monaco application for clinical use, follow these instructions.
If configuration is not complete, refer to the Monaco Installation Instructions for
more detailed information.
1. Double-click on the Monaco desktop icon.
OR
Click Start | All Programs | Elekta | Monaco to open and show the application.
2. Type a valid username and password.
Monaco® 2-1
Patient Management
Open the Patient
As soon as you open the application and log in, Monaco shows the Patient Selection
dialog box (Figure 2-1). From here, you can access all local or remote Monaco
patients.
Figure 2-1: Patient Selection dialog box
2-2
Patient Management
Open the Patient (cont.)
Local Patient Tab
Click this tab to show a list of patients that currently reside on the Monaco PC.
Remote XiO Patient Tab (not available for standalone Monaco users)
Click this tab to show a list of patients that currently reside on XiO. When you select a
patient from this list and open in Monaco, the patient becomes inaccessible in XiO.
Remote Focal Patient Tab
Click this tab to show a list of patients that currently reside on other Monaco
computers. When you select a patient from this list and open in a Monaco application,
the system moves the patient completely from one system to the other.
Selecting, Filtering and Loading a Patient
1. Left-click on a Clinic or Installation to show the patient listing.
NOTE: Patients that are grayed out indicate that they are in use or locked in
the current or remote application.
2. Filter the patients by typing the first few characters of the Patient Name or
Patient ID in the filter dialog. The filter works on both the Patient Name and
Patient ID text simultaneously.
3. Click the button next to the filter to remove the filter entry and show all the
patients.
4. Click the Patient Name title bar to reverse the order of the patient names.
5. Click the Patient ID title bar to reverse the order of the patient IDs.
Monaco® 2-3
Patient Management
Open the Patient
Selecting, Filtering and Loading a Patient (cont.)
6. Click the Creation Date title bar to reverse the order of the patients by date of
creation.
7. Double click on a Patient Name to load, or click on a Patient Name and click
OK. This action loads the patient/plans into the Patient Workspace Control.
The patient, studyset, plan, and server name appear in the title bar.
2-4
Patient Management (cont.)

Treatment Couch Library
This button opens a library of treatment couches or accessories that you can apply to
your plans. Eight sample couches are available for you. But, you can DICOM import,
contour and save your clinic-specific couches and accessories into this library for
future use. Refer to the exercise on Importing a Treatment Couch in this guide for
more information.
Sample Couches:
• sampleElekta
• sampleVarian
• Fraxion
• SampleConnexionHN
• SampleConnextionImaging
• SampleConnexionLatOpen
• SampleConnexionNoInlay
• SampleConnexionSolidInlay
NOTE: Before you use a sample treatment couch, you must complete these tasks:
a) Review sample couches for accuracy.
b) Force electron density values (default value is 1.0).
Monaco® 2-5
Patient Management
Treatment Couch Library (cont.)
Open Treatment Couch Library
1. Click Treatment Couch Library on the Patient Selection dialog box. The system
loads the couches into the Workspace Control.
2. Double-click on a couchtop or accessory in the workspace to load.
3. Edit couchtop structures just like any other structure in the system.
See the Contouring Tools section of this guide for more information on editing
contours.
Remove Couches from Treatment Couch Library
1. Click on the Monaco Application button followed by Treatment Couch|

Remove Couches from Library (Figure 2-2).
Figure 2-2: Remove Couches from Library
2. Under the Delete heading, place a check in the box next to the couches you
want to delete.
3. Click OK.
2-6

Import New Data
Use the Import New Data utility to manage the selection of DICOM series for import.
From this interface, you can import DICOM images from CT, PET, and MRI. You can
also import RT Structure Sets, RT Plans, RT Dose, and couchtop images. No user
intervention is necessary to determine patient orientation, image view orientation, or
image labeling. Monaco extracts all of this data automatically upon import based on
the DICOM header.
1. To access the DICOM import utility, click the Import New Data button on the
Patient Selection dialog box. This action opens the DICOM Import dialog box.
Figure 2-3: DICOM Import dialog box
2. Click the Browse button to search your network for the DICOM patient you
want to import. This opens a standard Windows browser. You can import
DICOM patients from a local folder, a CD, a removable drive, or any networked
location.
Monaco® 2-7
Patient Management
Import New Data (cont.)
NOTE: You can right-click in multiple locations on this dialog box to show a
menu of available options.
3. Select the loaded patient from the DICOM Patient drop-down list. Monaco
shows the study, studysets (image sets) and/or plans for this patient in the
window at the top left.
4. Left-click on the studyset, plan, or dose to select the data you would like to
import. If you would like to select multiple sets of information, hold down the
Ctrl key on the keyboard and left-click to select the data. DICOM Header
information is automatically shown in the top-right window.
NOTE: Monaco does not handle RT DOSE import of BEAM level or
CONTROL POINT level doses or dose of type MULTI PLAN. If you
compare doses in Monaco, you must import the total plan dose. The
import of large DVH files may fail. Contact Customer Support if the
import fails.
5. Select a local installation and clinic where you want this imported data to reside.
6. Monaco automatically shows a patient ID and Patient Name based on the
DICOM Header information, or you can enter a new patient ID and Name.
7. Click the Add button to add the selected data to the import. Monaco
automatically shows images in the image window on the right side of the dialog
box and populates the window below the Add button with the data you want to
import.
OR
Click the Clear button if you would like to clear your selections and start again.
OR
2-8
Patient Management
Click the Merge button to merge multiple image series from the same studyset
into one studyset for import.
NOTE: See Appendix E of this training guide for detailed scenarios about
the selection of images for DICOM Import.
8. If you do not import plans or dose, you can right-click on the studyset name and
select Rename from the menu to rename the studyset. The studyset name is now
editable. Type a new studyset name.
9. You can move the slider bars that appear just beneath the image to adjust the
window and level.
10. Right-click on the image to maximize a shown image.
11. Left-click on a new one on the list shown below the image to change the shown
cross section. The Left/Right, Anterior/Posterior, and Foot/Head rotational
information around the base image (transverse, sagittal, coronal) for the
displayed image shows to the right of the image list. These values are zero for
coronal, sagittal, and transverse images. These values are non-zero for oblique
MR images. If an image has less than one degree of rotation, it is transverse,
sagittal, or coronal. If an image has more than one degree of rotation, it is
oblique.
12. You can click on a cross section and click on the Remove button in order to
remove a cross section. The cross section appears grayed out. You can hold
down the Ctrl or Shift key on the keyboard and left-click to select cross sections
with your left mouse to remove multiple cross sections.
NOTE: If you import dose, Monaco does not show the Remove cross section
buttons.
13. Select the grayed out cross section and click on the Restore button to restore a
cross section. (Monaco only shows Restore if a selected cross section is grayed
out.)
14. Click on the Remove Even or Remove Odd button to remove all even or odd
cross sections.
Monaco® 2-9
Patient Management
15. Click the Restore Even or Restore Odd button to restore all even or odd cross
sections. (Monaco only shows Restore Even or Restore Odd if the selected cross
sections are grayed out.)
16. Select a CT-to-ED file from the CT-to-ED Assignment drop-down list.
17. (Optional) If you have any anatomical sites in the Installation/Clinic that you
selected and you want to assign one to this patient, select the anatomical site
from the Anatomical Group drop-down list.
NOTES: Anatomical groups are assigned to studysets instead of structure sets

to avoid overwriting anatomical groups that may exist on a structure
set.
Anatomical groups are not available to standalone users at this time.
18. Place a checkmark next to Delete After Transfer if you would like to delete the
patient from the location where you retrieved it. This is an easy way to clean up
the DICOM Import folder if you have one locally.
19. Click the Import button to complete the Import of the selected data.
20. Click the Show Log button to see the error log. Customer Support may ask for
this information if you call them because you cannot import your images.
21. When the DICOM Import dialog box clears, the import is complete. Click Close
to close the dialog box.
22. Click the Open Patient button to show the Patient Selection dialog box.
23. Select the imported patient from the Installation/Clinic where you imported.
2-10

Recalculate DICOM Plan
You can use the Recalculation of DICOM imported plans to create and calculate a
Monaco plan from an imported DICOM treatment plan. The imported DICOM plans
can come from any manufacturer’s treatment planning system. During the import,
Monaco converts the control point data in the DICOM file into a Monaco treatment
plan. Once the plan is recalculated, you can compare the imported DICOM dose with
the Monaco calculated dose. This comparison is done for various reasons but not
limited to the following: independent QA check, dose comparison for research
purposes, dose recalculation to transfer patient to a different machine. When you
assign a machine to an imported plan, verify that the machine geometry (leaves, jaws,
collimator/gantry angles, etc.) of Monaco’s TU match the machine geometry on the
original treatment planning system.
1. Right-click on a plan and select Recalculate DICOM Plan in the right-click menu.
The Map DICOM Machine to Monaco Treatment Unit opens.
Figure 2-4: Map DICOM Machine to Monaco Treatment Unit
2. Select a treatment unit in the Suggested Monaco TU drop-down menu on the Map
DICOM Machine to Monaco Treatment Unit dialog box. You only see Treatment
Units with a status of ‘Clinical’. You see an error message if none of your
Treatment Units match the imported machine.
3. (Optional) If you want to save the TU, place a checkmark next to Save Mapping to
save the settings selected. Future plans which use this same machine will use this
same TU mapping.
4. Click on the Reset to defaults button if you want to reset to the default setting.
Monaco® 2-11
Patient Management
Recalculate DICOM Plan (cont.)
5. Dose will not calculate until all the parameters of the plan are correct. Look in the
status bar at the bottom of the screen. Correct any error messages related to the
Prescription Dose or Patient Contours you see (shown in red).
Figure 2-5: Error message before calculating an imported DICOM RT Plan
6. If the imported MLC or Jaw positions violate constraints in Monaco, you will see a
warning message that the plan may not be deliverable. Click OK to close the
message. Monaco will usually continue with the dose calculation using the
imported MLC configuration.
Figure 2-6: Segmentation Validation error message
7. Monaco uses a relative electron density for its dose calculation. Some treatment
planning systems use a mass density. Monaco imports density overrides for a
structure when reported as relative electron density (for example, if there is
contrast in the bladder), you should check that structure densities are set correctly.
You can manually set a structure’s density. Use the Force ED and option on the
Structures tab of the Planning Control to define a structure’s density. Check that
you are using the correct cttoed file and that your structure densities are set
correctly. Differences in these parameters could cause differences in the dose
calculated in the 3rd party TPS and Monaco. For information on converting from
Mass Density to Relative Electron Density, see the Dose to Medium/Dose to Water
presentation in Volume III of this guide for more information.
2-12
Patient Management
Recalculate DICOM Plan (cont.)
8. Once you select a TU and address any errors, click Calculate to calculate dose.
9. You cannot select the Calculate button if the plan:
a. Is from Tomotherapy
b. Contains beam modifiers such as blocks, wedges, compensators,

applicators, cones or an add-on MLC
c. Contains electron or proton beams
d. Does not contain an MLC
e. Was imported prior to Monaco 5.1
NOTE: There is no treatment machine data contained within the DICOM

treatment plan file. Also, most of the calculation settings are not
contained in the DICOM treatment plan file. You must select and
verify the appropriate machine model for recalculation in Monaco.
Differences in these settings/data between the original calculation
and any Monaco calculation can result in calculated dose differences.
These differences can include: CT to ED File, Dose Grid, Dose to
Water vs. Dose to Medium, Heterogeneity Correction, and Structure
Set density overrides may not be read by Monaco.
Monaco® 2-13
Enter or Edit DICOM Export Settings
These settings apply to data that you want to export to any application that receives
DICOM Imports. They do not apply to sending data to XiO. The actual DICOM
export is done from the Output tab | DICOM Export. The export process is explained
in detail after this section.
Setup your DICOM File Export Data Location

Type in the location where you would like to store DICOM Export data when you
choose to export to a file.
1. To type in or edit the DICOM Export Settings, click Monaco Application

button| Setup | DICOM Settings to show the DICOM Settings dialog box.
Figure 2-7: DICOM Settings dialog box
2. The default location for the DICOM File Export data automatically appears.
You can click the Browse button to set a new data location, if desired.
3. The SCU Name is the AE_Title of the Monaco PC where you are entering these
settings. Monaco provides a default name. You can edit the default name. The
receiving application must have this AE_Title assigned in its DICOM Import
program in order to receive the exported data.
2-14
Patient Management
Enter or Edit DICOM Export Settings
Setup your DICOM File Export Data Location (cont.)
Setup Storage of Incoming Images for Future Export
If you plan to export image data that was previously transferred in to Monaco, you
must have the Store Incoming DICOM Images box checked before you import the
images. This creates a copy of the image data that is used during export. If you do not
plan to export image data, we recommend that you do not place a checkmark  in
this box to avoid the population of unnecessary sets of image data on your hard drive.
Setup DICOM Export Locations
Type in the location(s) where you would like to send DICOM Export data when you
choose to export to an SCP location.
1. Click Add or <click to add new row>.
2. Type the Label for the location. This is the location label you select from the
DICOM Export dialog box when you export to an SCP location.
3. Type the AE Title for the receiving system.
4. Type the resolvable hostname or a valid IP address for the receiving system.
5. Type the Port Number that will be used for this DICOM transfer.
6. Once you type in all the information for an export location, highlight the export
location you want to test. Click the Test button to verify communication between
the two systems.
7. Assuming the test was successful, click OK when you finish entering or editing
these settings.
8. Add or Delete Export locations. Highlight the location you want to remove and
click the Add or Delete button.
Monaco® 2-15
Patient Management
Export Patient via DICOM
You can export these objects through DICOM to a record and verify system or
another treatment planning computer:
• Images
• Specialty Images
• Structure Sets
• RT Plans
• RT Images (DRR’s)
• Monaco dose - total and/or individual beam doses for single prescription,
multiple prescription, and MR plans
• Monaco QA dose- total and/or individual beam doses
• DVH
In Planning or Plan Review, click Output tab | DICOM Export.
NOTE: If the Export option is not available, verify the information below:
(1) You have a patient loaded.
(2) You have turned on the proper DICOM license features.
2-16
Patient Management
Exporting via DICOM
Use these steps to export data via DICOM:
1. Click Output tab | DICOM Export to show the DICOM Export dialog box.
Figure 2-8: DICOM Export dialog box
2. Select the modalities you want to export. Monaco limits what you can export
based on the plan properties:
Monaco® 2-17
Patient Management
Exporting via DICOM (cont.)
Table 2-1 DICOM Export Options

RT Plan Option This option is only available if you
have a plan loaded.
RT Ion Plans Are exported as RT Plans. In the

export file, the machines are changed
to generic IEC photon machines.
Dose Option Only available if you have RT Plan

selected and dose was calculated in
Monaco.
Composite Plans You cannot export composite plans.
Multiple Prescriptions You can export all prescriptions, or

select which one(s) to export.
Frozen Dose You can export Frozen Dose Plans.
QA Plans You can DICOM export images,

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

the Total Dose box is checked.
Specialty Images MIN, MINiP, AVG can be exported.
MR Images and Structure Sets You can export T/S/C structure sets
for MR images. However, you cannot
export oblique structure sets. You
can export oblique MR Images.
2-18
Patient Management
3. (For Elekta non-micro MLC: Step and Shoot IMRT, VMAT, Conformal RT,
and dMLC plans. Siemens: Step and Shoot IMRTand Conformal RT Plans
only) When you check the RT Plan option, you can also check Composite Field
Sequencing to group beams with a common couch angle into a single control
point sequence. Composite Field Sequencing is not available if your plan
contains more than one Rx or multiple machines. (For detailed information
about composite field sequencing, refer to the Online Help.)
4. When you check the Include Setup Beams option, the system exports the setup
beams created in the beam spreadsheet. The Setup Beams/Sequences are
DICOM exported as SETUP with the RT plan.
5. When you click on the Addt’l Options button, the Additional Plan Export
Options dialog box shows a table of options you can DICOM export. You use
these options to match the information defined in your record & verify system.
Figure 2-9: Addition Plan Export Options dialog box
6. If you have RT images associated with your plan, you can select to export all the
images or select individual beam images. Below RT Image Options, you can
check the respective boxes to Add Overlays, Add Anatomy, and Add
Annotation.
7. When you check Total Dose, the system exports the total composite dose for all
the beams.
Monaco® 2-19
Patient Management
8. When you check individual beams below total dose, the system exports
individual beam doses.
9. When you select RT Plan as a modality to export, the system activates the Map
Machine feature. Click Map Machine to show the modeled machine names.
10. Next to each modeled machine name, type a name that the receiving system
recognizes.
2-20
Delete a Patient (Standalone Users Only)
If you are a standalone Monaco user and would like to delete a patient, use these steps:
1. Click the Monaco Application button | Delete Patients to show the Remove
Patient dialog box.
Figure 2-10: Remove Patient dialog box
2. Check the box next to the patient you want to Remove.
3. Click the Remove button. Monaco shows the Delete Patient Confirmation
dialog box.
Figure 2-11: Delete Patient Confirmation dialog box
4. You can select to Recycle, Delete, or Cancel the deletion.
Monaco® 2-21

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

• Start new Sim or Monaco plans
• View DICOM information about a studyset.
Here is a list of patient workspace control icons you might observe:
Study ID
Studyset (orientation is shown if non-
tranverse)
Structure Set (orientation is shown if
non-tranverse)
Conventional Plan
Conventional Plan with Dose
XiO IMRT Plan
XiO IMRT Plan with dose
Monaco Plan
Monaco Plan with Dose
Monaco QA Plan
Summation Plan (Plan Review)
Subtraction Plan (Plan Review)
Base Plan (used to create Composite
Plan)
Composite Plan (Bias Dose)
Composite Plan (With Dose)
Frozen Dose
Plan Approved
Multiple Prescription Plan
Figure 2-12: Workspace Icons
Multiple Prescription Plan (With
Dose)
2-22
Patient Management
Patient Workspace Control (cont.)
Load a Patient/Plan from Patient Workspace Control

Follow these instructions to load a patient that has recently been imported to Monaco
via DICOM, or a patient that already resides locally on the Monaco PC and was
opened from the Patient Selection dialog box.
You can load multiple plans and studysets at one time. The active studyset and/or plan
appear in Blue Underlined Italics in the workspace and also are listed on the title bar.
A studyset and/or plan that is loaded, but not active is shown in Black Bold in the
workspace. A secondary studyset is shown in Green Italics in the workspace. Studysets
and plans that are not loaded appear as Black in the workspace.
Load a Studyset
To load a studyset, double-click the studyset name.
OR
Click the studyset name then, click Load to load the selected studyset.
OR
Right-click on the name and select Load/Activate from the right mouse menu options.
Monaco® 2-23
Patient Management
Load a Patient/Plan from Patient Workspace Control (cont.)
Load a Primary and Secondary Studyset

The instructions below demonstrate how to load a primary and secondary studyset so
you can fuse them or use them both in contouring. It is assumed that both studysets
have been transferred into the system directly and both reside in the local directory.
Or they have both been transferred into XiO and you have selected the patient from
the Remote XiO Directory to be opened in Monaco.
1. Select the patient from the Patient Selection dialog box to open it and to show
both studysets in the Patient Workspace Control.
2. Click and Load the studyset that you want to be the primary studyset. (This is
the planning CT.)
3. Right-click on the studyset that you want to be the secondary studyset and
select Load/Set as Secondary. Studysets open directly in the Fusion activity if
they have not been fused, or open in the Planning or Plan Review activity, if they
have.
OR
Load the primary study set. Then, select one or multiple secondary studysets.
Right-click and select Load/Set as Secondary.
OR
Load all the studysets into the workspace as primary studysets using Ctrl or Shift
+ selecting multiple studysets. Then, load one of them as a secondary studyset.
Use the right mouse menu option on the Workspace Control to Load/Set as
Secondary.
2-24
Patient Management
Load an Existing Plan

To load an existing plan, double-click one of the plan names.
OR
Click one of the plan names, then click Load to load the selected plan.
OR
Right-click the plan on the Workspace Control and choose the option Load/Activate.
NOTE: Monaco shows an Electron Densities Warning message if the Studyset

timestamp is later than the Plan timestamp. It also shows the warning
message if the plan electron densities are different than the studyset
electron densities.
Figure 2-13: Electron Densities warning message
Unload an Existing Studyset and/or Plan
To unload a studyset and/or a plan, right-click on the studyset or plan name and select
Unload.
OR
Click a studyset or plan to highlight it. Then, click the Unload button at the bottom of
the Workspace Control.
If you unload a studyset where a plan is also loaded, both the plan and studyset are
unloaded.
Monaco® 2-25
Patient Management
Activate a Loaded Studyset and/or Plan
To activate a loaded studyset and/or plan that is not currently active, right-click on the
studyset or plan that you want to make active and select Load/Activate. Notice that
the plan updates and the active plan name updates on the title bar.
Load Existing Plan(s) Into a Specific Activity

You can load plans in Planning or Plan Review Activity through the Workspace
Control. Options are available based on whether or not the plan has calculated dose.
You can only review imported RT Ion Plans in Plan Review.
Right-click on a plan in the workspace control and select Load Into, then Planning or
Plan Review.
To load multiple plans at one time, hold down the Ctrl key while clicking on each plan
you want to load. Then, right-click and select Load Into, then Planning or Plan Review.
Delete a Plan
Right-click on a plan in the Workspace Control and select Delete Plan.
OR
Click on the Planning tab. Then, select Delete Plan button.
Studyset Info
You can show DICOM header information about a studyset. To do this, right-click on
the Studyset icon in the Patient Workspace Control and select Properties. This
action shows the Studyset Info dialog box with information such as:
• Number of Images
• Patient Name
• Patient ID
• Study ID
• Study Date
• Study Description
• Series Date
• Series Description
NOTE: You cannot edit the Studyset Info. It is read only. If the studyset
information is incorrect from the scanner, it cannot be changed in Monaco.
2-26

Frozen Dose
Frozen dose is saved dose that is no longer current. Monaco shows frozen dose with a
snowflake icon next to the plan in the Patient Workspace Control. When you
hover over the snowflake, Monaco shows you the reason the plan has frozen dose.
When you delete, edit a shape, or change the structure type from bolus or couch that is
assigned or assign a new couch, the system removes the dose of the current active plan
and freezes the dose for the saved plans with the same assigned bolus or couch. When
you load a frozen dose plan, the DVH shows the frozen dose with the current structure
set volumes, not those that were present at the time the dose was frozen. When you
load a plan with frozen dose, you have the option to keep the frozen dose or
recalculate (Figure 2-14)
Figure 2-14: Frozen Dose-Load Plan
A Monaco plan’s dose freezes if you:
• Change an internal structure with an assigned electron density.
• Change the CT to ED assignment.
• Modify the external structure.
• Edit or delete a bolus or couch structure assigned in a Monaco plan.
• Edit MLC Dynamics parameters.
• Edit MLC Geometry parameters.
• Edit MLC Leakage parameters.
• Edit a cone model.
Monaco® 2-27
Patient Management
Frozen Dose (cont.)
QA Plans
You can make a QA plan from a Monaco plan with frozen dose. For existing QA
plans, if the QA plan is based on the same modified studyset as the Monaco plan, the
QA plan dose becomes frozen too.
Multiple Prescription Plans
For Multiple Prescription plans, if any calculated prescription has frozen dose, the
snowflake icon is shown by the plan. This plan does not have to be fully calculated. If a
frozen prescription is modified then dose for all prescriptions is removed. Also, if a
prescription of a frozen dose plan is added or deleted, the dose is removed.
Patient Workspace Control Tooltip

When you place your mouse over an existing studyset or plan, Monaco shows a tooltip
that describes these items:
Studyset
• Studyset Name
• Image Type
• Number of Images
Plan
• Plan Name
• Description
• Delivery Mode (Monaco Plans Only)
• Modality
• Number of Beams
2-28
Navigating Monaco
Ribbons
Each ribbon contains several different groups (Figure 2-15). These groups keep similar
buttons in the specific group. You can double-click on any tab in the ribbon to
collapse the entire ribbons panel. You can also add buttons that you frequently use to
the Quick Access toolbar so you do not have switch between ribbons during treatment
planning. For detailed information about the various groups on each tab, refer to
Online Help.
Figure 2-15: Ribbons display
In addition to the ribbons, you can click on the Monaco Application button to
do these tasks:
• Open, close, or delete patients

• Save plans
• Save templates
• Manage Templates
• Change settings
• Add/remove treatment couches
• Change setup options

• View log files
• View Online Help
Monaco® 2-29
Navigating Monaco (cont.)

Styles
You can pick a color style for the Monaco interface. Click on the drop-down arrow to
the right of the Style button in the top-right corner of the ribbons. You can
choose one of these styles:
• Black
• Blue
• Aqua
• Silver
Planning Control
The Planning Control (Figure 2-16) contains several dialog boxes. You can click on
the associated tab to see the dialog box. The tabs below are available on the Planning
Control:
Figure 2-16: Planning Control
• Structures
• Prescription
• Beams
2-30
Navigating Monaco
Planning Control (cont.)
• IMRT Constraints
• Dose Reference Points
Planning Control-Tabs
Always Available: Limited Availability:
Structures Prescription (Only shown with 3D or

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

IMRT Plans in Planning Activity)
Dose Reference Points
Save a Plan
You can click on the Save button, or click on the Monaco Application button
then the Save or Save Plan As option to save your plan. The Save option saves the
active patient or plan with changes. The Save Plan As option lets you save the active
plan as a new plan.
1. Click Monaco Application button | Save or Save Plan As to show the Save As
Plan dialog box.
Figure 2-17: Save As Plan dialog box
Monaco® 2-31
Navigating Monaco
Save a Plan (cont.)
2. In the Plan Name field, type the plan name.
OR
Select a plan name you previously used in the drop-down menu.
3. In the Plan Description field, you can type a plan description up to 24 characters
long. The plan description appears in the plan’s tooltip on the workspace
control.
4. When you save a bias dose plan, you have the option to save the composite plan
or the current plan when you check or uncheck the option Include Base Doses.
5. Click the Save button to save the plan.
6. If a plan name already exists, the system prompts you to overwrite it.
2-32

Save a Template
To save your own plan templates, you must first add an existing plan template to your
patient. Make changes to the beams until your plan is set up the way you want it. Select
Save Template or Save Template as. The Save Template options saves the active
template with the changes you made. The Save Template as option lets you save active
template as a new template for future use. Complete these steps to save the beam
arrangement as a new template.
1. Click on the Monaco Application button then Save Template As to show the
Save Template As dialog box.
Figure 2-18: Save Template dialog box
2. Type the Template Name and Description.
OR
To overwrite an existing template, select a template from the Template Name

drop-down.
3. Select an Anatomical Site from the drop-down. This lets you filter your
templates by site when you start a new plan.
4. Select Save to save the template.
NOTE: Only users with Physics rights can overwrite an existing SIM or
Monaco template. All other users can save the template with a new
name.
Monaco® 2-33

Autosave Contours
Autosave is a function in Planning activity that, when activated, automatically saves
contours as you define them. The appropriate time to use this tool is when you start a
new patient and have not yet created any plans. This tool ensures that you do not lose
all of your contouring in the event of a catastrophic event, such as a power failure.
Place a checkmark next to Contour Autosave (Figure 2-16) on the Tools tab. Each
time you add, edit, or delete a contour, Monaco automatically saves all contours.
Figure 2-19: Contour Autosave
Close a Patient
To close a patient, click the Close Patient button.
OR
Click on the Monaco Application button then Close Patient.
OR
Open another patient. Monaco prompts you to save the currently shown patient’s plan
before you open the new one.
2-34
Image Navigation and View Types
Before you begin contouring and planning, it would be useful to understand how to
navigate through your images and show different views.
Throughout Monaco, you can choose to show different image views in selected
windows. These types of views include:
• Transverse
• Sagittal
• Coronal
• Oblique
• beams-eye view (DRR)
• Side by side primary and secondary images
• 3D view
Not all views are available in all activities. This section defines each view type and any
related tools available to manipulate those images.
Transverse, Sagittal, Coronal, and Oblique Views

All activities support transverse, sagittal, and coronal views. There are a multitude of
tools you can access when you right-click in any T/S/C/O window. In the Planning
activity, the T/S/C/O view that defaults is considered the Standard layout. Refer to
Online Help for detailed information about T/S/C/O Views warning messages.
Oblique Views
Only the Planning activity supports oblique views. Panning in a T/S/C view does not
pan an oblique view. Quick Locate will update an oblique view. Refer to Online Help
for detailed information about what functionality is available in oblique views.
Navigate Through T/S/C/O Images
There are several methods you can use to navigate through your transverse, sagittal,
coronal, and oblique images.
Monaco® 2-35
Navigating Monaco
Navigate Through T/S/C/O Images (cont.)
• Use the color coded T-bars (non-oblique images)

• Use the Scroll Wheel on the Mouse
• Use the Quick Locator Method
• Use the Navigation Toolbar
• Use the Page Up/Page Down keys (transverse images only)
• Use the Active Slice Tracker (transverse and oblique images only)
Use the Color-coded T-bars
Each of the three graphics windows has a color frame. The transverse image window
frame is green, the coronal image window frame is cyan (light blue), the oblique image
frame is white, and the sagittal image window frame is yellow. In each window,
Monaco shows colored T-bars representing the slice location of the currently viewed
slice for all three views.
The T-bars are called partial slice trackers. If you would like to show solid lines,
instead of T-bars, click the Workspace tab and remove the checkmark next to the
Partial Slice Tracker option.
T-Bars Solid Lines
Figure 2-20: Partial Slice Tracker selected and unselected
2-36
Navigating Monaco
Transverse, Sagittal, Coronal, and Oblique Views (cont.)
Navigate Through T/S/C/O Images
Use the Color-coded T-bars (cont.)
To navigate through the transverse images, hold down your left mouse button and
drag the green T-bar/line in the sagittal or coronal window. Monaco automatically
updates the transverse images as the T-bar/line moves.
To navigate through the coronal images, hold down your left mouse button and drag
the cyan T-bar/line in the sagittal or transverse window. Monaco automatically
updates the coronal images as the T-bar/line moves.
To navigate through the sagittal images, hold down your left mouse button and drag
the yellow T-bar/line in the coronal or transverse window. Monaco automatically
updates the sagittal images as the T-bar/line moves.
Use the Scroll Wheel on the Mouse
If you have a mouse with a scroll wheel, you can left-click in any transverse, sagittal,
coronal or oblique window to activate it. Use the scroll wheel to navigate through the
images.
Use the Quick Locator Method
You can quickly update the images to display a specific 3D location in all views by
double-clicking your left mouse in any T/S/C/O view as long as no other menu
option is selected.
OR
At any time, you can press the L key on your computer keyboard when your mouse
points to the specific location. A cross hair temporarily appears in the window you
click just before all the images update to that location. Pressing the L key is the only
quick locator option within the Fusion Activity and in any activity when the mouse is
occupied with other menu options.
Monaco® 2-37

Use the Slice Navigator Toolbar
The Slice Navigator toolbar (Figure 2-21) at the bottom of Monaco indicates the slice
positions of the transverse, sagittal, and coronal planes that are currently shown.
Figure 2-21: Navigation Toolbar
Use the Reference Plane Values
Click the up and down arrow buttons next to any field to change the slice shown for
that plane.
OR
Click the arrow buttons next to any field to highlight the field. Use the up/down arrow
keys on your computer keyboard, or the scroll wheel on the mouse to change the slice
shown for that plane.
OR
Type a distance value for each field to change the slice shown for that plane.
OR
Type in or use the arrow buttons to change the Active Slice. This field is available for
native (non-reconstructed) slices when you have Slice Mode turned on.
NOTE: If you click on Slice Mode, Monaco only lets you show real transverse
slices. If you do not select Slice Mode, you can show any real or
reconstructed transverse slice.
2-38

Use the Display Image Plane Option

In any T/S/C/O view, click the Display Image Plane button to
view an outline of the Active slice in the 3D view.
Use the Jump to Point Option

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

• Center of any structure
• Any defined interest point or marker
• Volume isocenter
• Plan isocenter
• Max dose (where available)
Use the Page Up/Page Down keys (Transverse Images Only)
Click the Page Up and Page Down keys on the keyboard to navigate through
transverse images. When you select Slice Mode, you can navigate through real
transverse slices and in 0.1 cm increments through Coronal and Sagittal slices. When
Slice Mode is not checked, you can navigate in increments of 0.1 cm.
NOTE: If the real transverse slices have a resolution smaller than 0.1 cm, then the
coronal and sagittal slices will be reconstructed with whatever is the
smallest transverse slice resolution.
Adjust Window and Level

The window and level settings let you control the overall brightness and contrast of an
image. You can adjust the window and level settings for each studyset independently
when you have more than one studyset loaded.
There are three methods available for adjusting window and level settings:
• Using the mouse
• Using the window/level toolbar
• Selecting user-definable window and level presets
Monaco® 2-39

Adjust Window and Level (cont.)
Adjust Window and Level Using the Mouse
1. Right-click in any transverse, sagittal, coronal, or oblique window and select the
Window/Level Tool option.
OR
From the Tools tab, click the Window/Level button to change the mouse
cursor to a black and white sun icon.
2. Hold down your left mouse button and drag up or down to change the level, or
left and right to change the window.
NOTE: If the studyset you want to adjust W/L for is not shown in the W/L
Affects box, you can toggle this when you hold down the shift key
on your keyboard, or when you move the P/S slider bar to 100%
Primary or 100% Secondary position.
Adjust Window and Level from the Window and Level on Tools tab
Type new values for the window and level in the Window and Level section on the
Tools tab as shown below:
Figure 2-22: Window Level Section of the Tools tab
OR
Left-click on the up and down arrows next to the window and level fields to adjust the
window and level in small increments.
2-40

Select an Image Set/View in the Window/Level Affects Drop-Down Menu
In the W/L Affects drop-down menu (Figure 2-23), you can select one of the image
sets shown on the screen.
Figure 2-23: W/L Affects Drop-Down Menu
The BEV, AP, and LAT view options do not appear in the W/L Affects drop-down
menu unless they appear on the screen.
Link W/L Affect to Image Sets
You have the ability to change the window/level affect for all common image sets.
Place a checkmark next to Apply to same type on the Tools tab, and then select the
desired Window and Level for all of the common image sets.
Monaco® 2-41

Adjust Window and Level Using User-Definable Window Level Presets
You can click on the Save As Preset button on the Tools tab to save,
edit, and delete preset window and level settings from this list.
Figure 2-24: Save Window/Level Preset Values
To apply presets to the shown images, click the arrow button next to the
Window/Level Preset field and select a preset option from the list.
Monaco applies the preset to all transverse, sagittal, and coronal images.
To apply a preset to a secondary studyset (fused studyset), change the option in the
W/L Affects field to Secondary Studyset. Select a window and level preset from the
list. Monaco applies the selected preset to the secondary studyset.
Non-Editable Window/Level Presets
The PET Default and PET DICOM Window/Level Preset Values are non-editable
values. The PET Default values are specific to the maximum pixel value in the studyset
window/level. Monaco stores The PET DICOM values: window width and window
level in the PET DICOM files. The system reads the values from the first image in the
image series.
2-42

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

• Right-click in any T/S/C/O or 3D window
Zoom
These procedures demonstrate the tools available to zoom and reset images.
Zoom Continuously
1. Click the Zoom button to change the mouse icon to a magnifying glass
icon.
OR
Right-click in any T/S/C/O or 3D view and select Zoom.
2. Hold down your left mouse button and drag left or right in any image window
to smoothly zoom the selected image.
Reset Zoom and Pan

1. Choose one of these two options:
• Click the Reset All Views button to reset zoom and pan in the
T/S/C/O and 3D views.
• Click the drop-down arrow next to the Reset All Views option to reset an
individual tool in the Navigate panel.
Figure 2-25: Reset Drop-Down Menu
Monaco® 2-43

Zoom (cont.)
Magnifying Glass
1. Click the Magnifying Glass tool to change the mouse into a moving
magnifying glass.
OR
Right-click in any T/S/C/O or 3D window and select the Magnifying Glass

option.
2. Hold down your left mouse button and drag over any image to magnify selected
areas.
3. Change the tool from a circle to a square by pressing the S key on the keyboard.
4. To change the magnification from 1.2x to 5x magnified, hold down your left
mouse to show the magnifying glass, then roll the scroll wheel to adjust the
magnification.
5. To change the size of the magnifying glass, hold down your left mouse to the
show the magnifying glass, hold down the shift key on the keyboard, then roll
the scroll wheel to adjust the size.
6. To add a border to the magnifying glass, hold down your left mouse to show
the magnifying glass, and then press the spacebar to turn on the border.
2-44

Zoom (cont.)
Zoom Area of Interest
1. Click the Zoom Area button to zoom in on an area of interest.
OR
Right-click in any T/S/C/O or 3D window and select the AOI Zoom option.
2. Hold down your left mouse button and drag to create a box around the area of
interest to zoom the area of interest on an single view.
3. You can click middle-click to reset the AOI zoom on a single view.
4. Hold down your left mouse button + the Shift key and drag to create a box
around the area of interest to zoom an area of interest in all views (T/S/C/O)
simultaneously.
5. Hold down the Shift key + the middle mouse button to reset. You can reset the
AOI zoom on all views.
Monaco® 2-45

Zoom and Pan T/S/C/O and 3D Images (cont.)
Pan
These procedures demonstrate the various tools available to pan and reset images.
1. Click the Pan button to change the mouse icon to a hand icon.
OR
Right-click in a T/S/C/O window and select the Pan option.
2. Hold down your left mouse button and drag in a T/S/C/O window to pan the
selected image.
2-46
Screen Layout
Layouts
A layout is a predefined set of view settings. The layouts are saved per Microsoft
Windows™ user and contain user-defined layouts and default layouts. All of the layouts
are not available at all times. The available layout menu options are determined by the
view types they contain. (Refer to Layouts in Online Help for detailed information
about the default layouts and their associated workflow(s) and activities).
You can do the tasks below with the layouts:
• Save Layouts
• Manage Layouts
Save Layout as Preset Option
You can save the layout configuration shown on your screen. You can save the layout
with an existing layout name or type in a new name.
Figure 2-26: Save Layout As dialog box
1. Click on the Workspace tab then the Save Layout as Preset button.
OR
Right-click in any T/S/C/O or 3D view and select Layouts | Save Layout As.
2. In the Layout Name: field, type in a name.
OR
Click on the Layout Name: drop-down menu to select an existing layout name
to save your layout as.
Monaco® 2-47
Screen Layout
Layouts
Save Layout as Preset Option (cont.)
3. Click Cancel to discard your changes.
4. Click Save to save your changes.
Manage Layouts
You can set default layouts, view, rename, and delete Global and User layouts in the
Manage Layouts dialog box. There are three tabs in the Manage Layouts dialog box:
• User Defaults
• User Layouts
• Global Layouts
1. Click on the Workspace tab then the Manage Layouts button.
OR
Right-click in any T/S/C/O or 3D view and select Layouts | Manage Layouts.
2-48
Layouts
Manage Layouts (cont.)
User Defaults
On the User Defaults tab, you can select a default layout per a specified workflow.
Figure 2-27: Manage Layouts (User Defaults) dialog box
1. Click on the drop-down arrow in the Layout column in the appropriate

workflow.
2. Select the user or global layout you want as the default layout for the appropriate
workflow.
3. Click Apply to accept your changes.
OR
Click Cancel to discard your changes.
4. Click OK to save your changes and close the dialog box.
Monaco® 2-49
Layouts
User Layouts
In the User Layouts tab, you can view, rename, and delete user layouts.
Figure 2-28: Manage Layouts (User Layouts) dialog box
1. Click on the user layout you want to rename and type in a new name.
2. Check the box next to the user layout(s) you want to delete.
3. Click the Delete button to delete the selected user layouts.
4. Click Yes to accept the changes and continue. If you click Yes, the changes are
permanent.
OR
Click No to reject the changes and go back the User Layouts dialog box.
OR
2-50
Layouts
Global Layouts
In the Global Layouts tab, you can view, rename, and delete global layouts. Global
Layouts are default layouts available to all users.
Figure 2-29: Manage Layouts (Global Layouts) dialog box
1. Click on the user layout you want to rename and type a new name.
2. Check the box next to the user layout(s) you want to delete.
3. Click the Delete button to delete the selected user layouts.
4. Click Yes to accept the changes and continue. If you click Yes, the changes are
permanent.
OR
Click No to reject the changes and go back the User Layouts dialog box.
OR
Monaco® 2-51
Image Navigation and View Types (cont.)

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

view: You can see T/S/C
views for up to three (3)
studysets/plans at the same
time
P-S Side-by-Side Registered Primary and
Secondary studysets/plans
in a side-by-side view
P-S Side-over-Side Registered Primary and
Secondary studysets/plans,
one view over the other
view
Side-by-Side Registered studysets/plans
in a side-by-side view
Side-over-Side Registered studysets/plans,
one view over the other
view
Custom Option to select the
number of panes you want
to show
2-52
Side-by-Side Layout (cont.)

2. Select the number of panes you want to show, or select one of the global side-by-
side layouts in the list.
3. Click on the Swap Views button to swap the location of the

studysets/plans in the side-by-side panes. Drag and drop the image to the location
you want to swap.
4. (Optional): Drag the borders inward/outward to adjust the size of the image.
NOTES: The message “Structures did not originate on displayed images”

appears when a structure set overlaps a studyset that the structures
were not done on.
The message “Structures/Plans did not originate on displayed images”

appears when both a structure set and plan overlap with a studyset that
the structures or plan was not done on.
Side-by-Side: Planning Activity
• You can click on the Window/Level button on the Tools tab to adjust the
window/level for individual studyset(s).
• You can click on the Copy Structures button on the Contouring tab to copy
structures from the active studyset to a selected or all registered studysets. (For
detailed information regarding copy structures, refer to the Contouring Tools
section of the guide.)
Side-by-Side: Plan Review Activity
• You can adjust the isodose display for individual plan(s).
• You can show all loaded plans in the DVH.
Monaco® 2-53
Image Navigation and View Types (cont.)

3D View
The 3D view option is available in the Planning and Plan Review activities. This view
shows the contours in a three-dimensional rendering. You can view the 3D contours
in wireframe, transparent, or solid rendering. When isolines are turned on for 3D, they
also appear in the BEV. In Plan Review, you can show isodoses in the 3D view. Refer
to Online Help for detailed information about 3D View warning messages.
You also have the opportunity to view the field projection of beams on the skin
surface in a 3D view. When beam projections overlap on the surface, Monaco shows
that overlap with twice the intensity of the single field. Monaco shows up to three
levels of intensity, so the intensity will not increase if more than three beams overlap.
To show field projection, you must show the patient contour rendering as solid (0%
transparency).
The 3D view has its own section (Figure 2-30) that includes tools to rotate and
translate the 3D image. The other tools in the Navigate panel are available for both 3D
and T/S/C images. You can right-click in the 3D window and select these same
options.
Figure 2-30: 3D Navigate Tools
2-54

3D View (cont.)
3D Rotate
1. Right-click in the 3D window and select the Rotate option.
OR
Click the 3D Rotate button on the 3D toolbar to change the mouse icon to
a 3D rotation icon.
2. Hold down your left mouse button and drag around the 3D window to rotate
the image.
Monaco® 2-55
3D View (cont.)
3D Translate
Translate differs from Pan in that translate shifts the patient off the axis of rotation. If
you translate, then rotate, you will rotate around an axis that is no longer the center of
the patient. You can also translate in and out of the screen to "cut away" contours so
you can see inside the contours.
1. Right-click in the 3D window and select the Translate in X and Y or Translate

in X and Z option.
OR
Click the 3DTranslate X/Y button or the 3D Translate X/Z

button on the Tools tab to change the mouse icon to a 3D
translation icon.
2. Hold down your left mouse button and drag in any direction to translate the
image off the axis of rotation.
OR
Hold down your left mouse button while pressing the Shift key on your
computer keyboard and drag up to translate into the screen, or down, to
translate out of the screen towards you and "cut away" the contours.
Reset 3D Image Navigation Functions

Reset 3D Functions
Choose one of these two options:
• Click the Reset All Views button to reset all the functions for the
T/S/C/O and 3D views.
• Click the drop-down arrow next to the Reset All Views button to reset an
individual function.
2-56
4D Imaging Overview
4D Imaging
4D imaging allows evaluation of multiple images sets that provide information about
how a patient’s anatomy moves over time. Monaco gives you a variety of 4D Tools to
use (Figure 2-31).
Figure 2-31: 4D Tools
Import 4D Data
You can import 4D data from Elekta XVI, GE, Philips, Siemens, and Toshiba. When
you import images that share the same DICOM Study ID and frame of reference
(FOR), they are put into a Study when imported. In a 4D data set, the image sets are
named by the patient’s breathing phase (Figure 2-32). The Series Description
information lists the phase name in the Studyset Info dialog box. For more detailed
information about DICOM Import, refer to Appendix E.
Figure 2-32: Image Set Names
Monaco® 2-57
4D Imaging Overview
4D Imaging (cont.)
Multiple Structure Sets
You can view multiple image sets and their structure sets for 4D image comparison.
You can also view structure sets from other image sets on the active image set.
1. To select multiple image sets, hold down the Ctrl key on the keyboard and left-
click on the image sets that you want to load.
2. Click Load to open the image sets.
3. Place a checkmark next to the structure sets you want to see. The active
contour(s) appear in the contour color and the inactive contours appear in gray
(Figure 2-33). Only like named structures among the structure sets appear.
Figure 2-33: 4D Structure Sets
Create a Specialty Image
You can create a specialty image when you select two or more image sets in the same
study.
1. To select multiple images, hold down the Ctrl key on the keyboard and left-click
on the image sets that you want to use to create.
2. Right-click in the Patient Workspace Control.
2-58
4D Imaging Overview
4D Imaging
Create a Specialty Image (cont.)
3. Select Create Specialty Image Set in the right-click menu. This opens the
Create Specialty Image Set dialog box (Figure 2-34).
Figure 2-34: Create Specialty Image Set dialog box
4. You can select a studyset in the Study drop-down menu.
5. Left-click the images in the Image Sets list that you want to use to create the
specialty image.
6. Click the radio button next to the image set you want to create: MIP (Maximum
Intensity Projection), MinIP (Minimum Intensity Projection), or Average.
7. Type a name for the specialty image set in the box. A default name is generated;
you can accept the default name or type in a new name.
8. To close this dialog box, you have two options:
• Click OK to accept your changes. The new specialty image set is added in
the Patient Workspace Control.
• Click Cancel to discard your changes.
Monaco® 2-59
4D Imaging Overview
4D Imaging (cont.)
Measurement Grid
The measurement grid appears in the T/S/C/O images. You can use it to measure the
total movement of the tumor volume. The grid is sizeable has many display options
from which you can make a selection. You usually use the grid in conjunction with
Cine to see how much the tumor moves in all directions.
Use Grid to Measure Movement
1. To show the grid, click the Grid button (Figure 2-35).
Figure 2-35: Grid Display
2. Click the drop-down arrow next to the Grid button to show the
Grid Options dialog box (Figure 2-36).
2-60
4D Imaging Overview
4D Imaging
Measurement Grid (cont.)
Use Grid to Measure Movement (cont.)
Figure 2-36: Grid Options
3. You can define the area of the displayed grid manually when you remove the
checkmark next to Full Grid and type in a length and width.
OR
You can click on the Grid Editing icon to draw and/or rotate the grid
with your mouse.
Monaco® 2-61
4D Imaging Overview
4D Imaging
Figure 2-37: Full Grid Figure 2-38: Defined Grid
4. You can type a different value in the Spacing field to change the grid line
spacing (Figure 2-39).
1 cm spacing 2 cm spacing
Figure 2-39: 1 cm Spacing field Figure 2-40: 2 cm Spacing field
2-62
4D Imaging Overview
4D Imaging
5. Click the drop-down arrow in the Grid Style field and make a selection, that is,
Solid lines, Dashed lines, or Dotted lines.
6. Click on the Color field to select a different grid color.
7. Type a value in the Rotation (deg) field to change the angle of the grid.
8. Click Reset to undo your changes.
OR
Click Close to save your changes and close the dialog box.
4D Margin
You can use multiple structures from multiple structure sets to specify a 4D margin.
Use the Auto Margin tool to make the new contour that encompasses the target
volume across all of the phases. This is typically used in conjunction with the cine
view. To create a 4D margin, you must have more than one studyset loaded with
contoured structures.
1. Click the Auto Margin icon on the Contouring tab.
2. Select the image set to apply the new structure to in the Image Set drop-down
menu.
3. Select the corresponding structure set that you want to use in the Structure Set
drop-down menu.
4. Select or type the structure name in the Structure drop-down menu. This is the
name of the new structure.
Monaco® 2-63
4D Imaging Overview
4D Imaging
4D Margin (cont.)
5. Select the image sets under the structure that you want to create an auto margin
for in the Structure Selection List. You can select one instance of the structure
at a time, or hold down the Shift key to select them all, or hold down the Ctrl
key to select multiple instances of the structure.
6. Click the Add button. This adds the data to the Selected Structures dialog box.
7. Type a Uniform, Variable, or Advanced margin, as desired.
8. Click the Apply to All button if you want the margin to apply to all instances of
the structure. Otherwise, the margin only applies to the instance of the structure
that was highlighted when the margin was made.
9. Click the Create button at the bottom of the dialog box.
10. Click the Close button when finished.
Print 4D Auto Margin Report
You can print an auto margin report from the Auto Margin dialog box for the last
created structure.
OR
You can print an auto margin report of all auto margin structures on the Output tab.
2-64
4D Imaging Overview
4D Imaging (cont.)
Cine View
You can use the cine view to create a movie that demonstrates the motion of the
structures during the breathing cycles (Figure 2-41). You can see the cine view in the
T/S/C images. You can draw or edit a contour in the cine view. It may be useful to use
the grid in conjunction with the cine view to see how much the volume moves in order
to draw or edit the contour.
Figure 2-41: Cine View Options
1. In any T/S/C image window, click on the Cine View icon to movie through
the images. This shows the cine tools in the toolbar and movies through the
images.
NOTE: This tool only becomes available when two studysets are loaded.
2. You can click the Play/Pause icon to stop/start the cine movie.
OR
Manually move the cine playbar.
3. Click on the Cine View Speed icon to adjust the movie speed.
4. Click on the Save Cine View icon to save the cine movie as an .avi file.
You can import saved movies and use them in presentations.
5. Click on the Image Sets icon to change the image sets shown in the cine.
You can select to see All Image Sets or select individual image sets to show.
6. When you are done, you can click on the Cine View button to minimize the
Cine toolbar.
Monaco® 2-65
DRR Views
You can view a DRR in Planning activity. There are three types of DRR views:
• BEV [Beam’s Eye View] DRR

• AP DRR
• LAT DRR
The AP DRR and LAT DRR are part of a larger window layout set call Virtual
Fluoroscopy. These views are typically used for virtual simulation activities. You can
also use them as AP and LAT setup beams.
All DRR views have optional features you can use to improve or enhance the DRR
image. Right-click in any DRR window for these options:
Filters Select from five preset filter options to apply to your DRR.
Quality Select from three options that affect the quality of the shown and printed
DRR.
Histogram Equalized Output A DRR post-processing technique where DRR values

are rescaled. (See the Online Help for more information.)
Show Wireframe Contours (BEV DRR only) Select this option if you want all the
contours to show as a wireframe.
Show 2D Transparency (BEV DRR only) Select this option if you want all the
contours to show in 2D transparency. This option is only available when the contours
appear in outline on the DRR and not in wireframe.
When you right-click in the DRR window and select an option, you can access these
additional options that only apply to DRR images.
• Show MIP (maximum intensity projection)

• Show Grid (reticule)
• DRR Volume of Interest Tool (on the toolbar)
• Print (see Image Printing Options section)
2-66
DRR Views (cont.)
Show MIP (Maximum Intensity Projection)
When you select this option, Monaco changes the DRR to a MIP image. This image
highlights areas of high contrast or high density. If you have placed wires or markers
on the patient's surface, they are usually highlighted in this view. To show the DRR
again, right-click and select the Show DRR option.
DRR MIP
Figure 2-42: DRR windows
Monaco® 2-67
DRR Views (cont.)
Show Grid (Reticule)

When you select this option, Monaco shows the jaw labels and yellow scale with tic
marks every 1 cm. To turn the jaw labels and grid display off, right-click in the DRR
window and select the Show Grid option. Monaco un-checks the option and removes
the grid from the selected window.
Grid Shown Grid Removed
Figure 2-43: DRR windows with and without Grid lines Removed
Jaw Labels
This option applies to all BEV and DRR windows. See the Treatment Units option
under Appendix C. Settings to define your jaw labels.
Figure 2-44: DRR Window with Jaw Labels
2-68
DRR Views (cont.)
DRR Volume of Interest Tool
This option applies to all DRR windows. You use it to digitally remove patient data to
render a more clinically useful DRR.
1. Click the DRR Volume of InterestI Tool button on the Plan Options tab
to place a purple box around the transverse image.
2. Resize the purple VOI box to remove patient data as needed.
This example demonstrates how you can use the VOI box to create a sagittal DRR
image that shows the vertebral body more clearly. Essentially, Monaco digitally
removed all the image information outside of the VOI box so that only the volume of
interest shows on the window.
Figure 2-45: Image without using the DRR VOI Tool
Monaco® 2-69
DRR Views
DRR Volume of Interest Tool (cont.)
Figure 2-46: Image using the DRR VOI Tool
Display Synth. CT
The Display Synth. CT option lets you see an image with Forced Electron Densities,
rather than the MR intensities. You can select Display Synth. CT for Transverse CT
and Transverse MR studysets when you are in Planning and Plan Review mode. Click
the Display Synth. CT option on the Workspace tab to show a

Synthetic CT instead of the MR image.
2-70
DRR Views
Display Synth. CT (cont.)
Figure 2-47: Synthetic CT of the Pelvis
Room’s Eye View

The Room’s Eye View (REV) image below gives real-time virtual simulation with
patient and treatment machine visualization. You can select Room’s Eye View in
Planning and Plan Review activities. The REV option is only available when beams are
present.
Figure 2-48: Rooms Eye View (REV) Image
Monaco® 2-71
Room’s Eye View (cont.)
Room’s Eye View-Display Options
Room’s Eye View is available in any window. Elekta, Varian, and generic machines are
shown in REV based on the machine you selected in your plan. If more than one
machine is selected, REV shows the machine associated with the active beam. You can
rotate, pan, and zoom the REV image.
1. Right-click in a window.
2. Select View Type | REV.
In REV, the current transverse slice image is shown with the structures turned on in
the Structure Control dialog box. The Transverse W/L setting is applied to REV. You
can use the 3D transparency settings to adjust the structures’ transparencies in REV.
Room’s Eye View-Menu
You can control REV display options in the right-click drop-down menu.
Check/uncheck display options to show/hide in the REV window.
You can view the following attributes in REV:
• Treatment Machine
• The active beam or starting angle of sequence
• MLC shape
• Room Lights/Lasers
• Room Décor
• Couch
• CT Images
• Structures (Contours)
• Axes
2-72
Room’s Eye View
Room’s Eye View Menu (cont.)
Figure 2-49: Rooms Eye View (REV) Right-click Menu Options
Monaco® 2-73
Additional Navigation and Screen Customization Tools
Maximize and Restore a Window
You can maximize any window to full screen for better visualization and restore the
screen back to a four-window format using these steps.
1. Right-click in any window and select the Maximize option to maximize the
image to full screen.
2. Right-click in the maximized window and select the Restore option to restore
the screen back to a four-window format.
Patient Orientation Icon

Each view has a patient orientation icon. This icon depicts the outline of a patient with
three colored spheres. Each sphere represents a specific orientation label.
Figure 2-50: Patient Orientation icon
Blue - Represents the anterior of the patient
Green - Represents the superior of the patient
Yellow - Represents the left side of the patient
2-74
Additional Navigation and Screen Customization Tools (cont.)
Move Control Dialog Box

You can pin/unpin any control dialog box. You can move an unpinned dialog box
within the system and re-pin it at the top, bottom, left, or right of the screen.
1. To move a control dialog box, left-click and hold at the top of the control dialog
box.
2. Drag the control dialog box and place the cursor on one of the arrows that face
the location where you want to place the control dialog box.
NOTE: When you hold your cursor over an arrow, the screen highlights in
blue where the control dialog box will be placed (Figure 2-51).
Figure 2-51: Moving Control dialog box
3. Release the mouse to place the control dialog box. Pin/unpin to create a tab.
4. Click the Unpin icon to collapse the control dialog box to a tab.
Monaco® 2-75
Additional Navigation and Screen Customization Tools (cont.)
Move Control Dialog Box (cont.)
Figure 2-52: Pin\Unpin Control dialog box-tab
5. Hover over the tab to show the control. Click the Pin icon at the top of the
control dialog box to re-pin the dialog box in the window.
2-76
Printing Options
Within all activities, you can print or export a PDF file of any image view shown on
the screen, or you can print the entire screen. You can also print Monaco IMRT plan
reports (that is, if the Monaco plan was pulled in using Focal Share), or DICOM plan
reports. Refer to Online Help for detailed information about the Reports warning
messages.
NOTE: To have your clinic name print on all your printouts (except screen print
jobs), in Planning activity, from the Edit drop-down menu, select the
Settings option. Select the Clinic Info tab and type the Clinic name you
want to appear on your printouts.
Print/Export a Transverse, Sagittal, Coronal, Oblique, or 3D Image

1. In any image view, right-click and select the Print option to show the Report
Comments dialog box.
2. Type an optional report comment.
3. Click OK to show the Slice View or 3D View report.
4. Print the image by clicking the Print button in the upper-left corner of the
dialog box.
OR
Export the image to a PDF file by clicking the Export Report button to
show the Save PDF File In dialog box. Select a location to save the file and click
Save.
5. Close the Print dialog box.
Monaco® 2-77
Printing Options (cont.)
Print or Export the Screen

1. Click on the Print Screen button on the Output tab to show the print screen
dialog box.
2. Click the Print button in the upper-left corner of the dialog box to print the
image.
OR
Export the image to a PDF file by clicking the Export Report button to show the
Save PDF File In dialog box. Select a location to save the file and click Save.
2-78

Print DRRs
When printing a DRR, you have several print and display options. This section
describes the options for printing these images. Right-click on any window that
contains a DRR and select the Print option to show the DRR Print Dialog box.
Figure 2-53: DRR Print Dialog box
Monaco® 2-79
Printing Options
Print DRRs (cont.)
Select the Print Type
Print type options are DICOM Print and Windows Print. DICOM print lets you print
in DICOM format to a DICOM printer (example, Codonics), a Secondary Capture
SCP (example, a record and verify system), or to a local or network file. The Windows
Print option lets you print the image on the screen to a Windows type printer.
1. When you select a DICOM printer or a Secondary Capture SCP, you can select
from the drop-down list of available printers or locations next to SCP Name.
NOTE: Assistance from Systems Support is required to initially set up a

DICOM printer or Secondary Capture SCP location.
2. You can set the DICOM file location when you click the Change Filename
button and enter the location where you want to place the file.
3. If desired, you can override the patient ID for DICOM Print files. Place a
checkmark in the Override Patient ID checkbox and type the new ID in the
field.
4. If you select Windows Print, select a printer from the available Windows
Printer list. You can edit printer properties. Click the Properties button and
make your edits.
2-80
Printing Options
Print DRRs (cont.)

Select Options and Copies
The options available are Show Annotations, Show Overlays, and Zoom Factor. Zoom
factor lets you print your DRR to scale. Calibration is required.
1. Place a checkmark in the Show Annotations box to show the text that is
printed on the DRR regarding the patient name, ID, plan name, etc.
2. Place a checkmarkin the Show Overlays box to print the Patient Orientation
Icon and Grid (graticule) and Jaw Labels on the DRR.
3. Place a checkmark in the Show Displayed Anatomy box to print the

individual contours that you selected to display on the Beam and Structure
Control dialog boxes. No structures are printed if this option is not selected.
This only affects BEV and DRR views.
4. Use the Zoom Factor to designate the percentage that the printed image is
zoomed (in or out) from the original size.
NOTE: You should establish a calibration factor if you desire scaled

printing. First:
(1) Print a test image.

(2) Measure a 10 cm line on the test image, and call it x.
The calibration factor is 10/x.
(3) Click the Calibrate button.
(4) Type the calibration factor.
(5) Click OK to close the dialog box.
The scaled magnification of the final image may now
be controlled by entering a zoom factor.
A single calibration factor is required for each printing device. The

calibration factor is independent of the screen image size and paper
orientation. It is dependent on paper size
5. Type the number of copies you would like to print.
6. Click OK to complete.
Monaco® 2-81

Print or Export Monaco IMRT Plan Reports
You have two options for printing/exporting reports. You can print/export individual
reports, or create a custom report consisting of a group of selected reports and graphic
displays. You can print reports or export them to a PDF file.
Print/Export Individual Reports
1. Right-click on a loaded plan in the Patient Workspace Control.
2. Select Individual Report | <report>.
3. Optionally, type a Report Comment, and then click OK.
4. Click the Print Report button to print the report.
OR
Click the Export Report button to export the report.
2-82

Print/Export Custom Reports
1. Right-click on a loaded plan in the Patient Workspace Control.
2. Select Customized Report to show the Customized Reports.
Figure 2-54: Customized Reports dialog box
3. Place a checkmark in the box next to each report and graphic display you want
to print/export.
Monaco® 2-83
Printing Options
Print/Export Custom Reports (cont.)
4. (Optional) Click the Order button if you want to change the order of the printed
reports and graphic displays.
Figure 2-55: Customized Reports-Order
5. (Optional) Click the Save as… button if you would like this same set of reports
and graphic displays to be saved as a template for printing/exporting.
6. Click Print or Preview. Preview shows the customized report on the screen
before printing/exporting. Each report is shown under its own tab. However, the
customized report is printed or exported as one continuous document.
2-84
Printing Options
Print/Export Custom Reports (cont.)
7. Type an optional Report Comment. Click OK to print, export, or preview the

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

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

2. Click on the DICOM Plan button on the Output tab.
3. To Print the report, click the Print Report button.

OR
To Export the report, click the Export Report button.
Monaco® 2-85
CT Simulation Options
You can do a full CT Simulation in Monaco within the Planning activity. Planning is
flexible enough to accommodate just about any CT Simulation scenario. In addition,
Planning offers Virtual Fluoroscopy simulation. Both methods are outlined here.
If you plan to use Gammex or LAP lasers for CT Simulation, please see the Monaco
Installation Instructions guide for more detailed information.
Determine the Shifts to a Structure Center, Interest Point, Marker, or Beam

Isocenter
On the CT simulator, you placed fiducial markers on the patient's surface. These
procedures demonstrate how to shift from the center of those markers to the center of
the target volumes.
There are four ways to shift from your original isocenter:
(1) Shift to the center of a structure.

(2) Shift to the beam isocenter once a beam has been placed.
(3) Shift to an interest point or marker location.
(4) Shift to a manually defined isocenter using Virtual Fluoroscopy.
1. Click the Scan and Setup Reference button on the Plan Options tab
to show the Setup Reference dialog box.
NOTE: In order to determine shifts, you must check the Lock Shift option
.
Monaco® 3-1

Isocenter (cont.)
2. Scroll through the transverse images to find the fiducial markers. Once located,
align the green vertical and horizontal bars on your transverse image window
so that they intersect these points.
NOTE: Starting coordinates for the Scan Reference are set to Volume Isocenter.
Figure 3-1: Setup Reference to Determine Scan Reference Point Location
3. On the Setup Reference dialog box, place a checkmark  in the Lock Scan
Reference field. This action locks those coordinates so you do not have to repeat
this step for any future shifts.
Figure 3-2: Setup Reference Point dialog box
4. Click the Selected Point drop-down menu and choose the contour or interest
point, markers, or beam isocenter to where you wish to locate the isocenter.
3-2

Isocenter (cont.)
5. Click the drop-down arrow and select the Patient orientation when scanned.
Figure 3-3: Patient orientation when scanned drop-down list
6. If you have Gammex lasers, the Autorun option is available. Place a checkmark
 in the Autorun box to automatically move the lasers to the new isocenter
position.
The system shows the shifts in the Shifts (Setup Reference-Scan Reference)
box. If you have selected in the Laser System settings to show the Absolute
Coordinates for your CT, the system shows those settings under the Absolute
Coordinates heading. Refer to the Monaco Installation Instructions for more
information regarding the setup of your laser system settings.
After you determine the shifts, you can either print the shift information, or
send the shift information to a laser marking system.
7. Click the Print button to print the shift information.
8. Click the Send to Laser button to send the shift information to the Laser
Marking System.
9. Click the Close button on the Setup Reference window when finished.
10. You can finish contouring critical structures at this time.
NOTE: For assistance, refer to the various Contouring procedures

described in Help.
Monaco® 3-3
CT Simulation Options (cont.)
Determine the Shift using Virtual Fluoroscopy
Virtual Fluoroscopy lets you do all the necessary simulation functions on a computer-
generated patient image reconstructed from CT data. The "virtual patient" created is
an accurate model you can use for treatment setup and planning, and permits visual
enhancements such as structural localization and ports for designing conformal
therapy. Virtual Fluoroscopy is less time-consuming for patients and clinicians
because you can change beam parameters without having to do an entire re-
simulation. You can use it to do these tasks:
• Localize anatomical structures

• Provide information for accurate patient marking
• Optimize beam placement
• Verify using beam's-eye-view digitally reconstructed radiographs (DRRs)
In the Virtual Fluoroscopy window, a green marker represents the initial scan
reference point. Light blue lines and a light blue marker represent the setup field and
setup reference point.
1. In Planning, in any of the windows, right-click and select the Layouts | Virtual
Fluoro option from the mouse menu to show an AP and Lateral DRR in the two
bottom windows.
Figure 3-4: Virtual Fluoroscopy Layout
3-4
Determine the Shift using Virtual Fluoroscopy (cont.)
2. Click the Scan and Setup Reference button on the Plan Options tab to
show the Setup Reference dialog box.
Figure 3-5: Transverse Image window
4. Relocate the isocenter on the virtual fluoroscopy images by using one of two
methods:
(1) When you place your mouse pointer over the viewable DRR, this cursor
appears, and lets you pick up and move the treatment field.
(2) On the field edge of the treatment beam outline, left click on any of the six-
perimeter squares and pull outward or inward to adjust to a desired size.
NOTE: Hold down the Shift key on your computer keyboard while doing
this process moves the field asymmetrically.
5. As you move the center of the field, the setup reference point values
automatically update.
Monaco® 3-5
Determine the Shift using Virtual Fluoroscopy (cont.)
6. When you are done, click the Print button to print the shift values shown.
7. Click the Close button to close the Setup Reference dialog box.
Determine Shifts in Absolute Coordinates
The same instructions apply to creating absolute coordinates as they are for creating
relative coordinates. The only difference is the setup in Edit/Settings/Laser System. See
the Monaco Installation Instructions topic on entering these setting to show absolute
coordinates.
The Scan Table Height is the only editable field. Type the actual table height value of
the scanner for the final shifted position. This value appears on the printout.
Determine Setup Reference Coordinates
Complete these instructions if you know the coordinates for the scan reference point
and the shift values/directions and want to determine the setup reference point’s
relative coordinates.
1. Click the Scan and Setup Reference button on the Plan Options tab
to show the Setup Reference dialog box.
3-6
Determine Setup Reference Coordinates (cont.)
3. On the Setup Reference dialog box, place a checkmark  in the Lock Scan
Reference field. This action locks those coordinates so you do not have to repeat
this step for any future shifts.
Figure 3-6: Setup Reference Point dialog box
4. Click the drop-down arrow and select the Patient orientation when scanned.
Figure 3-7: Patient orientation when scanned drop-down list
5. Remove the checkmark from the Lock Shift option. This lets you edit the shift
values.
Figure 3-8: Setup and Lock the Shift
6. Edit the X, Y, or Z shift values and the shift directions, as needed. The Setup
Reference Point Coordinates update as the shift values/directions change.
7. Click the Print button to print the shift information.
8. Click the Send to Laser button to send the shift information to the Laser
Marking System.
Monaco® 3-7
Determine Setup Reference Coordinates (cont.)
9. Click the Close button on the Setup Reference window when done.
Assign CT-to-ED to Patient
Create and Edit a CT-to-ED File (Standalone Users Only)

As a standalone user, you may need to create or edit a CT number to electron density
conversion file. If you have multiple Monaco workstations, you must make these
additions or changes on each workstation as they do not share this information.
NOTE: It is your responsibility to verify that the correct CT-to-ED file is used on
the treatment planning systems during dose calculation.
Create and Edit a CT-to-ED File (Monaco with XiO Users)

When you use Monaco with XiO, the CT-to-ED files initially transfer from XiO when
the server is setup. However, once the XiO CT-to-ED files reside on the Monaco box,
they will not be updated if changes are made to them on XiO. Once changes are made
in XiO, update the Monaco servers to update the information in Monaco. Updates
made in Monaco will not transfer back to XiO. Typically, this CT-to-ED file dialog box
is for Standalone users.
NOTE: It is your responsibility to verify that the correct CT-to-ED file is used on
XiO during dose calculation.
3-8
Create and Edit a CT-to-ED File
Create a New CT-to-ED File
1. Click the Monaco Application button. Select Setup | CT-to-
ED files from the menu. Monaco shows

the CT-to-ED Conversion Files dialog box.
Figure 3-9: CT-to-ED Conversion Files dialog box
2. Click the drop-down arrows in the Installation and Clinic fields and select an
Installation and Clinic name.
3. Click the Clear Data button if CT-to-ED values are already shown and you
would like to start a new table.
4. (Optional) Type a Description just above the CT-to-ED graph.
Monaco® 3-9
Create and Edit a CT-to-ED File
Create a New CT-to-ED File (cont.)
5. Type CT values and corresponding ED values. Press the Tab key after you type
each value.
NOTE: You must type at least three (3) CT-to-ED conversion values to save
the file.
6. Once you have input all the CT and ED values, click the Save As button to show
the save CT-to-ED dialog box.
Figure 3-10: Save CT-to-ED dialog box
7. Select a Clinic and Manufacturer.
8. Type a File Name.
9. Click OK when finished.
10. (Optional) Click the Print button to print the CT-to-ED file.
11. Click OK when you are done inputting values.
3-10
Create and Edit a CT-to-ED File (cont.)
Edit an Existing CT-to-ED File to Create a New CT-to-ED File
1. Select the Installation, Clinic and Name of the file you want to edit.
2. Edit the CT and/or ED values. Press the Tab key after each value is input.
3. Click the Save As button to show the Save CT-to-ED dialog box.
4. Select a Clinic, Manufacturer and type a new File Name.
5. Click OK when done.
Assign CT-to-ED to Studyset

If you did not already assign a CT-to-ED file to your patient or studyset, or you would
like to select a different CT-to-ED file, you can do so using the following steps.
1. Click the Assign CT to ED button on the Plan Options tab. Monaco

shows the Assign CT-to-ED to Studyset dialog box.
Figure 3-11: Assign CT-to-ED dialog box
2. Select a CT-to-ED file from the list.
3. Click OK to assign the selected CT-to-ED file to the open studyset or patient.
Monaco® 3-11
Planning on MR Studysets
If you plan on an MR Studyset you must use Forced Electron densities in place of a
CT-to-ED file. Monaco shows a warning message when you start a new treatment
plan.
Figure 3-12: Force ED Warning Message
1. Click OK to acknowledge the message.
2. Click the Structures tab on the Planning Control to see a list of the structures.
3. Type a new Relative ED if you do not want to use the default value.
Figure 3-13: Relative ED field on the Structures tab of the Planning Control
3-12
Fusion Activity
Fusion Activity
Overview
Fusion is a process that lets you register CT, MRI, and/or PET studysets for the
purpose of contouring from either studyset or both studysets. You can also view
the dose in Plan Review on fused studysets.
Open a Primary and Secondary Studyset
The instructions below demonstrate how to open primary and secondary

studyset(s) so you can fuse them. It is assumed that all studysets have been
transferred in using the same patient ID and all reside in the local directory.
1. Select the patient from the Patient Selection dialog box to open it and show
both studysets in the Patient Workspace Control.
2. Click on the studyset that you want to be the primary studyset. This is
typically the planning CT.
3. Click Load.
4. Right-click on the studyset that you want to be the secondary studyset and
select Load/Set as Secondary. If you have not previously fused the images,
the system automatically places you in Image Fusion activity. You can load
multiple secondary studysets. However, only one can be active at any time.
OR
Load the primary study set. Then select one or multiple secondary
studysets. Right-click and select Load/Set as Secondary.
OR
Load all the studysets into the workspace as primary studysets (using Ctrl or
Shift + selecting multiple studysets). Then, load one of them as a secondary
studyset using the right-mouse menu option on the Workspace Control to
Load/Set as Secondary.
Monaco® 4-1
Fusion Activity
Fusion Activity
Open a Primary and Secondary Studyset (cont.)
Studyset Volume Toolbar

The Studyset Volume Toolbar controls the visualization for the primary and
secondary studysets.
Select How to Show the Primary and/or Secondary Studysets

You can use the sliderbar in the Studyset Volume Toolbar to choose to view the
Primary, Secondary, or blended studyset on the screen.
Figure 4-1: Blended Slidebar
Apply a colormap to a Studyset

You can use the colormap to replace the grayscale pixel values of an image with
different color schemes to enhance the data visualization.
Figure 4-2: Show Images and Colormap options
1. To apply a colormap to studyset, select the studyset from the drop-down menu.
2. Select a colormap from the Colormap drop-down list located on the

Studyset Volume Toolbar.
Colormap Display Options:

• Grayscale
• Inverse
• Green wash
• Hot-Iron
• Hot-Cold
• Magenta wash
• Pseudocolor 1
• Pseudocolor 2
• Red wash
• Spectrum
4-2
Fusion Activity
Fusion Activity
Masking Options (Optional)
You can use masks to limit the amount of image data used by the auto
registration algorithm to determine the best performance. The masking only
defines the registration 3D field-of-view and does not cause changes in the
studyset CT images. Each of the options uses a different method to accomplish
this. You should only need to choose a mask if you have tried to auto-register
the studysets and failed. Always use No Mask first, it is the default option. If
you experience a problem with incorrect masking, indicated by erroneous
removal of valid patient image data, you can try the other methods.
On the Fusion tab, select a Masking option to apply to the primary studyset.
On the Fusion tab, select a Masking option to apply to the secondary studyset.
These are the available masking options:
Figure 4-3: Masking options
Patient Contours
This option resets all pixels outside a user-defined patient contour to a value that
does not occur in the original image. You can also use it can to limit the slices
included in the volume when one study has many more slices than the other.
Monaco® 4-3
Fusion Activity
Fusion Activity
Masking Options (Optional) (cont.)
Shape/Intensity Model
This option removes the background on CT studies, therefore defining the
patient boundary. It uses heuristics and a very fast boundary detector to
repeatedly re-contour the patient for a range of CT intensity thresholds. Over
some predictable range of CT numbers, the length of these contours does not
change appreciably. The contours corresponding to the CT number in the middle
of that range is considered the patient boundary. The subsequent mutual
information calculation only uses voxels inside these contours to represent the
patient.
RE Segmentation
This option (relative entropy method) removes the background from the CT
studyset images, hence defining the patient boundary. This starts with a flexible
contour defined by a parametric function, and the shape is then changed by
varying the function parameters. The shape corresponding to the maximum in
the RE is then saved. The RE is a type of distance between probability
distributions (outside-patient-intensities versus inside-patient-intensities) and it
is at its maximum when the patient most completely separates from the
background. This method works a little better than shape/intensity for HN cases
with a headframe in the image.
No Mask (default)
This option does not remove the background and should always be used first
before trying the other options.
4-4
Fusion Activity
Fusion Activity
Create a Registration
Create a Registration Manually

1. Enhance the visualization of the display so that you can better see the
individual structures.
(1) Click the Zoom button to view more or less of the image.
(2) Move the slider bar on the Studyset Volume toolbar between the P
(primary image) and S (secondary image) to gradually transition
between the two studysets (see the Fusion Display Options for more
information).
(3) Make a selection from the Colormap list to change the pixel color
representation of the images in the secondary studyset.
(4) Click the Window/Level button to adjust the window and level
settings for the images in the studyset.
Use Translate and Rotate to adjust the position of the secondary studyset.
2. To translate (move) the secondary studyset, position the pointer over the
image inside the translate/rotate circle so that the translate pointer
shows on the window, then drag the image to the desired location.
3. To rotate the secondary studyset, position the pointer over the image
outside of the translate/rotate circle so that the rotate pointer shows on
the window, then drag clockwise or counterclockwise to rotate the image
around the origin of the secondary studyset.
4. Click the Save button on the toolbar to save the registration or auto register.
Monaco® 4-5
Fusion Activity
Fusion Activity
Create a Registration (cont.)
Point Registration
You can register two images with Point Registration. This method requires you to
put three or more points on the corresponding anatomy of the primary and the
secondary studysets in order to register the images. When you have placed your
points, you can assign them to the related points of the other studyset before
registration.
Figure 4-4: Point Registration with primary and secondary image points
Add Points in Point Registration
1. Click on the Point Registration button on the Fusion tab to open

the Point Registration dialog box.
2. Place your primary points on any of the T/S/C/O views. The points are
shown as a blue cross with a point identifier.
3. Press the spacebar to change to the secondary points.
4. Place your secondary points on any of the T/S/C/O views. The points are
shown as a red cross with a point identifier.
4-6
Fusion Activity
Fusion Activity
Point Registration (cont.)
5. (Optional) You can reassign the points in the Point Registration dialog
box (Figure 4-5).
Figure 4-5: Point Registration-Assign Points

6. Click in the Include checkboxes next to each point to not use the points in
the registration.
7. Click on the Start button to begin the registration.
8. When the registration is complete, click Close to close the dialog box.
Monaco® 4-7
Fusion Activity
Fusion Activity
Point Registration (cont.)
Delete an Individual Point in Point Registration

1. Choose from one of these two options:
• Click on the row in the Point Coordinates table.
• Click on the point in the studyset. The cursor changes from a crosshair to
a circle.
2. Press the Delete button on your keyboard.
Delete Multiple Points

1. Right-click on a point in the Point Coordinates dialog box.
2. Choose from one of the options listed in the right-click menu:
• Delete Selected Point
• Delete Primary Points
• Delete Secondary Points
• Delete All Points
Create a Registration using Auto Registration

Auto Registration estimates the geometric transformation that best registers
corresponding anatomic details in two 3D studysets of the same patient's
anatomy. The registration criterion is mutual information and is a measure of the
statistical similarity of the overlapping data. The “best registration” is that
transformation giving the maximum value of the mutual information. The
Mutual Information (MI) algorithm uses the entire patient area to determine the
fusion of the images. See the Use the VOI Masking Tool discussion described
later in this section to find out how to define your own area.
4-8
Fusion Activity
Fusion Activity
Create a Registration using Auto Registration (cont.)
1. Click the Start/Resume Auto Registration button

to start the Auto Registration process. While it is running, the Auto
Registration button changes to the Stop Automatic Fusion
button. The Image Fusion Progress meter appears
on the screen, this meter indicates the current mutual information value
(MI). Monaco uses the Mutual Information algorithm for the auto-
registration process, the MI value continues to rise until the system reaches
the best auto registration result.
2. (Optional) If you would like to stop the process before it is complete, click
the Stop Auto Registration button.
3. Click the Start/Resume Auto Registration button to restart the process.
NOTES: Visually Verify All Auto Registration Results! Auto Registration

may not produce clinically acceptable results. If Auto Registration
does not produce clinically acceptable results and you save the
registration, plans created using the registration will be inaccurate.
To avoid inaccurate plans, visually verify all Auto Registration
results before saving the registration.
Running Auto Registration repeatedly may yield better results, but
takes more time and yields smaller improvements.
Monaco® 4-9
Fusion Activity
Fusion Activity
Create a Registration using Auto Registration (cont.)
Use the VOI Masking Tool

The VOI Masking tool is an optional tool you can use during Auto Registration.
It lets you define the area that corresponds to the volume that is utilized for the
MI registration algorithm.
1. Click the VOI Masking button to place a purple box

around the transverse, sagittal, and coronal images. The box also shows on
the 3D image.
Figure 4-6: Transverse, Sagittal, and Coronal images
2. Resize the purple VOI box to change the area where the registration
algorithm will be applied.
3. Auto Register the images as usual.
4-10
Fusion Activity
Fusion Activity
Create a Registration using Auto Registration
Use the VOI Masking Tool (cont.)
4. You can turn off the VOI Masking tool when you toggle the VOI Masking
button to the off position.
OR
On the Image Fusion Progress dialog box, remove the checkmark in the VOI
box.
Figure 4-7: Image Fusion Progress dialog box
Monaco® 4-11
Fusion Activity
Fusion Activity
Verify the Results of the Alignment
You must determine the accuracy and applicability of the registration before
using it in treatment planning. To do so, you should examine the image
alignment on multiple cross sections in at least two of the three orientations.
We do not guarantee the absolute accuracy of the registration.
Fusion Display Options

There are essentially four Fusion Display options that you can use in any activity
when fused images are present. These tools enable you to easily review and verify
the accuracy of the fusion.
Figure 4-8: Fusion Display options
Blended Display
The blended option lets you blend the primary and secondary images
transparencies to verify the fusion. It is the default Fusion Display Option. If you
change the display and would like to get back to the Blended option, use one of
these methods.
1. Click the Blended tool on the Fusion Display Options toolbar.
4-12
Fusion Activity
Fusion Activity
Fusion Display Options (cont.)
Transition between Primary and Secondary Images

When in Blended Display, use these instructions to change the display of the
primary and secondary images.
1. Move the slider bar on the Studyset Volume toolbar to gradually transition
between two studysets. This has the effect of one studyset gradually
appearing (fading in) while the other studyset is gradually disappearing
(fading out), moving toward the P transitions to the primary studyset,
moving toward the S transitions to the secondary studyset.
OR
On the slider bar, click the P to immediately show the primary or S to

immediately show the secondary.
OR
Right-click in any T/S/C view and select View Primary or View Secondary
to immediately show 100% primary or 100% secondary image.
OR
Press the Home or End keys on the keyboard to immediately show 100%
primary or 100% secondary image. Press either of these keys twice to return
to 50% of both shown.
NOTE: When the primary or secondary display is set to 100%, the W/L
Affects: are automatically set to the corresponding studyset.
2. You can change the appearance of the secondary studyset when you select a
display option to the right of the secondary volume option on the blender
bar.
Monaco® 4-13
Fusion Activity
Fusion Activity
Horizontal, Vertical and Checkerboard Display

These three Fusion Display Options are similar in functionality. All affect the
display of the secondary image. The Horizontal option shows the secondary
image as horizontal stripes. The Vertical option shows the secondary image as
Vertical stripes. The Checkerboard option shows the secondary image as a
checkerboard pattern.
Click the Horizontal , Vertical or Checkerboard

tool on the Fusion Display Options toolbar. The lowest number of
stripes or checks shows by default. Click the down arrow to the right of the tool
to select a different number.
NOTE: You can customize the number of stripes or checks when you select
the Custom option on the drop-down menus that show the number
of stripes or checks.
4-14
Fusion Activity
Fusion Activity
Pan/Reset Fusion Display Options

Use this option to pan Horizontal, Vertical, or Checkerboard displays of the
secondary image.
1. Click the Pan Checkerboard button on the Fusion Display Options

toolbar.
2. Hold down your left mouse button in any T/S/C view and drag to pan the
secondary image.
3. Reset the pan. Click the Reset Checkerboard button on the Fusion
Display Options toolbar.
Monaco® 4-15
Fusion Activity
Fusion Activity
Verify the Results of the Alignment (cont.)
View/Edit the Transformation Matrix

After you fuse the images, you can view the current transformation matrix and
edit the translation values, if necessary.
1. Click the View Current Transform button on the

toolbar.
Figure 4-9: View Transformation MatrixTmpl dialog box
2. Edit the X, Y, or Z translation values, if necessary.
3. Reset the registration back to its last saved values. Click the Reset
Registration button.
4-16
Fusion Activity
Fusion Activity
View/Edit the Transformation Matrix (cont.)
4. Click OK to save the transformation or Cancel to discard any changes.
Only a single transform exists between two studysets. For example, if you
fuse study A with study B, you can load either studyset as primary or
secondary and they will be fused. The application automatically verifies the
transforms that are saved on the disc for the study set, if applicable. The
application automatically recognized implicit transforms. If a transform
conflict occurs, the application shows the conflict resolution dialog and
prompts you to choose the path to use:
Figure 4-10: Transform Paths dialog box
The system considers a unity transform for a set of two studysets and
shows them as fused if all the following conditions exist:
• They have the same frame of reference.
• They have the same patient position (HFP, HSP, etc.).
Monaco® 4-17
Fusion Activity
Fusion Activity
(Optional) Registering Multiple Studysets
If you have multiple studysets for one patient, you can fuse one pair, save the
registration, and then fuse the second pair using the same registration. For
example, you have a CT studyset and an MRI studyset that has a TI and T2 study
that are already paired using the same transform matrix.
1. Fuse the CT studyset with the MRI T1 studyset and save the registration.
2. Go back into Planning and load the CT studyset and the MRI T2 studyset.
Whatever studyset was loaded as the primary in step 1 must also be loaded
as the primary in this step.
3. Fuse the CT studyset and the MRI T2 studyset. Select the Use Prior
Registration button. Monaco shows the Use Prior
Registration dialog box.
Figure 4-11: Use Prior Registration dialog box
4. Click the drop-down arrow and select the studyset transform that you
want to use to register the second set of images.
5 Click OK. Monaco automatically fuses the second set of images to the
primary using the same transform registration as the first set.
4-18
Contouring Tools
Contouring Tools
Overview
Planning Activity has a comprehensive set of Contouring tools. The tools let you
contour structures using a variety of techniques. This section illustrates how to access
and use each of the Contouring tools located on the Contouring ribbon (Figure 5-1).
Figure 5-1: Contouring Ribbon
Like most Windows applications, there are many ways to activate contouring tools,
besides clicking the button on the ribbon. You can also select contouring tools when
you right-click in a transverse, sagittal, coronal, or oblique (T/S/C/O) window and
select a contouring tool from the Contour submenu. Some contouring tools have
keyboard shortcuts available. Refer to the Monaco Quick Reference card or the
Monaco User’s Guide for a complete list of keyboard shortcuts available.
For the purposes of this training guide, we refer to the more commonly used methods
of contouring tool selections and make note of any anomalies you may encounter.
Monaco® 5-1
Contouring Tools
Contouring Tools
Draw Contour
You can use the Draw Contour tool to manually draw a contour. The procedure
below walks you through the steps to draw structures using the Draw Contour
button on transverse, sagittal, or coronal images.
NOTE: For best contouring results, we recommend that you contour a single
structure entirely in a single view (either transverse, sagittal, or coronal)
instead of contouring a single structure in multiple views.
1. Click the Contouring tab.
2. On the Structure Edit panel, select the name of the Structure

you wish to contour.
OR
Type the new name of a structure.
3. Click the Draw Contour button.
4. (Optional) Select the Drawing Assistant button.
NOTE: When you use this tool, the system puts you in edit mode once you
draw the contour. But, when you scroll to the subsequent slice, it takes
you back to draw mode. If you movie to a slice where you have already
drawn a contour with the same structure name, the system places you
in edit mode. This is an optional feature that you use in conjunction
with the Draw Contour tool.
5-2
Contouring Tools
Contouring Tools
Draw Contour (cont.)
5. You can contour on transverse, sagittal, coronal, and oblique images when you
hold down your left mouse button and trace continuously.
OR
You can point and click to form the contour.
NOTE: You need to “render” contours drawn/edited in a sagittal or coronal

view in the transverse view before the system shows them as outlines
in a BEV. Otherwise, the BEV shows the contours in wireframe
visualization. To render the structure in the transverse, de-select the
active contouring/editing tool or select the structure in the transverse
view.
6. Before you close the contour, you can press the Backspace key as many times as
needed to erase the drawn contour point by point.
7. To finish the contour, double-click your left mouse button.
OR
Place the last point in the box that is formed at the start of the contour.
NOTE: While drawing a contour, slide the cursor on the Fusion ribbon to
adjust the blending between two fused studysets (P and S).
8. Click Page Up or Page Down to move to the next transverse slice.
OR
Use the scroll wheel on the mouse to move to the next slice.
9. If you would like to show the contours with thicker lines, click Workspace |
Thick Contour Lines to show the contours with thicker
lines.
Monaco® 5-3
Contouring Tools
Contouring Tools
Replace (Contour Editing Tool)
The Replace Contour tool lets you do these tasks:
• Edit a contour.
• Replace a section of that contour.
• Shrink or expand the contour to fit the image structure.
• Move the contour to match the structure edges.
• You can edit a contour on a transverse, sagittal, or coronal image.
1. To edit a contour that you have drawn, click the Replace Contour button to
place an edit box around the structure you want to edit (Figure 5-2).
Figure 5-2: Replace Contour Edit Box
2. Hold down your left-mouse button and draw to replace a section of your
contour. Edit only a section of the contour at a time for best results.
You can also hold down your left-mouse button in the corners or on the sides of
the edit box to shrink or expand the contour in all directions. You can do this in
either width or length direction, asymmetrically, or symmetrically.
When you do an asymmetric movement, hold down the Shift key on your
computer keyboard. Then, left-click and drag the boxes that are either at the
corners of the box or in the middle of each segment.
5-4
Contouring Tools
Contouring Tools
Replace (Contour Editing Tool) (cont.)
3. If you made an edit and the system replaced the wrong segment, right-click and
select Contour | Swap Contour.
4. You can move the contour when you place your mouse pointer in the center
of the structure or along the edge of the bounding box, then hold down the left
mouse button and drag the contour to a new location.
5. You can rotate the contour when you place your mouse pointer over the dot
located just below and to the right of the edit-bounding box. Hold down the left-
mouse button and drag to rotate.
6. You can mirror a selected contour right to left in a transverse or coronal view
when you click the Mirror Selection button on the
contouring ribbon. Click the Mirror button a second time, or right-click and
select Edit | Undo to reverse the action.
NOTE: Structures are mirrored and rotated based on the center of the
bounding box that surrounds the selected structure, not necessarily
the center of the structure volume. The mirror option is not available
on the Sagittal view.
7. Right-click in any transverse, sagittal, or coronal window and select Edit. Then,
Undo, Cut, Copy, Paste, or Delete to do these actions.
NOTE: You can only do the cut, copy, and paste functions within the same
view. For example, if you cut a structure from a transverse image, you
can only paste it in a transverse image.
Monaco® 5-5
Contouring Tools
Contouring Tools
Contour Editing Tips

When you have contours that overlap or are very close together, use these tips to
ensure you select the correct contour for editing. These tips apply anytime you are in
edit mode.
1. The edit bounding box is the same color as the contour you want to edit.
2. The sleeve of the mouse pointer hand changes color so that you know when
to click to select a different contour.
3. With one contour selected, click the Tab key on the keyboard to toggle through
all the displayed contours until the one you want to edit is selected.
5-6
Contouring Tools
Contouring Tools
Guide Radius
Use the guide radius display (Figure 5-3) as a visual cue when you want to draw a
contour at a specific distance around a structure or target. It helps you determine the
size of the guide circle when you use these Contouring tools:
• Drawing Assistant
• Reshape Contour
• Draw Contour
• Replace Contour
• Paintbrush
Figure 5-3: Guide Radius
The guide circle is a circle that appears around the mouse pointer when you use any
of the above tools. You use it to create a contour that is a given distance away from
another object or represents the size of the contouring paintbrush.
1. To increase the guide radius value, press the up arrow , right arrow , or the
greater than sign > on your computer keyboard.
2. To decrease the guide radius, press the down arrow , left arrow , or the less
than sign < on your computer keyboard.
3. You can also use the keyboard/mouse combination of shift+ mouse scroll to
adjust the size of the guide radius.
Monaco® 5-7
Contouring Tools
Contouring Tools
Reshape Contour (Contour Editing Tool)
This tool lets you edit a contour by stretching a defined section of a contour on a
transverse, sagittal, or coronal image.
1. To edit a contour that you have drawn, click the Reshape Contour
button.
2. Use the guide radius value to determine the length in cm of the segment of the
contour you would like to stretch.
Contour by Shapes
The Shapes button lets you create contours based on four basic shapes:
circle, square, rectangle, and ellipse. Select the shape from the drop down menu. Click
on a transverse slice to place the shape. You can resize and edit it just like any other
contour. You can create contours by shape on transverse, sagittal, or coronal images.
NOTE: For best contouring results, we recommend that you contour a single
structure entirely in a single view (either transverse, sagittal, or coronal)
instead of contouring a single structure in multiple views.
1. Click the down-arrow next to the Shapes button to show a list of

shapes from where you can make a selection.
2. Left-click on a shape to select it. The system places a checkmark next to the
name of the shape and changes the mouse pointer to a cross.
3. In any transverse, sagittal, or coronal image window, hold down your left-mouse
button and drag to create the shape in the size you want.
4. Continue this process and add more shapes to the currently shown slice.
OR
Move to a new slice and add the selected shape.
5-8
Contouring Tools
Contouring Tools
Paintbrush
The Paintbrush tool lets you fill in (paint) an area in the transverse, sagittal, or
coronal view that you want to contour as a structure. You can also edit and smooth
any existing structure when you use this tool. A plus (+) sign on the paintbrush tool
pointer indicates you intend to draw. The minus (–) sign indicates you intend to
erase. The paintbrush is resizable, and you can paint/erase with an opaque,
transparent, or outline brush.
Contour Using the Paintbrush Tool
1. Select the structure name that you want to contour/edit in the Structure field on
the Contour ribbon.
2. Click the Paintbrush button.
3. In any transverse, sagittal, or coronal image window, hold down your left-mouse
button and drag the mouse using slow smooth strokes to paint a structure.
NOTES: 1) For best contouring results, we recommend that you contour a

single structure entirely in a single view (either transverse sagittal, or
coronal) instead of contouring a single structure in multiple views.
2) The Drawing Assistant is disabled when you use the Paintbrush

tool, since this tool lets you draw and edit immediately without the
need to select another tool.
4. The guide radius value determines the size of the paintbrush. Range is 0.1 to 10
cm in steps of 0.1 cm. Change the value as described in the Guide Radius topic
earlier in this section.
Monaco® 5-9
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Smoothing Contours Using the Paintbrush Tool

Use the paintbrush tool as a smoothing tool to push out or push in the contour you
are drawing.
1. Click the Paintbrush button.
NOTE: When you check the Erase option, the paintbrush erases the
contours.
Place your mouse cursor on the edge of a contour. If the guide radius is mostly
inside the contour and the + sign is in the middle of the paintbrush pointer
when you hold down the left mouse, the system adds or smoothes from the
inside, pushing the contour out.
If the guide radius is mostly outside the contour and the – sign is in the middle
of the paintbrush pointer when you hold down the left mouse, the system
erases or smoothes from the outside, pushing the contour in.
If you are in the process of pushing out the contour and want to switch to
pushing in (or vice versa), you can hold down the Ctrl key, move your mouse
in or out of the contour, then release the Ctrl key, all without releasing the left
mouse.
5-10
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Change the Transparency of the Painted Area

You have the option to use a paintbrush stroke that is outline, opaque (solid), or
transparent.
Left-click on the down arrow at the bottom of the Paintbrush button to select a
transparency option (Figure 5-4).
Outline Opaque Transparent
Figure 5-4: Transparency of Painted Area
Erase the Painted Contour
You can erase all or part of any contour when you use one of these methods.
1. Left-click on the down at the bottom of the Paintbrush button and select Erase
Mode.
OR
Hold down the Shift key on the keyboard along with the left mouse button.
2. In the image window where you want to edit, hold down your left mouse button
and drag the mouse using slow smooth strokes to erase the painted structure.
Monaco® 5-11
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Paintbrush Enhancement Tools
You can use Edge Detection and Structure Avoidance in a variety of combinations
(separate, together, and with other paintbrush features) and scenarios.
Edge Detection Tool
Edge Detection enhances the paintbrush tool because it gives you

the capability to quickly delineate structures on CT or MR images. As you delineate a
structure, the paintbrush tool detects the interface of the delineated structure and
adjacent tissue as it samples the image’s pixel values.
Structure Avoidance Tool
Structure Avoidance enhances the paintbrush tool because it

lets you stay away from adjacent structures as you delineate a new structure with the
paintbrush tool.
Edge Detection Sensitivity
The Edge Detection Sensitivity tool defines how strictly the

paintbrush tool follows the pixel values of the image (as it detects differences in image
pixel values). The sensitivity tool values range from 100% - 0%:
 100%: Represents normal paintbrush tool activity, therefore, no detection in

differences of image pixel values occur
 0%: Uses strictest detection of pixel values
Lower sensitivity percentages behave stricter and are “more sensitive” to differences
in image densities. The recommended starting value is 10% - 20%.
5-12
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Paintbrush Enhancement Tools (cont.)
Considerations When Using Paintbrush Enhancement Tools
1. Refer to previous sections for Paintbrush properties and functions.
2. Select or create the structure to delineate.
NOTE: Monaco software does not currently support ring-shaped

delineations.
3. Make note of adjacent structures to avoid.
4. Evaluate image characteristics of the structures for optimal use of the tool.
NOTE: You can better delineate some structures than others, in part, based on
image characteristics.
Desirable Image Characteristics of Structures:
Well-defined interface to adjacent structure
• Brain (skull interface)
• Lung (chest wall interface)
Homogeneous, non-grainy
• Heart
• Liver
Less Desirable Image Characteristics of Structures:
Grainy-rendered structures
• Rectum
• Brain
Monaco® 5-13
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Considerations When Using Paintbrush Enhancement Tools (cont.)
There may be significant density variations within structures, such as structures that
have an inner portion and outer portion. In these cases, use caution to keep the
crosshair “+” of the paintbrush tool within the outer density of the structure.
• Bone (femur, pelvis)
• Kidney
5. Adjust the window/level (gray-scale) for uniform density to the desired structure.
Using Structure Avoidance with Paintbrush Tool
Use this example if you plan to delineate a structure adjacent to a previously

delineated structure.
1. Review the Considerations When Using Paintbrush Enhancement Tools

discussed in the previous section.
2. Select Structure Avoidance .
NOTE: Do not close the Structure Avoidance Properties dialog box, as this
action deactivates Structure Avoidance capability. Select “Minimize”
to maintain Structure Avoidance activity (Figure 5-5).
5-14
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Using Structure Avoidance with Paintbrush Tool (cont.)
Figure 5-5: Structure Avoidance Properties dialog box
3. Refer to the table below to do the listed functions inside the Structure Avoidance
Properties dialog box.
Table 5-1: Structure Avoidance Properties functions and instructions
Function Instructions
a) Add structure to be avoided Click on <click to add a new row> and
select desired structure.
b) Delete a structure from the Right-click on the structure to delete and
Properties list select Remove.
c) Save a Template File for Select Save As and create an identifiable
group of avoidance name.
structures
d) Apply + or – margin to the Type the desired margin in the
structure designated location within the dialog
box.
4. Continue with remainder of structure delineation.
Monaco® 5-15
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Using Structure Avoidance with Edge Detection
Use this example if you intend to delineate a structure adjacent to one of these:
• A previously-delineated structure (contained in Structure list)
• A non-delineated structure (not contained in Structure list)
1. Use Considerations When Using Paintbrush Enhancement Tools and pay close
attention to the desirable image characteristics.
2. Review the previous section about the Edge Detection Sensitivity Tool.
3. Create Structure Avoidance parameters as described in previous example.
NOTE: Do not close the Structure Avoidance Properties dialog box, as this
action deactivates the Structure Avoidance capability. Select
“Minimize” to maintain Structure Avoidance activity (Figure 5-5).
5-16
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Using Structure Avoidance with Edge Detection (cont.)
4. Select Edge Detection from the Manual Contouring Panel.
OR
Right-click Contour | Paintbrush | Edge Detection.
5. Set Sensitivity Tool at starting position of 10% - 20%. Adjust, if necessary, as you
delineate the structure. For this example, we used 15% (Figure 5-6).
Figure 5-6: Edge Detection Sensitivity Tool
6. If the structure is too grainy, you can do one or both of these actions:
Adjust the sensitivity to a higher value. But, note that the new structure “pulls in”
from the adjacent structure (non-delineated)
OR
Adjust the Window/Level (gray scale) to minimize graininess. But, this

adjustment may degrade anatomy visualization.
7. Delineate the new structure and evaluate the system’s ability to avoid these issues:
A previously delineated structure(s) listed in Structure Avoidance Properties

dialog box
OR
An adjacent non-delineated structure
Monaco® 5-17
Contouring Tools
Contouring Tools
Paintbrush (cont.)
Using Structure Avoidance with Edge Detection (cont.)
Figure 5-7: Example of the a) Edge Detection Tool as it detects the

skull/brain interface, and b) Structure Avoidance Tool as it
avoids the previously delineated target (PTV)
8. Continue with remainder of structure delineation.
5-18
Contouring Tools
Contouring Tools
Auto Contouring
EZ Sketch Tool
The EZ Sketch button is a contouring tool that gives you the ability to quickly
and effectively create a 3D structure on transverse images. You can select this tool on
the Auto Contouring panel (Figure 5.8). The EZ Sketch tool uses a sphere to sample
the pixel data used to create the 3D structure. This tool may work better with
homogeneous, non-grainy structures, such as, brain and lung.
Figure 5-8: EZ Sketch
EZ Sketch – Initial Creation
1. Click the EZ Sketch Start/Stop button on the Auto Contouring Panel.
NOTE: The Global Edit option on the EZ Sketch dropdown list is always
highlighted during the initial creation of a contour.
2. Select the structure you want to contour. Determine the center of the structure in
your T/S/C views.
NOTE: You can use the Quick Locator method to update the images.
3. Draw a sketch line inside the structure in two or more T/S/C views. The sphere is
red when you draw inside the structure.
Monaco® 5-19
Contouring Tools
Contouring Tools
Auto Contouring
EZ Sketch Tool
EZ Sketch – Initial Creation (cont.)
Figure 5-9: EZ Sketch – Draw Inside of Structure
4. Hold down the Shift key and draw a sketch line around the outside of the
structure. When you hold down the Shift key, the sphere turns blue.
Figure 5-10: EZ Sketch – Sketch Outside of Structure
5. (Optional) You can click the Undo button on the Contour Edit panel or the
Reset button on the Auto Contouring panel to undo what you have
drawn.
6. EZClean removes all contours smaller than the volume defined in EZClean
on the Auto Contouring panel.
5-20
Contouring Tools
Contouring Tools
Auto Contouring
EZ Sketch
EZ Sketch – Initial Creation (cont.)
7. Click the EZSketch Execute button on the Auto Contouring panel.

This generates the structure contour (Figure 5-11).
Figure 5-11: EZ Sketch – Contour Generated
8. To accept you contour, click the EZ Sketch Start/Stop button.
EZ Sketch Edit Mode – Refine Contour
You are automatically placed in edit mode after the initial contour creation. When
you are in EZ Sketch edit mode, you can refine a small portion of the contour you
need to modify. EZ Sketch edit mode lets you add more sketches to refine your initial
contour.
1. Change the Edit Radius on the Auto Contouring panel, if needed. The default
value is 2.0.
NOTE: The option to change the radius diameter is only available if you are in
edit mode and when Global Edit is not selected.
Monaco® 5-21
Contouring Tools
Contouring Tools
Auto Contouring
EZ Sketch (Cont.)
EZ Sketch Edit Mode – Refine Contour (cont.)
2. Use the EZ Sketch sphere to draw inside/outside along your previously created
sketch lines where it is needed (Figure 5-12).
After Initial Execution After Addition of New Sketch Line
Figure 5-12: EZ Sketch Edit Mode – Refine Contour
3. Click the EZ Sketch Execute button on the Auto Contouring panel,

once you add the new stroke lines on the inside/outside of the structure to create
the edited contour.
4. Click the EZ Sketch Start/Stop button to accept your changes.
5-22
Contouring Tools
Contouring Tools
Auto Contouring
EZ Sketch (Cont.)
EZ Sketch Edit Mode – Global Edit
If you want to re-create the entire contour and use new sketches, click the Global
Edit option when the initial creation of the sketches are complete. You can add new
sketches to your existing sketches, or click on the Reset button to draw new
sketches.
EZ Sketch – Quick Scheme
You can select the Quick Scheme option in the initial creation or edit mode. This
option has a coarse resolution to provide a faster creation of a contour. You should
only use this option for larger structures, such as, patient.
Using Other Editing Tools
After you accept your EZ Sketch contour, you can use any of the editing tools to fine
tune the contour. The Edge Detection tool is a good tool to edit/smooth your
contour after you accept your EZ Sketch contour.
Monaco® 5-23
Contouring Tools
Contouring Tools
Copy Structure
The copy structure tool lets you copy and rename an entire structure from a primary
studyset to a primary studyset, or from a primary studyset to a secondary studyset. To
copy a contour from a primary studyset to a secondary studyset, you must first fuse
the primary and secondary studysets loaded. Otherwise, the copy steps are the same.
NOTE: If you create a contour in a sagittal or coronal view, then want to use the
Copy Structure option, you must “render” the structure in the transverse
before the new contour name appears on the Copy Structure list. To
render the structure in the transverse, de-select the active
contouring/editing tool, or select the structure in the transverse view.
1. Open a studyset (or fused studysets) with existing contours.
NOTE: If you draw the structures on a secondary studyset (example, an MRI),

and you want to copy those structures to the primary CT, you must
load the MRI as the primary and copy the contours to the Secondary
(CT). When you are ready to plan, open the CT as the primary and
the MRI as the secondary. All copies of the structures from the MRI
show on the CT.
3. Click the Copy Structure button to show the Copy

Structures dialog box (Figure 5-13).
Figure 5-13: Copy Structures dialog box
5-24
Contouring Tools
Contouring Tools
Copy Structure (cont.)
4. New Structure Names are editable. Click on a new structure name and type a
new name, if desired.
5. Select the structure(s) you want to copy by placing a checkmark in the checkbox
in the copy column.
6. Click OK to copy the structures.
OR
Click Cancel to discard your selections. The system adds Contours to the
Primary or Secondary studyset, depending on your selection.
NOTE: Contours may not look the same when copied onto the new studyset.
See the online help topic Copy a Contour for more information about
how to create copied contours.
Monaco® 5-25
Contouring Tools
Contouring Tools
Copy Superior/Inferior, Anterior/Posterior or Right/Left
This exercise demonstrates how to:
• Copy a single contour to the next superior or inferior slice on a transverse

view
• Copy to the next anterior or posterior slice on a coronal view
• Copy to the next right or left slice on a sagittal view
Copy Superior and Inferior
Transverse View
2. Click drop-down arrow in the Structure field and select the structure you want
to contour, or type a new name.
3. Contour a structure on one transverse slice.
4. Click the Copy Superior or Copy Inferior

button on the contouring ribbon to copy that contour to the next superior or
inferior slice.
OR
Right-click in the transverse window and select either the Copy Superior or
Copy Inferior option.
5-26
Contouring Tools
Contouring Tools
Copy Superior and Inferior (cont.)
Sagittal View
1. Click the drop-down arrow in the Structures field and select the structure you
want to contour.
OR
Type a new name.
2. Contour a structure on one sagittal slice.
Right-click in the sagittal window and select either the Copy Left or Copy Right
option.
OR
Use Ctrl + L or Ctrl + R keyboard shortcuts to copy to patient’s left or right,

respectively.
Monaco® 5-27
Contouring Tools
Contouring Tools
Copy Superior and Inferior (cont.)
Coronal View
1. Click the drop-down arrow in the Structures field and select the structure to be
contoured.
OR
Type a new name.
2. Contour a structure on one coronal slice.
3. Right-click in the coronal window, then select the Copy Anterior or Copy
Posterior option.
OR
Use Ctrl + A or Ctrl + P keyboard shortcuts to copy to patient’s anterior or

posterior respectively.
5-28
Contouring Tools
Contouring Tools
Interpolation
This exercise demonstrates how to interpolate contours between slices on any

transverse, sagittal, or coronal views.
1. Click the drop-down arrow in the structures field and select the structure you
want to contour.
OR
Type a new name.
2. Contour the structure on the starting and ending cross-sections using any
method you choose.
3. Click the Interpolate Contour button to interpolate all the slices

in between the ones drawn to create a solid contour.
NOTE: You can only interpolate in a sagittal or coronal view when Draw,
Replace /Reshape or Paintbrush is also selected. If you did not
interpolate while in Draw mode, you have to select one Replace or
Reshape. Then, select the contour (to get the edit bounding box) in
the view for which you want to do the interpolation
Monaco® 5-29
Contouring Tools
Contouring Tools
Auto Threshold
This exercise demonstrates how to create a contour with Auto Threshold. Auto
Threshold is a process where a curve is created around a highly contrasted structure.
The amount of image contrast is user-definable. Auto Threshold is a tool you use to
quickly create contours on transverse studysets, such as the patient surface, lung,
spinal cord, or any other highly contrasted structure.
1. Select the contour name Patient.
2. Click the auto Threshold button to show the Auto Threshold dialog
box (Figure 5-14).
Figure 5-14: Auto Threshold dialog box
3. Choose AutoSkin in the Window/Level Presets drop-down menu or type in the

Window and Level values to provide a good level of contrast between the air and
the patient surface.
4. In the sagittal window, close the yellow box on the posterior of the patient to
remove the table from the area to be contoured. To do this, hold down your left
mouse button and drag the yellow box edge.
5. On the transverse image, left-click a point (anterior to the area to be contoured,

but inside the yellow box). The system propagates this point to all slices, and
renders the patient contour on all slices.
6. Verify the contours are correct on the sagittal/coronal images. If the contours
are not correct, place a checkmark  in the Delete Existing Contours on Affected
Slices box.
7. Click a new point to replace all existing contours and creates new ones.
8. Click the Close button.
5-30
Contouring Tools
Contouring Tools
Auto Segmentation
This exercise shows you how to create a contour using Auto Segmentation. Auto
Segmentation is a process where a curve is automatically generated around a
structure with fairly uniform density. Structures on which you may consider using
auto segmentation are liver, kidneys, spleen, and possibly the bladder.
1. On a CT studyset, choose an appropriate contour name.
2. Click the auto Segment button to show the Auto Segmentation

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

Segmentation link in the Online Help.
Use the Page Up and Page Down keys on your computer keyboard to
repeat the above steps on another slice.
5. Once you complete contouring in Auto Segmentation, click the Close button.
Monaco® 5-31
Contouring Tools
Contouring Tools
Auto Margin
Auto Margin lets you automatically create contours in three dimensions based on a
combination of existing structures. You can set margins around structures and create
structure combinations. You can accomplish this through "including" and
"excluding" specific structures plus a margin distance from those structures.
There is an Advanced Margin tool which supports a template that lets you calculate
the isotropic margin from the CTV to the PTV necessary to deliver at least X% of the
prescription dose to the CTV for Y% of the population.
Monaco comes with the default template: LUNG SBRT1. You use this as a starting
point to build your own templates with the data obtained in your clinic. The LUNG
SBRT template is only a starting point. The local practice for each institution should
determine the data needed for Margin Recipe. You can save the templates with empty
cells to account for the patient specific errors.
You can also create and save common margin templates to use on any patient.
For more information on Workflow Scenario for Margin Recipe Usage, refer to the
Appendix of this guide.
5-32
Contouring Tools
Contouring Tools
Auto Margin
Create an Auto Margin
1. Click the Auto Margins button on the Contouring panel.
Figure 5-16: Auto Margin dialog box
2. Click the drop-down arrow in the New Structure Name field and select a new
structure name from the list.
OR
Type a new structure name.
NOTES: You can sort the structure selection list by study or by structure.
When you select By Structure, you need to click the expansion icon
of the structure and select the Structure Set.
3. Click By Study .
Monaco® 5-33
Contouring Tools
Contouring Tools
Auto Margin
Create an Auto Margin (cont.)
4. Click on a structure name in the Structure Selection List.
5. Click the Add button to add that structure to the Selected Structures list with a
plus-sign in front of it.
OR
Click on a structure name in the Structure Selection List. Click the Subtract
button to add that structure to the Selected Structures list with a minus sign in
front of it.
NOTES: A plus sign signifies that the structure is to be included.

A minus sign signifies that the structure is to be excluded.
6. If you would like to remove a structure that you added to the Selected Structures
list, click the structure you want to remove to highlight it. Click the Remove
button below the list to remove it.
When creating margins around structures, you have the capability to set variable or
uniform margins.
7. To make a variable margin, type margin distances in the S (superior), I

(inferior), L (left), R (right), A (anterior), and P (posterior) fields in the Margins
at (cm) area. These margin distances determine how far the new contour is from
the structure selected (highlighted) in the Selected Structures list.
NOTE: If you type a value in one of the fields in the Margins at (cm) area (S, I,
L, R, A, or P) with the Link button shown, the system
automatically fills the related field with the same value. To type
different values in paired fields, click the Link button so that it
changes to the Unlink button. Type the values. For example, if the
system shows the Link button, type 2.0 in the L field. The system puts
2.0 automatically in the R field. If you click the Link button so that it
changes to the Unlink button, you can type 0.5 in the L field
without automatically changing the R field.
5-34
Contouring Tools
Contouring Tools
Auto Margin
Create an Auto Margin (cont.)
8. To create a uniform margin around a structure, check the box Uniform Margin
(Negative Allowed) option.
9. Type the value for the uniform margin you would like to create. It is possible to
create negative uniform margins. To do so, type a negative value for the margin
(Figure 5-17).
Figure 5-17: Creating a Negative Uniform Margin
10. Click the Create button to create the new contour.
11. (Optional) If you would like to clip the contour at the patient's surface, check the
box next to Clip at Patient Surface. When you select this option, the system lets
you to clip the contour inside the patient surface by a specific amount. Type this
value in the Clip Inside By (cm) box.
Monaco® 5-35
Contouring Tools
Contouring Tools
Auto Margin
Common Margin Templates
You can create and save common auto margin templates to use on future patients.
However, you can only apply a saved template to the same selected structures and the
structures must be included or excluded as they were when the template was created.
Save a Template
1. After you create an auto margin or define margins, you can save it as a template
when you click the Save as button.
2. Type a unique name for the template.
3. Click Save on the Save as Template dialog box.
4. If you make additional changes to this template and want to save over the existing
name, click Save on the Auto Margin dialog box to save the changes.
5-36
Contouring Tools
Contouring Tools
Auto Margin
Common Margin Templates (cont.)
Apply a Template
1. Click the Margins button on the Contouring tab.
2. Click the drop-down arrow in the New Structure Name field and select a new
structure name from the list.
OR
3. Add the structure(s) to the Selected Structures list. Include or Exclude as

appropriate.
4. Click the drop-down arrow in the Apply Margin Template field and select the
margin you want to apply.
NOTE: When you place the mouse cursor over the template name, the system
lists the structures and margin saved with that template.
5. Click Create to create the new margin.
Monaco® 5-37
Contouring Tools
Contouring Tools
Auto Margin
Using Advanced Margins
The advanced margin tool is probability-based margin and calculates the PTV
margin required to deliver at least X% of a prescription dose to the CTV for Y% of
the population. The approach is based on the margin recipe of van Herk et al. The
advanced margin tool lets you account for systematic and random errors during
patient preparation and planning and customize the input values2.
You can also save advanced margin templates to use on future patients.
The application uses the formula below to calculate the prescribed PTV Margin (M)
in single dimension, necessary to deliver at least X% of the prescription dose to the
CTV for Y% of the population:
M PTV , X %,Y % [cm] = α Y Σ + β X σ 2 + σ p2 − β X σ p

Where:
αY Unitless constant related to the percentage of the population for

which the desired margin applies (see table below for α Y values
assuming perfect conformation in 3D)
Σ Standard deviation (cm) of the systematic errors (see white paper in

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

Online Help)
i
Σ≡ ∑Σ n =1
2
Si The sum in quadrature over all systematic errors
βX Unitless constant related to the isodose level which should cover the
“moving” CTV (see table below for β X values )
i
σ ≡ ∑ σ 2 Ri The sum of the squares of all random errors
n =1
σp Width of the penumbra modeled by a cumulative Gaussian
5-38
Contouring Tools
Contouring Tools
Auto Margin
Using Advanced Margins (cont)
NOTE: For prostate, the σ p value used in the ‘classic van Herk’ margin formula is
0.32 cm. This corresponds to an 8 MV beam in water. In lung with an
assumed homogeneous density = 0.25 g/cm3, the σ p value used is 0.64
cm. This is also for an 8 MV beam. For simplicity, it is assumed the tumor
is the same density as the lung and there are no adjacent solid tissues.
Below α Y and β X based on the van Herk at al. data.
Confidence Level α Y 3D Dose Level βx

(% of patients) (% Rx Line)
80% 2.16 80% 0.84
85% 2.31 85% 1.03
90% 2.50 90% 1.28
95% 2.79 95% 1.64
99% 3.36 99% 2.34
NOTE: You can find multiple references regarding this margin recipe in the
Online Help for the white paper on this product.
Monaco® 5-39
Contouring Tools
Contouring Tools
Auto Margin (cont.)
Create an Advanced Margin
1. Click the auto Margins button on the Contouring tab.
2. Click the drop-down arrow in the Structure: field and select a structure name
from the list.
OR

appropriate.
4. Click the Advanced Margin button to open the Advanced Margin dialog box.
Figure 5-18: Advanced Margin dialog box
5-40
Contouring Tools
Contouring Tools
Auto Margin
Create an Advanced Margin (cont.)
5. Select the Alpha Table you would like to use from the Alpha Table Selector dialog
box.
6. Edit the Confidence Level (%), which is the percent of the population that
receives at least X% of the prescription dose. The Alpha value updates
automatically based on the Alpha Table selected.
7. Select the Beta Table you would like to use from the Beta Table Selector dialog
box.
8. Edit the Prescription Line (%), which is the percentage of the prescription dose to
the CTV for Y% of the population. The Beta value updates automatically based
on the Beta Table selected.
9. Edit the Sigma Penumbra value, which describes the width of the penumbra
modeled by a cumulative Gaussian.
10. The Independent Multiplier option refers to the multiplier values in the
Systematic and Random Component Tables. If you would like to define
multipliers for each direction independently, place a checkmark next to the
Independent Multiplier option. This lets you type in different multiplier values
for each direction. The default value is unchecked, since typically the same
multiplier is used for each direction.
Monaco® 5-41
Contouring Tools
Contouring Tools
Auto Margin
Create an Advanced Margin (cont.)
11. Edit the Systematic and Random Components for each direction. Edit the
Multiplier for each. (Fields can be left blank and stored blank in a template for
patient specific data.)
Systematic Components are as follows:
• Localization Accuracy-Systematic Localization Error
• Intrafx-Systematic Intra-fraction Variability
• Delineation- Tumor Delineation Uncertainty
Random Components are as follows:
• Localization Accuracy- Random Localization Error
• Intrafx- Random Intra-fraction Variability
• Resp Motion- Respiratory Motion
12. (Optional) Add additional Systematic or Random Components. Click the <click
to add a new row> and type a new component name and corresponding
direction and multiplier information. You can also remove the components when
you select Remove from the right-mouse menu and click on the row you want to
remove. You can also rename each of the components, if necessary.
13. As you edit each field, the system dynamically updates the margins for each
direction in the MARGIN (cm) fields.
14. Click OK to close the Advanced Margin dialog box. The advanced margin values
automatically populate in the Margins (cm) fields on the Auto Margin dialog box.
15. Click Create on the Auto Margin dialog box to create the advanced margin
contour on the patient.
5-42
Contouring Tools
Contouring Tools
Auto Margin (cont.)
Save an Advanced Margin Template
1. Set up an advanced margin as described in the previous steps.
2. Before you leave the Advanced Margin dialog box to create it, click the Save as
Template button.
3. Type a new template name. This template is now available for all future use of
the advanced margin tool.
4. If you make additional changes to this template and want to save over the existing
name, you can click Save on the Auto Margin dialog box to save the changes.
Apply an Advanced Margin Template
1. Click the auto Margins button on the Contouring tab.
2. Click the drop-down arrow in the Structure: field and select a structure name
from the list.
OR

appropriate.
4. Click the Advanced Margin button to open the Advanced Margin dialog box.
5. Select an Advanced Margin Template from the drop-down list.
6. Click OK to close the Advanced Margin dialog box. The advanced margin values
automatically populate in the Margins (cm) fields on the Auto Margin dialog box.
7. Click Create on the Auto Margin dialog box to create the advanced margin
contour on the patient.
Monaco® 5-43
Contouring Tools
Contouring Tools
Auto Margin (cont.)
Print a Margin Report
Once you create a margin on a patient, you can print the Auto Margin report. Click
the Print button on the Auto Margin dialog box.
NOTE: You can only print the margin report after you create the margin and
before you close the Auto Margin dialog box.
EZClean
You can remove contours smaller than a volume you define in the EZClean dialog
box (Figure 5-19). You can remove the small contours for the active contour selected
or for all of the contours in the studyset.
Figure 5-19: EZClean dialog box
1. Click on the EZClean icon on the Auto Contouring panel.
2. Type a value in the Remove volumes smaller than ____ cm3.
NOTE: The value you type is linked between the PET Threshold Contouring,
EZClean, and EZSketch EZClean options. If you type a value in the PET
Threshold Contouring dialog box or in the EZClean option on the Auto
Contouring panel, it becomes the default value that appears for
subsequent patients.
5-44
Contouring Tools
Contouring Tools
EZClean (cont.)
3. Click the Clean All Structures button to remove all of the contours less than or
equal to the value you typed for all structures in the studyset.
OR
Click the Clean Structure button to remove all of the contours less than or equal
to the value you typed for just the active structure.
4. When you are done, click the Close button.
Monaco® 5-45
Contouring Tools
Contouring Tools
Select and Group Contours and Structures
Occasionally, you may want to select and group contours or structures so that you
can do specific edit functions on them as a whole.
1. Select Replace Contour to place you in edit mode.
2. (For Contours) Select individual contours to group. Hold down the Ctrl key on
your computer keyboard and left-click on each contour to select. The system
places a dashed-line bounding box around each contour selected.
3. (For Structures) Right-click in an image window and select Selecting. Then,

Select All from the drop-down menu. The system places a solid-line bounding
box around each structure.
OR
Select individual structures to group. Hold down the Ctrl+Shift keys on your
computer keyboard and left-click on each contour to select them. The system
places a solid-line bounding box around each structure selected.
4. With contours or structures selected, right-click in the same image window and
select Grouping then Group. A single solid-line bounding box encompasses all
the contours.
5. The edit functions Cut, Copy, Paste, Undo, Resize, Move, Rotate and Mirror
apply to the entire group of contours or structures. The Replace tool still works
on individual contours within the grouped set of contours or structures.
NOTES: (1) Groups of structures or contours are mirrored and rotated based
on the center of the bounding box surrounding the selected structure.
(2) If you copy and paste structure(s) to the same studyset, the
structure name already exists. So, the new structure name is a
combination of the original structure name and a consecutive number
(ex. GTV1, GTV2…). You can rename the new structure, if desired.
6. To ungroup a set of contours or structures, right-click in an image window and

select Selecting, then Select All. Right-click in the same image window and select
Grouping, then Ungroup.
NOTE: If you leave edit mode, then return, you are able to select contours
individually for editing. However, if you Select All again, the contours
or structures remain grouped.
5-46
Contouring Tools
Contouring Tools
Delete Contours or Structures
This exercise shows you how to delete individual contours or entire structures.
Use this method to delete an individual contour.
1. Click the Replace Contour button.
2. Select the contour you want to delete.
3. Press the Delete key on your computer keyboard.
Use this method to delete an entire structure.
1. Select the structure you want to delete in the structure name box on the Contour
panel.
2. Click the Delete Structure button on the Structure Edit panel.
OR
Click the Shift and Delete keys on your computer keyboard.
NOTE: Prior to deleting the structure, the system provides you with a
warning message that asks: Are you sure you want to clear all
contours from structure?
Monaco® 5-47
Contouring Tools
Contouring Tools
Anatomical Groups
You can create, copy, and delete anatomical groups as well as delete structures in an
anatomical group.
Create an Anatomical Group
1. Click on the Tools tab.
2. Click on the Anatomical Groups button.
3. Click on the Create New Anatomical Group button.
4. Type a name in the Input New Anatomical Group Name dialog box.
• Click OK to save your changes.
• Click Cancel to exit this dialog box without saving.
6. Click on <click to add a new row> to add a new structure.
7. Modify the structure’s properties.
8. You must click Apply | OK to save your changes.
Copy Anatomical Group
1. Click on the drop-down arrow under Anatomical Group Name to select the
anatomical group you want to copy.
2. Click on the Copy Anatomical Group button.
3. Type a name in the Input New Anatomical Group Name dialog box.
4. Click on <click to add a new row> to add a new structure.
5. Modify the structure’s properties.
6. When you have made your changes, click Apply | OK to save.
5-48
Contouring Tools
Contouring Tools
Anatomical Groups (cont.)
Delete Anatomical Group
1. Click on the drop-down arrow under Anatomical Group Name to select the
anatomical group you want to delete.
2. Click the Delete Anatomical Group button.
• Click Yes to delete the anatomical group listed.
• Click No to cancel.
NOTE: When you click Yes, the anatomical group is permanently deleted.
Apply Anatomical Groups
You can predefine structure names during the contouring process when you add an
anatomical group.
2. Click the Apply Anatomical Group button.
3. Select the groups you want to add. Left-click on them to highlight.
4. Click OK to close the dialog box. The system shows the contours associated with
the selected group(s) in the structures list.
Monaco® 5-49
Contouring Tools
Contouring Tools
PET Tools
SUV Calculation
You use the SUV Calculation icon to calculate the SUV value of a PET image
set. You can click on the SUV Calculation drop-down menu to select one of the SUV
normalization options for the displayed PET image. (For detailed information about
the formulas used to calculate the SUV values, refer to About PET Imaging in Online
Help).
NOTE: Any patient imported before version 3.30 does not enable SUV
Calculation. Therefore, a cursor value appears without units.
The SUV value normalization options include:
• Body Weight (g/ml)
• Body Surface (cm2/ml)
• Lean Body Mass (g/ml)
In addition, you can show the Philips SUV if you have a Philips scanner and the
appropriate Philips private tags. (Refer to the DICOM Conformance Statement for
details.)
5-50
Contouring Tools
Contouring Tools
PET Tools
SUV Calculation (cont.)
You can select one of these options as the default SUV normalization in the SUV
Calculation drop-down menu. The Body Weight (g/ml) option is the system default.
Figure 5-20: SUV Calculation Drop-Down Menu
Monaco® 5-51
Contouring Tools
Contouring Tools
PET Tools (cont.)
SUV Calculation (cont.)
DICOM Editor for SUV
The information in the DICOM SUV Editor for SUV dialog box (Figure 5-21) is
automatically sent with the PET DICOM files. The system reads this information
from the first slice in the studyset. You can update or type in missing information
needed for the SUV calculation. This information is used to calculate the SUV.
Figure 5-21: DICOM SUV Editor
1. Select SUV Calculation | DICOM Editor for SUV.
2. Select a normalization type in the SUV: drop-down box.
5-52
Contouring Tools
Contouring Tools
PET Tools
SUV Calculation
DICOM Editor for SUV (cont.)
3. Select the weight units in kilograms (kg) or pounds (lbs).
4. Type in the Weight at the time of the PET scan.
5. Select the height units in meters (m) or inches (in).
6. Type in the Height at the time of the PET scan.
7. If you choose the Lean Body Mass normalization option, you have to select a Sex.
8. Click the drop-down arrow in the Acquisition Date field to select a date in the
calendar. The system automatically populates this value from the first image in
the image set.
9. Type the Acquisition Time. You can click on the up/down arrows to adjust the
time. The system automatically populates this value from the first image in the
image set. When you process data for GE scanners, the system uses the GE
Private Attribute as the Acquisition Time. (See the DICOM Conformance
Statement for more information.)
NOTE: You cannot calculate SUV if the Acquisition Date/Time is before

RadiopharmaceuticalStart Date/Time.
10. Type a Radionuclide Half-Life in seconds.
11. Type in a Radionuclide Total Dose. Select unit: MBq or Ci.
12. Type a Radiopharmaceutical Start Date. Click the drop-down arrow in the field
to select a date in the calendar.
13. Type a Radiopharmaceutical Start Time. You can click on the up/down arrows
to adjust the time.
Monaco® 5-53
Contouring Tools
Contouring Tools
PET Tools (cont.)
SUV Calculation
DICOM Editor for SUV (cont.)
14. Click the Reset to DICOM Values to change the dialog box back to the values
from the DICOM file.
15. Click Calculate to accept the values and calculate the SUV. The dialog box
remains open.
OR
Click Close to discard your changes and close the dialog box.
PET Threshold Contouring
You can use the PET Threshold Contouring tool to create contours for PET
studysets. In the PET Threshold Contouring tool dialog box, you can choose to
define the volume of interest (VOI) as a sphere or a cuboid.
1. Use the Locate option to find the center of the target.
2. Click on the PET Threshold Contouring icon and select the VOI Sphere
or VOI Cuboid. The PET Threshold Contouring dialog box opens. (Figure 5-
22).
OR
Press the S key to change the VOI shape when the tool is open.
5-54
Contouring Tools
Contouring Tools
PET Tools
PET Threshold Contouring (cont.)
Figure 5-22: PET Threshold Contouring dialog box
3. Drag the VOI to adjust the location or size in a T/S/C view while the PET
Threshold Contouring dialog box is open (Figure 5-22). The max. Value within
the VOI updates as you move the VOI.
4. Click Tools | Jump to Point | Center of VOI. This places the center of the T/S/C
views to the center of the VOI.
Figure 5-23: Jump to Point button – Center of VOI option
Monaco® 5-55
Contouring Tools
Contouring Tools
PET Tools
PET Threshold Contouring (cont.)
5. Type a value in the Percent: or Absolute: field to define the threshold value. You
can also slide the threshold slider bar to adjust the threshold values. Move the
slider bar to the right to increase the threshold, or move it to the left to decrease
the threshold.
Figure 5-24: PET Threshold Slider Bar
NOTE: If the SUV Calculation option is selected, the units are shown as
SUVbw, SUVbsa, SUVlbm or SUV (if Philips SUV is used). If the
SUV Calculation option is deselected, the units are shown as Bq/ml,
CNTS. If no units are shown, units other than CNTS or Bq/ml were
used, or the patient was imported from a software release prior to
3.30).
6. (Optional) Click in the Threshold Color: box to change the threshold color.
7. Mark if you want to Use Active Primary, or Use Secondary Studyset if you have
two PET studysets loaded.
8. Check the Delete Existing Contours box to delete any contours with the same
name as the PET contour. The system deletes the existing contour after you click
Create in the PET Threshold Contouring dialog box.
9. Check the Remove volumes smaller than __ cm3 box to delete any contours
smaller than or equal to the value you typed in the field.
10. Click the Create button to generate the contour.
5-56
Contouring Tools
Contouring Tools
PET Tools (cont.)
Click on RAW icon to select PET Image Type
You can click the Raw Image Display button to switch between
interpolated and pixelated images (Figure 5-25). Monaco creates a contour based on
the image type.
Pixelated/Raw Image Interpolated Image
Figure 5-25: PET Image Types
Monaco® 5-57
Contouring Tools
Contouring Tools
Import Treatment Couchtop
This tool lets you add imported contoured treatment couches or other external
accessories onto any studyset, plan, or QA phantom. This lets the algorithm
accurately account for dose when a beam travels through this device. Use the same
tools to contour the couch structures as you use to contour patient anatomy.
NOTE: When you add a treatment couchtop to a studyset that has existing
calculated plans, this action does not invalidate the existing plans.
Prerequisites
• DICOM import couchtop images into the system.
• When you contour the couchtop structures, designate the structure type as
Couch and assign the electron density value on the structures tab in the
planning control (Figure 5-26).
Figure 5-26: Planning Control | Structures tab

• Save contoured couchtops into the Treatment Couch Library. Select Monaco
Application Menu | Treatment Couch | Save as Treatment Couch.
5-58
Contouring Tools
Contouring Tools
Prerequisites (cont.)
1. Click the Plan Options tab.
2. Click the Import Positioning Device button.
3. Select the Couchtop or other device you want to add to your patient
(Figure 5-27).
Figure 5-27: Import Treatment Couch

4. (Optional) If you have existing couch structures and you want to replace them
with the one you selected here, place a check in the Remove Existing Couch
Structures box.
5. Click OK. The system adds the entire scanned couchtop to the patient. You now
have the opportunity to position the table or accessory on/under your patient.
Monaco® 5-59
Contouring Tools
Contouring Tools
6. On the Treatment Couch Position dialog box (Figure 5-28), you can type shift
values or use the up/down buttons.
Figure 5-28: Treatment Couch Position dialog box
OR
You can move the couch with the mouse in the transverse, sagittal, or coronal
image window.
NOTE: You only have one opportunity to position the couch. If you want to
reposition the couch, delete the current couch and re-import a new
one.
7. Click Done. The system crops the couchtop superiorly and inferiorly and creates
a wireframe contour of the couchtop that matches the slice spacing of the plan’s
CT studyset. The system adds the couchtop structure names to the structure
control.
5-60
Contouring Tools
Contouring Tools
8. If necessary, you can edit the couchtop structures just like any structure in the
structure control.
9. You must assign a couch to the beams in order for the dose calculation to take it
into account. This option is on the Treatment Aids section of the Beams tab on
the Planning control.
Figure 5-29: Beams Control | Treatment Aids Window
Monaco® 5-61
Contouring Tools
Contouring Tools
Generate Bolus
You can create a bolus structure type on Transverse studysets, in the Structures
spreadsheet. (Figure 5-30). You must create a bolus structure type in order to activate
the Generate Bolus icon.
Figure 5-30: Structure Spreadsheet
1. Type a name in the Structure field on the Contouring tab.
OR
Add a bolus structure in the Structures spreadsheet. You must create a bolus
structure type in order to activate the Bolus button.
5-62
Contouring Tools
Contouring Tools
Generate Bolus (cont.)
In Monaco, you can use the Generate Bolus tool to create a bolus structure in
Planning activity. Complete these steps to create a uniform surface bolus with a
desired thickness. This example assumes a 1.0 cm bolus.
1. Click on the Bolus button. This opens the Generate Bolus dialog box
(Figure 5-31).
Figure 5-31: Generate Bolus dialog box
2. You can modify the description in the Bolus Description option.
3. Select a structure in the Base Structure drop-down list. The system default is the
external structure. You can select another structure in the drop-down menu, for
example, bolus as the base structure. Monaco warns you if you do not select the
patient contour as the base structure (Figure 5-32).
Monaco® 5-63
Contouring Tools
Contouring Tools
Figure 5-32: Base Structure warning message
4. Type a value in the Thickness (cm). The default value is 1.00.
5. Type a value in the Relative ED option. Click the Monaco Application

button. You can set up the default value in Settings | Ports and Materials.
6. In the transverse view, put the bolus start and end points on the base structure.
For studysets in the Feet First orientation, the system creates bolus
counterclockwise from the start point to the end point. For studysets in the Head
First orientation, the system creates bolus clockwise from the start to end point.
7. (Optional): You can move the mouse over the point and press the Delete key on
the keyboard to remove it.
8. You can put the top and bottom points to define the bolus in any of the T/S/C or
BEV views.
9. In the Generate Bolus dialog box, click Generate to make the bolus.
10. Click Close to close the dialog box.
11. (Optional): You can update the description, thickness, or density. Re-open the
dialog box and type the new value. Click Update to make the changes.
5-64
Contouring Tools
Contouring Tools
Generate Bolus – Fill VOI
You can use the Fill VOI option to make a non-uniform area a flat surface (Figure 5-
33).
Figure 5-33: Fill VOI
1. Create a Bolus structure in structure properties.
2. Click on the Generate Bolus dialog box.
3. Select a structure in the Base Structure drop-down list.
4. Type a value in the Electron Density option.
5. Place a checkmark in the Fill VOI box.
6. Adjust the VOI box in the T/S/C views.
7. Click Generate to create the bolus.
Monaco® 5-65
Contouring Tools
Contouring Tools
Generate Bolus (Cont.)
Bolus – Editing Tools
After you generate your Bolus contour, you can use any of the editing tools to adjust
the bolus contour.
Structure Planning Control
Structure Properties refers to specific properties that relate to each individual

structure. You can view / edit the structure properties below from the Planning
Control.
1. Click the Structure tab on the Planning Control (Figure 5-34).
NOTE: You can pin and move the Planning Control tabs. If necessary, click
the Workspace tab | Reset Controls.
Figure 5-34: Planning Control | Structure Tab
2. You can rename a contour when you highlight a structure in the Name column
and type a new name.
3. Left click on the Color field to open the Color palette and change the color of the
structure.
NOTE: XiO supports a limited color palette and uses the next closest color to
the one selected here when plans are sent and opened in that product.
Upon return to Monaco, the color selected here is used.
4. Check the box in the Visible column to toggle the structure contour on and off.
Clicking the column header will toggle the visibility of all structures on or off.
5. Volume (cm3) is a display-only field.
5-66
Contouring Tools
Contouring Tools
Structure Planning Control (cont.)
6. Select a Structure Type. Options are:
• Internal - use for all internal structures
• External - use only for the patient contour
• Couch - use only for couchtop or accessory structures imported through the
couchtop tool.
• Bolus – use for creation of bolus outside the patient contour
7. You can define the Electron Density of the structure when you type a Force ED
density value.
8. (Optional) Check the box next to Fill ED if you want to fill the structure with the
representation of the Electron Density.
9. Check the Show 2D outline box to view the structure outline. When you click the
column header, this toggles the outlines on or off for all of the structures.
10. You can use the slider bar to increase or decrease both 2D Transparency and 3D
Transparency. The slider bar controls the transparency of structures in the
transverse, sagittal, coronal, and EV windows. This tool is available in all
activities. Structures created in Monaco are automatically assigned a 2D and 3D
transparency of 50%.
Monaco® 5-67
Planning Tools
Planning Tools
Overview
This section discusses all of the Planning tools that are available in this activity (that is,
except Contouring). The format is such that you can walk through the software and
follow along with the steps in each section.
Start a Sim Plan using Templates

To start a plan, you select a template. There is a range of default templates from where
you can make a selection. However, once you begin planning, you can create and save
your own templates.
Information saved in a template includes these:
• Number of Beams
• Beam Geometry Information
• Treatment Machine Information
• Algorithm
Other preferences are saved per workstation. See the Settings section in the Appendix
section of this guide for more information.
NOTE: The default templates given to you are only available to get you started.
Specifically, these templates were created using machines that you will not
have in your clinic. Therefore, upon first use, select a default template.
Next, select a machine that is available in your clinic. Once you create the
plan, save it as a template so that you can use it for future planning.
Complete these steps to start a Sim plan.
1. Click the Plans button to show the Plan Template dialog box.
OR
Right-click on the studyset in the workspace control where you want to add the
plan. Select New Sim Plan to show the Plan Template dialog box.
Monaco® 6-1
Planning Tools
Planning Tools
Start a Sim Plan using Templates (cont.)
Figure 6-1: Plan Template dialog box
2. Select a template from the drop-down list. The number of beams associated with
that template appears automatically.
NOTES: There is a special case for Sim templates saved with multiple beam
energies. It is possible to save a template where multiple beam
energies are used. However, if you change the machine on the Select
Template page, all the beams will be assigned the new machine
energy.
You cannot use MR Studysets to create a Sim Plan.
3. Select the isocenter.

OR
Type the isocenter coordinates.
4. Select a machine file from the drop-down list.
5. (Optional) If you want to plan the patient with the feet towards the gantry,
place a checkmarkin the box next to the option.
NOTE: When you select the feet towards the gantry option, the transverse
image shows as if you are looking from the head of the patient to the
foot. Sagittal, Coronal, 3D and BEV images shows with the foot of
the patient pointing toward the top of the window. This holds true
for all activities except Fusion Activity.
6-2
Planning Tools
Planning Tools
Start a Sim Plan using Templates (cont.)

6. (Optional) If you want to auto conform the ports to a specific structure, place a
checkmark  in the box next to auto conform.
7. Select the structure to which you want to conform your ports.
8. If the ports are to be MLC ports, place a checkmark  in the box next to MLC.
9. Type the value for the margin.
10. Click OK to show the selected template’s beam arrangement and ports.
Save a Template
To save your own templates, you must first add an existing template to your patient.
Make changes to the beam arrangement and number of beams until your plan is set up
the way you want it. Complete these steps.
1. Click on the Monaco Application Menu button.
2. Select the Save Template As option to show the Save as Template dialog box.
3. Type the template name. Click OK.
OR
1. To overwrite an existing template, click on the Monaco Application Menu

button.
2. Select the Save Template option to show a dialog box asking if you are sure you
want to save this template.
3. Click Yes if you would like to overwrite the selected template with the new beam
arrangement.
OR
Click No to cancel.
Monaco® 6-3
Planning Tools
Planning Tools
Manipulate Beams
This section walks you through the process manipulating beams and their parameters.
Beam Toolbar
Figure 6-2: Beam Tools
When you use these tools (Figure 6-2), you can do these tasks:
• Start a New Plan - This option lets you create a new Sim or Monaco plan.
When you choose a Monaco plan, you can create a 3D or IMRT plan.
• Close Plan - This option closes the currently loaded plan.
• Delete Plan - This option deletes the currently loaded plan.
• Import Plan Template - This option lets you select a plan template to start a
new plan.
• Add a New Beam - This option creates a new beam.
• Duplicate Beam - This option makes a copy of the active beam.
• Duplicate and Oppose Beam - This option makes a mirror image copy of the
active beam.
• Delete Beam - This option deletes the active beam.
• Edit Beam - This option lets you move the beam using the mouse.
There are three ways to manipulate beam parameters in Planning Activity:
• Edit/Change Values in the Beam Spreadsheet
• Move the Beam Isocenter for a Single Beam or Group of Beams
• Change the Gantry or Collimator Using the Mouse
6-4
Planning Tools
Planning Tools
Manipulate Beams (cont.)
Beam Visibility
Use the Beam Visibility Control (Figure 6-3) to turn selected beams on and off in
transverse, sagittal, coronal, and 3D windows. The beam highlighted in red is the one
currently shown in the BEV.
• Click on an individual beam name

to turn the selected beam on or off.
• Click on the heading Plan/Rx/Beam
to toggle all beams on or off.
• Click on a specific prescription to
turn the beams on and off for the
prescription.
• Click the Current button to show
only the current beam selected in the
BEV.
• Click the + next to the prescription
to show a list of the beams in that
Figure 6-3: Beam Visibility Control prescription.
• Click the – next to the prescription to
close the list of beams for the
prescription.
Move the Beam Isocenter
You can move a single beam to a new isocenter or a set of multiple beams to a new
isocenter. This tool is not available for rotational arc beams.
Monaco® 6-5
Planning Tools
Planning Tools
Move the Beam Isocenter
Move a Single Beam
1. Click the Edit Beam button on the Planning tab. Click on the link icon on
the Isocenter Location column to unlink the isocenters. This lets you move the
current beam by default.
OR
Leave the isocenter location linked so you can move all the beams’ isocenter to
the same location at once.
2. On the transverse, coronal, or sagittal view, move the beam isocenter. Hold
down your left mouse button and drag the four-way arrow when it appears
on the center of the beam.
Move Multiple Beams as a Group (for all types of plans)
To move beams as a group, they must all share the same isocenter.
1. From the Beams tab on the Planning Control, make sure the link icon is
closed to move the isocenter of all the beams that share the same isocenter,
regardless of the beams’ display status.
2. On the transverse, coronal, sagittal or beams-eye view, move the beam isocenter
for the group of beams that share the same isocenter. Hold down your left
mouse button and drag the four-way arrow when it is shown on the center
of the beam.
OR
On the Beam Spreadsheet, change the isocenter location for the selected beam.
This automatically changes the isocenter for all beams that share the same
isocenter.
6-6
Planning Tools
Planning Tools
Manipulate Beams
Change the Gantry or Collimator Using the Mouse

You can only change the gantry or collimator for a single beam using the mouse.
Rotate the Gantry or Collimator Using the Mouse

1. On the beam spreadsheet, select the beam that you want to adjust the gantry or
collimator with the mouse.
2. Click the Move Beam button on the Beams tab on the Planning Control.
3. On the transverse or sagittal view, rotate the gantry. Hold down your left mouse
button and drag to rotate the circular arrow icon (when it is shown) on the
beam.
NOTE: The axis of the beam moves within a plane that passes through the
isocenter and is perpendicular to the axis of rotation of the gantry.
Therefore, beam rotation is never available in the Coronal view,
because the plane of rotation is always perpendicular to that view.
Whether it is available in the Transverse or Sagittal view at any given
time depends on the couch angle, but is always available in at least
one of them.
4. On the beams-eye view, rotate the collimator. Hold down your left mouse
button and drag to rotate the circular arrow icon when it is shown on the
beam.
Monaco® 6-7
Planning Tools
Planning Tools
Edit/Change Values on the Beam Spreadsheet

Click the Beams tab on the Planning Control and type the new values in the Beams
dialog box. This dialog box provides you with global beam editing.
Figure 6-4: Beams dialog box
NOTE: You can use the left and right arrow keys to move left and right.
You can use the Tab key to move right.
You can use the up and down arrow keys to go up and down.
You can use the Enter key to move down.
6-8
Planning Tools
Planning Tools
Beam Spreadsheet – Sim Plans
The beam spreadsheet for sim plans has four tabs:
• General
• Geometry
• Treatment Aids
• All
You can add, edit, or delete beams as well as modify beam properties. When you
load a sim template, the beams from the template populate in this dialog box. You
can edit the loaded beams in the Beam Spreadsheet.
NOTE: The beam spreadsheet updates in real time. Any change you make is
reflected immediately. We recommend that you save your plan before you
make any updates to avoid loss of data.
Monaco® 6-9
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – General Tab
In the Beam Spreadsheet for Sim plans, you can add, edit, and delete beams. You can
also edit the following beam properties in the General Tab:
• Beam
• Description
• Field ID
• Machine ID
• Delivery
• Total Weight (Gy)
• Algorithm
• Setup
• Isocenter Location
• X, Y, Z coordinates
Figure 6-5: Beams dialog box – General tab
6-10
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – General Tab (cont.)
Add/Edit/Delete Beams
1. Click on the Beams tab on the Planning Control.
2. To add a new beam, left click the New Beam button or left click on the
words <click to add a new row>.
3. Type a unique Description for each beam.
4. Select a Machine, if applicable.
5. Select Total Weight(Gy) for each beam.
6. In the Algorithm column, select Monte Carlo Photon or Pencil Beam Photon.
7. Select SAD or SSD in the Setup column.
8. Select the Isocenter Location for the each beam. The system shows the Isocenter
Coordinates each beam.
9. Click Close when you have added all your beams.
Copy a Beam
1. Left-click to highlight the beam you want to copy.
2. Click the Duplicate Beam button to show the copied beam.
Delete a Beam
1. Left-click to highlight the beam you want to delete.
2. Click the Delete Beam button to delete the selected beam.
Monaco® 6-11
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – General Tab (cont.)
Renumber Beams
1. Left-click to highlight the beam you want to renumber.
2. Type the new number in the Beam column for the current beam.
NOTE: If you type a beam number that is used within the plan or another
prescription, the 2 beam numbers are switched.
Reorder Beams
1. Left-click to highlight the beam you want to move.
2. Click the Beam Up or the Beam Down button to reorder the beams
on the list.
Number Beams Consecutively

1. You can reorder the beams in the list when you add or remove a beam/sequence.
2. Add/remove a beam in the beam spreadsheet list.
3. Left-click on the Beam heading. The beams are renumbered in the list in
ascending order.
Link Machine ID and/or Isocenter Location

You can plan with multiple isocenters and machines. You can save templates with
multiple isocenters and machines. You have the ability to reset all the beams to a
common isocenter. Restore the link above the Isocenter Location column on the
Beam Spreadsheet dialog box, then select the desired isocenter location for one of the
beams in the Isocenter Location column. The remaining beams’ isocenter locations
update to match the isocenter location you selected.
6-12
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – General Tab
Link Machine ID and/or Isocenter Location (cont.)
You can assign different isocenter locations to each beam or a group of beams. Break
the link in the Isocenter Location column to modify the desired beam isocenter
locations. You can restore the link when you have set the desired location for each
beam in the list. The beams with a common isocenter link (Figure 6-6) updates when
you change the isocenter location of any beam in that group.
Figure 6-6: Beams – Isocenter Location link
You can reset the beams to a common machine. Restore the link above the
Machine ID column on the Beams dialog box, then select the desired machine ID for
one of the beams in the Machine ID column. The remaining beams’ machines update
to match the machine ID you selected. You can assign different machine IDs to each
beam or a group of beams. Break the link in the Machine ID column (Figure 6-7)
to modify the desired beam machine ID. You can restore the link when you have set
the desired machine for each beam in the Machine ID Link.
Figure 6-7: Beams – Machine ID Link
Monaco® 6-13
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – Geometry Tab

You can edit these fields on the Beam Spreadsheet for sim plans in the Geometry tab
(Figure 6-8):
• Beam
• Description
• Gantry
• Collimator
• Couch
• Jaw Width and Length
You can uncheck the Asym box to set the width and length jaws symmetrically if
desired.
Figure 6-8: Beams – Geometry tab
6-14
Planning Tools
Planning Tools
Beam Spreadsheet for Sim Plans – Treatment Aids Tab

The Treatment Aids tab (Figure 6-9) is where you can add, edit, or delete the beam as
well as modify the Beam, Description, Isocenter Location, and X, Y, and Z coordinates.
Figure 6-9: Beams – Treatment Aids tab
Beam Spreadsheet for Sim Plans – All Tab
The All tab shows the combined information from the General, Geometry, and
Treatment Aid tabs.
Print a Beam Summary Report
1. In the Planning Activity, click the Beam Summary button to open the
Beam Summary dialog box.
2. Type an optional report comment. Click OK to show the Beam Summary

Report.
3. Click the Print button in the upper left corner of the dialog box.
Monaco® 6-15
Planning Tools
Planning Tools
Feet First Sim Plans
Create a Feet First Sim Plan

You can create a feet first sim plan in Monaco. The patient orientation represents the
position of the patient in the T/S/C, 3D, and BEV images (Figure 6-10). In this
example, the patient’s left leg is being treated.
Figure 6-10: Patient Orientation Icon: Feet First Sim Plan
1. Double-click on the studyset in the Patient Workspace.
2. Click the drop-down arrow next to the New Plan button to select a plan
type.
3. Select the New Sim Plan option.
4. Select the template, isocenter, and machine information in the drop-down

menus.
5. Place a checkmark in the box next to the Plan with Feet Toward Gantry
option.
6-16
Planning Tools
Planning Tools
Change Treatment Orientation for Monaco IMRT Plan
Create a Feet First IMRT Plan

You can create a feet first IMRT plan in Monaco. You can select the treatment
orientation for Monaco IMRT plans in the New Monaco Plan dialog box (Figure 6-
11).
Figure 6-11: Treatment Orientation
1. Double-click on the studyset name in the workspace control.
2. Click the drop-down arrow next to the New Plan button to select the plan
type.
Monaco® 6-17
Planning Tools
Planning Tools
Change Treatment Orientation for Monaco IMRT Plan
Create a Feet First IMRT Plan (cont.)
3. Select New Monaco Plan in the drop-down list.
4. Type in plan name and description.
5. Select the template that you want to import.
6. Select the Treatment Unit, Modality, Algorithm, Energy, and Isocenter

Location.
7. Click on the Head First or Feet First radio button to select the treatment
orientation. The scan orientation information is listed above. If you change the
treatment orientation so that it differs from the scan orientation, Monaco shows
a message for you to verify the information (Figure 6-12).
Figure 6-12: Treatment Orientation warning message
6-18
Planning Tools
Planning Tools
Port Tools
Port tools are only available for non-IMRT plans in Planning activity. You can draw
ports manually, or you can create ports using the AutoPort tool.
These are the port tools available in Planning activity (Figure 6-13).
Figure 6-13: Port Tools
• Create/Edit Ports/MLC
• Snap Jaws to Port
Auto Conform a Port

This section demonstrates how to create an auto-conformed port around an existing
structure using blocks, apertures, or MLCs in the Create/Edit Ports dialog box (Figure
6-14) You can also combine apertures with blocks or MLCs with blocks.
1. Click the Create and Edit Ports button on the Planning tab.
Figure 6-14: Create/Edit Ports dialog box
Monaco® 6-19
Planning Tools
Planning Tools
Port Tools
Auto Conform a Port (cont.)
2. The Current Port field defaults to NEW PORT. Ports are numbered
automatically as they are created.
3. Select a Port type: Block, Aperture or MLC. Click the associated radio button.
4. If you selected MLC, edit the Leaf Insertion and Closed Leaf Position, if
necessary.
5. If you selected Aperture or Block, you can edit the Port Properties. Click the
Port Properties button (Figure 6-15).
Figure 6-15: Port Properties dialog box
6. Click the drop-down arrow in the Structure field and select a structure name
around which you want to conform.
7. Type a Margin value in the Margin field. This represents the margin you want to
have around the structure.
8. (For Apertures and MLCs) If you want the collimator jaws to snap to the port
extents, check the box next to Snap Jaws to Port or click the Snap Jaws to Port
button.
9. (For Apertures and Blocks) If you want to rotate the port along with any
collimator rotation, check the box next to Rotate Port with Collimator.
10. Click Close when you are done.
11. If you do not want the Port to update with the beam movement after it is auto-
conformed to the structure, select NONE in the Structure field on the
Create/Edit Ports dialog box.
6-20
Planning Tools
Planning Tools
Port Tools (cont.)
Draw a Port
You can manually draw a port using the mouse. The port drawing tool works the same
as the contour drawing tool.
1. Complete steps 1-5 above.
2. On a BEV, hold down the left mouse button and draw the port shape.
3. (For Apertures and Blocks) If you want the collimator jaws to snap to the port
extents, check the box next to Snap Jaws to Port.
NOTE: This option only affects the length jaw for machines with width jaw
that track the MLC.
4. (For Apertures and Blocks) If you want to rotate the port along with any
collimator rotation, check the box next to Rotate Port with Collimator.
Edit a Port or MLC

This exercise shows you how to edit a port when you use these methods.
• Replacing a segment of the port/MLC

• Resizing the port/MLC
• Moving the port/MLC
• Editing individual MLC leaves
• Use the Leaf Table to edit the port
• Editing the Closed Leaf Position
Monaco® 6-21
Planning Tools
Planning Tools
Port Tools
Edit a Port or MLC (cont.)
Replace a Segment of the Port/MLC
1. Click on the Create and Edit Ports button. The mouse cursor for editing a
port or MLC is .
2. Select the port you want to edit from the Current Port drop down list.
OR
Click on the port on the BEV window.
3. Hold down your left-mouse button at the start of the replacement

segment and drag the mouse to the end of the replacement segment.
Move the mouse (always in the same direction) by clicking to place a
series of points and dragging to create curves. When you release the
mouse button, the system replaces the segment on the screen.
4. If you made an edit and replaced the wrong segment, right-click and
select the Swap Block option (available only for Aperture/Block).
OR
Click the Swap Block button on the Planning tab.
6-22
Planning Tools
Planning Tools
Port Tools
Resize the Port/MLC
1. Click the Create and Edit Ports button.
2. Select the port you want to resize from the Current Port drop down list.
OR
3. On the edit bounding box, move the pointer to a resize handle at one of
the corners so that the pointer becomes either a or a .
4. To make the port smaller, drag toward the center.
OR
To make the port larger, drag away from the center.
5. To resize asymmetrically, hold down the shift key on your computer
keyboard and move the pointer to a resize handle at one of the corners
so that the pointer becomes either
a or a .
OR
1. Move the pointer to a resize handle on one of the box's edges so that the pointer
becomes either a or a .
2. To make the port smaller, drag toward the center.
OR
To make the port larger, drag away from the center.
3. To resize asymmetrically, hold down the Shift key on your computer
keyboard and move the pointer to a resize handle at one
of the edges so that the pointer becomes either a or a .
Monaco® 6-23
Planning Tools
Planning Tools
Port Tools
Move the Port/MLC
2. Select the port you want to move from the Current Port drop down list.
OR
3. Click a point inside the bounding box, but not on the border. The mouse
pointer becomes a four-pointed arrow .
4. Drag the mouse to the new location.
5. Release the mouse button at the new location to refresh the window.
6. You can rotate the port when you place the mouse over the dot at the lower-right
corner and drag it around.
Edit Individual MLC Leaves
1. Click on the Create and Edit Ports button.
OR
3. Hold down your left mouse button outside the yellow edit box boundary and
drag any leaf to a new position. The collimator drags open, if necessary.
6-24
Planning Tools
Planning Tools
Port Tools
Use the Leaf Table to edit the port
1. Select Create and Edit Ports.
2. In the Create/Edit Ports dialog box, click the Show Leaf Table button.
Figure 6-16: Show Leaf Table button
3. The leaf table shows:

• The pair number for the MLCs
• The position of the left and right leaf for a specific pair. You can edit the
positions. Type in the position value for the leaf.
• The Parked column is read-only. It shows which leaf pairs are used in the
port shape. A check mark in the Parked column for a leaf pair means it is
not being used in the port shape.
Figure 6-17: Leaf Table
4. Click the Hide Leaf Table button to close the leaf table.
Monaco® 6-25
Planning Tools
Planning Tools
Port Tools
Edit the Close Leaf Position
OR
3. Edit the value for the Closed Leaf Position. The edited value will set the top and
bottom closed leaves to the entered value.
OR
Edit the closed leaves with the mouse. Hold down your left mouse and drag any
closed leaf that is not immediately adjacent to the field opening. Each set of
closed leaves (top and bottom) move independently.
Delete a Port
2. Select the port you want to delete from the Current Port drop down list.
OR
3. Press the Delete button on the keyboard.
6-26
Planning Tools
Planning Tools
Port Tools
Maintain Field Borders

This option lets you maintain the field borders or maintain the isocenter location
when you switch from asymmetric to symmetric jaws. The option is located in
Planning activity on the Planning tab.
When you click on the Maintain Field Borders button, (the icon is highlighted in
orange) and change an asymmetric field to a symmetric field by un-checking the
Asymmetric box on the Beams tab on the Planning Control, field borders are
maintained and the isocenter is moved to the geometric center of the field.
When Maintain Field Borders is off and an asymmetric field is changed to a

symmetric field by un-checking the Asymmetric box on the Beams tab on the
Planning Control, the system maintains the current isocenter and moves the field
borders to the symmetric field size shown on the beam.
Measure Tool
The Measure tool lets you take measurements on any transverse, sagittal, coronal, or
oblique image. You can apply more than one ruler to the images. The measure tool is
available in all activities.
Use the Measure Tool
1. Click on the Measure Tool button on the Tools tab.
2. On any transverse, sagittal, coronal, or oblique image, hold down your left mouse
button and drag to create a measurement ruler that shows the length as the ruler is
drawn.
Remove the Measurement Rulers
Click the Remove Measure Graphics button.
Monaco® 6-27
Planning Tools
Planning Tools
Interest Points and Markers

You can place interest points or markers on transverse, sagittal, coronal, and oblique
slices in a variety of ways (and in any activity, except Fusion). You can add Interest
Points and Markers in Planning and Plan Review activities. You can also print an
interest point and marker report.
Place Interest Points or Markers
1. Click the Interest Points/Markers button on the toolbar. Monaco shows the
Interest Points& Markers dialog box (Figure 6-18).
Figure 6-18: Interest Points & Markers dialog box
2. Click the New Interest Point or New Marker button to add a point or marker to
the center of the patient. The point or marker number and coordinates show on
the Interest Points & Markers dialog box.
OR
Place an Interest Point. Left-click anywhere on a transverse, sagittal, coronal, or

oblique image to place the point.
OR
6-28
Planning Tools
Planning Tools
Place Interest Points or Markers (cont.)
Place a Marker. Left-click anywhere on a transverse, sagittal, coronal, or oblique

image while you hold down the Shift key on the keyboard.
NOTE: When you add Interest Points or Markers, the software forces slice
mode, so points and markers are always placed on real transverse
slices.
3. Type a Description for the point or marker next to its coordinates in the Interest
Points & Markers dialog box.
4. Move the point on a transverse, sagittal, coronal, or oblique image. To do this,

place the mouse pointer over the point or marker. (The mouse pointer visually
changes to look like this .) Hold down your left mouse button and drag the
point or marker to a new location.
OR
Type new coordinates for the point or marker in the dialog box.
NOTE: The interest point or marker’s new location may re-order the list if
the Y value is less than the interest points and markers that are
already made.
5. Click Done when complete.
Monaco® 6-29
Planning Tools
Planning Tools
Interest Points and Markers (cont.)
Verify an Interest Point or Marker

Use this tool to verify which point is shown on a transverse slice.
1. Open the Interest Points and Markers dialog box.
2. Place your mouse cursor over the Interest Point or Marker. (The mouse pointer
visually changes to look like this .) A tool tip shows the point number and
name.
Figure 6-19: Transverse slice with an Interest Point
Locate an Interest Point or Marker

To easily locate an interest point or marker you have placed, open the Interest Point
and Marker dialog box. Select the interest point or marker. Click on it to highlight in
the dialog box. Click the Jump to Point button. The system updates all image views to
show the interest point or marker.
6-30
Planning Tools
Planning Tools
Delete an Interest Point or Marker

To delete interest points or markers, open the Interest Points & Markers dialog box.
Click on a point or marker in the list to select it. Then, click the Delete button on the
dialog box.
OR
Place your mouse pointer over the point or marker. (The mouse pointer will change to
look like this ). Then, press the Delete key on your computer keyboard.
Print the Interest Point and Marker Report

From the Interest Point and Marker dialog box, click the Print option. Type an
optional Report Comment and click OK. The report shows as a preview on the
screen. Click the Print button to print it
Dose Reference Points (Plans from Monaco IMRT only)

Dose reference points (DRP) are computed in Monaco and represent point doses to
user-defined locations on a per-beam basis. The information represented in dose
reference points can be reported or exported to external systems for the purpose of
independent MU calculation checks or dose tracking in a record & verify system. You
can click on the Dose Reference Points tab on the Planning Control to view the dose
reference point dialog box in Planning or Plan Review activities. You cannot edit dose
reference points in Monaco Sim.
Monaco® 6-31
Planning Tools
Planning Tools
Image Statistics
You can view the image statistics for all loaded datasets. Select the Image Statistics
button from the Tools section of the Tools tab. Monaco shows the Image
Statistics dialog box. Monaco also shows a yellow region of interest tool in all loaded
studysets.
Figure 6-20: Image Statistics dialog box
Figure 6-21: Region of Interest Tool in All Loaded Studysets
1. Click Show Image Statistics For Other Loaded And Registered Studysets to
show the statistics for all studysets you have loaded. The upper section of the
Image Statistics shows the information for the active studyset. You can select the
additional studyset for which you want to view the information when you select
the studyset name on the lower section of the Image Statistics.
6-32
Planning Tools
Planning Tools
Image Statistics (cont.)

Monaco shows the image statistics information by default within user defined
(size and the position) Volume of Interest (appears as a yellow sphere on the
T/S/C views).
2. To add a structure to the statistics list, click on <click to add a new row>.
3. To change the structure, click on the Structure’s field and change the selection.
4. To remove the structure, right-click on the corresponding Structure field and

select Remove.
5. Use the mouse to move the region of interest around the displayed images. Use
the mouse or type a value in the VOI Diameter (cm) field to shrink or enlarge
the VOI. Monaco shows the VOI on all studysets selected for the display on the
Image Statistics.
Monaco shows the Min, Max, Mean, Median, Standard Deviation and Volume
for all loaded studysets. These values are determined from all voxels which are
completely contained within the structure or VOI. The Volume shown for the
VOI is calculated using the user-defined VOI Diameter. Monaco shows units for
these values for PET image sets if the studyset is imported in the version 3.3 or
later. For SUV values, the units correspond to the units of the SUV
normalization used (for example for Body Weight normalization, you see
SUVbw). See the SUV Calculation section for more information on the SUV.
You do not see units if the studyset originated in an earlier version of Monaco.
For CT studysets, the displayed units are HU (Hounsfield Units) and ED

(Electron Density). For MR study, no units are shown. Generally, the same units
appear on the image statistics as on the Volume Cursor.
Monaco only calculates Peak Value for PET studysets. Peak Value is the largest
possible mean value of a user defined size spherical VOI (default diameter is 1.2
cm) positioned within a structure or VOI. The Peak Value calculation is a four
step process:
a. System calculated the peak mask.
Monaco® 6-33
Planning Tools
Planning Tools

b. Monaco iteratively centers a sphere with the diameter set to the value
defined in the Set Peak Value Sphere Diameter to: field on the Settings
dialog box over all the voxels in the structure or VOI in such way that it
includes only the voxels fully encompassed by the structure/VOI. This
shows one of all possible peak-value spheres positions. The diameter of
the sphere defaults to 1.2 cm. You can change this value if you have
administrator privileges. This sphere is independent of the sphere used
in the VOI calculations. Monaco overlays this sphere on a cube which
has been sub-divided into voxels. Monaco sets the voxel size equal to the
resolution of the PET images. Monaco determines what % of each voxel
is contained within this sphere.
Figure 6-22: Tumor volume (shaded) overlaid with mask and grid
The above graphic shows the Tumor volume (shaded area) overlaid
with the mask and grid. The dark grey voxel is the current location
where the Peak Value is being calculated.
6-34
Planning Tools
Planning Tools

c. Monaco calculates for each voxel, the product of the mask value times
the PET value. The sphere must fit completely inside the structure or
VOI and all voxels covered by the peak sphere are fully included in the
structure/VOI. Monaco will report N/A in the Peak Value field if this is
not the case. For example, if the Diameter of the VOI is less than the
diameter of the Peak Value Diameter, you will see N/A in the Peak Value
field.
0 0.5 .75 1 .75 .5 0 142 114 112 126 144 148 146 0 57 84 126 108 74 0
.5 1 1 1 1 1 .5 170 141 107 126 135 156 138 85 141 107 126 135 156 69
.75 1 1 1 1 1 .75 144 118 103 114 110 130 108 108 118 103 114 110 130 81
1 1 1 1 1 1 1 x 122 118 120 115 108 117 83 122 118 120 115 108 117 83
=
.75 1 1 1 1 1 .75 116 164 146 127 123 116 84 87 164 146 127 123 116 63
.5 1 1 1 1 1 .5 102 151 112 104 108 103 73 51 151 112 104 108 103 73
0 .5 .75 1 .75 .5 0 56 90 84 66 76 16 61 0 45 63 66 57 8 0
a: Peak Mask b: PET Values c: a x b
Figure 6-23: Weighted Average of the Values Calculation
d. The last step is to calculate the weighted average of the values to

determine the final Peak Value. Monaco sums the PET SUV values from
(c:) and divides it by the sum of the Mask values in (a:) to get the Peak
Value. In this example, 4820/39 gives a Peak Value for the shaded cell of
123.6.
Monaco® 6-35
Plan Review
Overview
Plan Review lets you evaluate and compare treatment plans utilizing a dedicated set of
user-friendly tools. You can evaluate plans which were created in Monaco. You can
also evaluate plans which were imported from another system, including proton spot
plans.
Open Plan(s) into Plan Review

It is assumed that you have already selected a patient with calculated and saved plans,
and that this patient's studyset(s) and plans appear in the Patient Workspace.
Figure 7-1: Patient Workspace
1. Select and load plans. Right-click on each in the Workspace Control and select
Load/Activate.
OR
Load multiple plans at one time. Hold down the Ctrl key and left-click on each
plan you want to load. Then, right-click and select Load Into Plan Review.
2. (Optional) Load a fused secondary studyset. Right-click on the studyset and

select Load/Set as Secondary.
3. If you have multiple plans loaded, you can change the active plan. Double-click
on its name on the Workspace Control, or select Load/Activate from the right
mouse menu.
Monaco® 7-1
Plan Review
Change the Isodose Display

In plan review, you can change the isodose display to one of five options. You can
select the options from the bottom of the Isodose Control panel The Grid Volume
section on the Planning tab has the options to show Dose or Raw Dose (which shows
un-interpolated dose distribution).
Figure 7-2: Change the Grid Type
See the Help for more information about these options.
Figure 7-3: Colorwash consists of a continuous band of color from

dark red (highest dose) to dark blue (lowest dose) shown
transparently on the CT data. This option automatically allocates the
colors based on a higher and lower limit entered in the Isodose
Control panel. No dose appears below the lower limit.
Figure 7-4: Isofill consists of regions of distinct colors that represent

the dose ranges. A list of dose values and colors associated with them
appear in the Isodose Control panel. The dose levels on the Isodose
Control panel represent the lower boundary, that is, a given color
shows doses greater than or equal to the value in the legend.
Figure 7-5: Isobands consists of bands of distinct colors that

represent the dose ranges. The Isodose Control panel shows a list of
dose values, colors associated with them, and checkboxes to turn each
isoband on and off. Dose shows in the bands that are greater than or
equal to the value in the legend, plus the user-definable Thickness %
of the normalized dose.
7-2
Plan Review
Change the Isodose Display (cont.)
Figure 7-6: Isolines are lines around the border of the

individual isodose levels that indicate the isodose colors.
This shows in the Isodose Control panel a list of dose
values, colors associated with them, and checkboxes to
turn each isoline on and off.
Figure 7-7: Reference Dose shading gives a visual

representation of the dose distribution associated with
the placement of the hot (red) and cold (blue) reference
dose cursors on the DVH graph. Dose values in between
the hot and cold reference doses appear in tan. Move the
reference dose cursors on the DVH graph to change the
distribution of the dose on the image.
Change the Transparency of the Dose Display

Use the Grid Volume toolbar to change the dose transparency shown on the primary
studyset.
1. On the Planning tab, select Dose or Dose Raw grid type option.
2. Position your mouse pointer on the Grid Volume slider bar. The dose intensity
applies to the colorwash, isofill, and isobands display. It does not affect the
display of isolines, which always show at full intensity.
3. Click and drag the pointer all the way to SS (studyset) on the left side of the fader.
NOTE: When you move the pointer towards SS, the dose transparency
increases. When it is all the way to SS, no color wash dose overlay is
visible.
4. Click and drag the pointer all the way to G (dose grid) on the right side of the fader.
NOTE: When you move the pointer towards G, the dose transparency
decreases. When it is all the way to G, the color wash dose overlay is
at maximum visibility.
Monaco® 7-3
Plan Review
Save an Isodose Template

You can save customized isodose settings for the IsoFill, IsoBand, and IsoLine mode
(Figure 7-8). You can type in values and choose the DVH line colors and click on Save
As to save the customized settings. You can select the Default template, to reset the
values and colors.
Figure 7-8: Save an Isodose Template
1. Type in values for each isodose line you want to change.
2. Change the color next to the isodose line.
• Click on the drop-down arrow in the 2D column to turn the 2D visibility off
for individual isodose lines.
• Click on the All 2D Off button to turn off all isodose lines in the 2D view.
7-4
Plan Review
Save an Isodose Template (cont.)

• Click on the drop-down arrow in the 3D column to select a transparency style
for individual isodose lines.
• Click on the All 3D Off button to turn off all isodose lines in the 3D view.
5. Click on the Save As button when you have made your changes to save the template.
• Type in a name in the Template Name field.
• Click on the drop-down arrow to select an existing template name.
7. Click Save to create the template.
8. (Optional) Select the Default template to reset the values.
9. The isodoses which are displayed, the dose value on the Normalization Panel, and
the Rx Dose on the Prescription panel are all linked together. If you use a Default
Isodose Template and update the Rx Dose, the Dose Normalization and the
displayed Isodoses also updates. However, if you use a Custom Template, or make
an edit to the Default Template, this link breaks. You can reselect the Default
Isodose Template to restore the link between the Normalization Dose, Rx Dose,
and isodose display. See the Rescale by Modifying Fractional Dose heading in this
section for more information.
(Optional) Transition between Two Studysets

This option is only available if you purchased Fusion and selected a fused set of images
to view in Plan Review. Use the Studyset Volume toolbar to transition between the
primary and secondary studysets.
1. On the Fusion tab, select the secondary studyset name in the Show Images
drop-down menu.
2. Adjust your isodose display option, if needed.
3. Position your mouse pointer on the Primary/Secondary slider bar to gradually

transition between the two studysets. This has the effect of one studyset
gradually appearing (fading in) while the other studyset is gradually disappearing
(fading out), moving towards the P transitions to the primary studyset, moving
towards the S transitions to the secondary studyset. Shortcut keys on the
keyboard are Home and End. Press either of these keys twice to return to 50% of
both shown.
Monaco® 7-5
Plan Review
(Optional) Transition between Two Studysets (cont.)

4. You can change the appearance of the secondary studyset in the as: drop-down
menu to the right of the secondary studyset name on Show Images menu.
See Fusion Activity section for more information on this topic.
Beam Visibility Control

1. In Single Plan mode, use the Beam Visibility Control to turn selected beams on
and off in transverse, sagittal, coronal, and 3D windows.
Figure 7-9: Beam Visibility Control
2. Click on an individual beam/sequence name to turn the selected beam/sequence

on or off.
3. Click on the heading Plan/Rx/Beam to toggle all beams/sequences on or off.
4. Uncheck the box below Dose for each beam or Rx to toggle dose off.
5. Click on the heading Dose to toggle all beams/sequences on or off.
6. If you plan with Bias Dose, the base plan name appears on the Beam Visibility
Control to let you toggle the dose on or off.
7. When you have multiple plans in view, you can toggle all beams on or off. If one
of the plans is a bias dose plan, you can toggle Base Dose on or off.
7-6
Plan Review
Beam Summary
1. Click the Plan Options tab, then the Beam Summary button to show the
Beam Summary dialog box.
Figure 7-10: Beam Summary dialog box
2. When multiple plans are loaded, click the down arrow next to the Plan box to
show a list of plans. If you click on another plan, Monaco shows the beam
summary for that plan.
3. Click OK.
Monaco® 7-7
Plan Review
Structure Control
The Structure Control shows a color-coded list of all the contoured structures for this
patient.
Toggle Structure On and Off

You can turn structures on or off, one-by-one, on this control when you click on the
contour name(s).
OR
You can click on the heading Structure to toggle all beams on or off.
Figure 7-11: Structure Visibility
7-8
Plan Review
View Images from XiO

If you captured images in XiO and saved them with your XiO plan, you can view them
in Plan Review. For more information on capturing bitmap images in XiO, see the XiO
Training Guide.
1. Click on the Plan Options tab, then the Image Viewer button to show the
dialog box with images associated with the shown plan(s).
2. Select a plan from column on the right to show the thumbnail images that are
available for the selected plan.
3. Select a single thumbnail image. Double-click on the image.
4. Click on Browse to search for images.
5. Select multiple images. Hold down the Shift key on the keyboard and left-click
the first and last image of the set, then click the Open Images button.
OR
Hold down the Ctrl key on the keyboard and select several images. Left-click on
each one, then click the Open Images button.
Monaco® 7-9
Plan Review
Change the DVH Display Properties

From the DVH group on the Plan Options tab, you can edit DVH display properties,
view DVH statistics, and create structure combinations (Figure 7-12).
Figure 7-12: DVH Group
DVH Statistics-Statistics Tab

The DVH Statistics dialog box is an interactive dialog box that gives statistical
information that relates to the structures that appear on the Total Volume DVH
graph. To see the hot and cold statistical information, you can either directly type in
hot and cold reference dose values or type in % volumes or cm3 for each structure on
the DVH Statistics-Statistics tab, or move the red (hot) and blue (cold) reference dose
cursors on the DVH Graph to show the hot and cold doses and volumes on the DVH
Statistics-Statistics tab.
NOTE: For multiple prescription plans, the DVH Statistics report shows
information only for the prescription doses that are checked in the Beam
Visibility dialog box.
Figure 7-13: DVH Statistics - Statistics tab
% in Volume
For Monaco plans, this value is always 100% for all structures. For imported plans
where the calculation grid is user defined, the value may not be 100% if the structure is
outside of the defined calculation grid volume.
7-10
Plan Review
DVH Statistics – Statistics Tab (cont.)
Is in SS
This column represents structures within the studyset. This value is always yes for
structures that do not extend to the first or last slice image.
Edit the Reference Doses and % Volumes on the DVH Statistics Dialog Box
You can edit the reference dose values and % volumes for individual structures
directly on the DVH Statistics dialog box.
1. Click the DVH Statistics button on the Plan Options tab.
OR
Right-click in the DVH window and select the Statistics option to show the
DVH Statistics dialog box.
2. Left-click anywhere along the row of the structure where you want to put a
reference dose value or % volume. The row is highlighted in blue.
3. Left-click in the Cold or Hot reference dose or volume field for the selected
structure and type the value you want to show, then press the Tab key. An
associated reference dose cursor appears on the DVH graph and represents the
position of the value you input.
NOTE: If you typed in the ref dose or the % volume, the field where you
typed your value appears in a lighter (highlighted) shade of red or
blue.
4. You can sort and resize any column as needed.
Monaco® 7-11
Plan Review
DVH Statistics (cont.)
Edit the Reference Doses and % Volumes on the DVH Graph
You can edit the reference dose values and % volumes for individual structures
directly on the DVH Graph. Or, you can type values into the Reference Dose Control.
1. Change the Isodose display to Reference Dose on the isodose control panel.
Figure 7-14: Isodose Display as Figure 7-15: Reference Dose Cursors on

Reference Dose the DVH Graph
2. Select a structure name from the drop-down list on the Reference Dose Control
for which you would like to set the dose cursors.
7-12
Plan Review
DVH Statistics
Edit the Reference Doses and % Volumes on the DVH Graph (cont.)
3. Use one of the methods below to update the reference doses:
On the DVH Graph, hold down your left mouse button and drag the red and
blue reference dose cursors.
OR
Move the hot (red) or cold (blue) slider bars on the Reference Dose Control.
OR
Type in hot and cold dose values or % volumes on the Reference Dose Control.
NOTE: If you want to switch the value that you put on the Reference Dose
Control from dose to % volume, you must open the DVH Statistics
dialog box and highlight the dose or % volume field for the selected
structure. The heading in the Reference Dose Control changes to the
selected value.
4. The DVH Statistics dialog box is automatically updated with the selected cursor
values and reference doses.
NOTE: You can open or close the Statistics dialog box when you set the
Reference Doses. When the statistics dialog box is open, the
application shows the updates in real time.
Monaco® 7-13
Plan Review
Change the DVH Display Properties (cont.)
DVH Statistics – Display Tab

The Display tab lists all of the contoured structures in your plan. You can check the
Enabled box to view a structure in the Statistics tab. The structures used in the
prescription are automatically enabled. You can also view and manipulate the
Heterogeneity and Conformity Index values in the Display tab. These indices
provide information along with the hot and cold statistical information relating to the
structures shown on the Total Volume DVH graph. You can use these tools to
evaluate plans in the DVH statistics.
Figure 7-16: DVH Statistics Display Tab
Heterogeneity Index
The Heterogeneity Index (HI) gives information regarding the dose uniformity
within the target volume(s). You can also view this information on the Statistics tab.
The Heterogeneity Index is directly calculated from the DVH statistics. Change the
High Dose Ref. (%) and Min. Dose Ref (%) values to manipulate the Heterogeneity
Index value. The High Dose Ref. (%) uses the dose that covers the hottest percentage
of the tissue based on the value you type in this field. The Min. Dose Ref. (%) uses the
minimum dose that covers the percentage of the tissue based on the value you enter.
Heterogeneity Index= [Dose that covers x% of tissue (x= High Dose Ref. %)/Dose
that covers y% of tissue (y=Min. Dose Ref)]
7-14
Plan Review
DVH Statistics – Display Tab (cont.)
Conformity Index
The Conformity Index gives information that describes the degree to which
prescribed isodose volume conforms to the shape and size of the target volume(s). You
can also view this information on the Statistics tab (Figure 7-17). Prescribed V. (cm3)
is the target volume of tissue that receives the prescription dose. Target V. (cm3) is the
target structure volume. This value defaults from the structure properties. You can
change the Prescribed Dose (Gy) to manipulate the Conformity Index and
Prescribed V. (cm3) values. (Refer to online help and published references for detailed
information about the Conformity Indices equation.)
TV12 = (Volume of Target that receives the Prescription dose) 2
TV = Target Volume
VR1= Total Volume of the Prescription Isodose: (You must convert the isodose to a
structure in order to show the VR1
value.)
Conformity Index = TV12
TV * VR1
Figure 7-17: DVH Statistics-Indices on Statistics Tab
Monaco® 7-15
Plan Review
DVH Statistics – Display Tab (cont.)
Print/Export the DVH Statistics
1. Click the DVH Statistics button on the Plan Options tab.
2. Print or Export the DVH statistics report. Click the Print button to show a
Report Comment dialog box.
NOTE: If you have multiple plans shown, the system prompts you to choose
a single plan or all plans for which you want to print the statistics
report.
3. Type an optional Report Comment that you would like Monaco to add to the
printed Statistics page.
4. Click OK to show the DVH Statistics Report.
5. You can print this report. Click the Printer button. You can Export the
report to file in PDF format when you click the Export Report button in
the upper left corner of the dialog box.
6. Click OK to close the DVH statistics dialog box.
7-16
Plan Review
DVH Color Setup

Set the background color for the DVH Graph.
1. Click the DVH Color Setup button on the Plan Options tab
OR
Position your mouse cursor in the DVH window. Right-click and select the
Background Color option from the menu to show the Grid Color dialog box
below that lets you select from any of 16 colors.
Figure 7-18: DVH Color Setup
2. Click on a color box to select the DVH Background color.
3. Click OK to accept the background color change.
Monaco® 7-17
Plan Review
DVH Properties Setup

The DVH Properties dialog box is where you can edit specific DVH properties, such as
the dose/percent and volume maximums, grid style, DVH line thickness, resolution
and bin width. Refer to Online Help for detailed information about Single Plan and
Multiple Plan DVH warning messages.
1. Click the DVH Properties Setup button on the Plan Options

tab.
OR
Position your mouse cursor in the DVH graph area. Right-click and select the
Properties option from the menu list. The system shows the DVH Properties
dialog box (Figure 7-19).
NOTE: The DVH Properties setup dialog box is slightly different and
depends on your normalization option. If you select Absolute
normalization, the field in the upper-left corner of the dialog box
represents dose. If you select Percent normalization, the field in the
upper left corner of the dialog box represents percent dose.
Figure 7-19: DVH Properties dialog box
7-18
Plan Review
DVH Properties Setup (cont.)
2. Select the Dose Maximum value for the X-axis. Options are Plan Maximum, or
you can select a User Specified dose/percent value.
3. Select the Display Volume As value for the Y-axis. You can choose to show the
volume in Percent or Absolute (cm3).
4. Select a User Specified percent, or cm3 for the Volume Maximum based on the
display type you chose as the Display Volume As value.
5. Click on the Horizontal and Vertical checkboxes to set the DVH display with
both vertical and horizontal grid lines.
6. Select the Grid Line Style you would like for the system to show.
7. Edit the Thickness of the DVH line by typing a pixel value of 2-11.
NOTE: The values for Thickness, Resolution, and Bin Width are applied to
plans not created with an older template (Monaco 1.02or earlier) that
do not contain default values or imported plans. If you have a
template from Monaco 3.20, or earlier with the Pixel Thickness as 1,
the value changes to two (2) due to the updated range.
8. Edit the Resolution of the DVH graph by typing a value in centimeters. The
range is 0.1 to 1.0.
NOTE: The Total DVH and corresponding DVH Statistics will be

interpolated from the dose grid using the DVH Resolution. To
minimize the effect of this interpolation, use a DVH Resolution that
is equal to or an even multiple of the dose grid size. For example, if
you have a 4 mm dose grid size, use a 2 or 4 mm DVH Resolution.
9. Edit the Dose Bin for the DVH graph. Type the Bin Width. The range is 1.0-
50.0. The Bin Width is applied to the shown DVH and to the exported DVH.
10. Click OK to save the changes.
Monaco® 7-19
Plan Review
Create Structure Combinations for the DVH

This tool lets you create structure combinations for use with the DVH. You can add or
subtract structures, show the DVH for only the intersection of two structures, or use
these options in combination. For example, you may want to add both lungs together
and subtract out a lung tumor to show the DVH of the healthy lung tissue. Use (+) to
add structures, (-) to subtract structures, and (*) to show the intersection of structures.
Add Structures
1. Click the Structure Combinations button on the

Plan Options tab.
OR
Right-click in the DVH window and select the Structure Combinations option
to show the Structure Combination Editor dialog box (Figure 7-20).
Figure 7-20: Structure Combination Editor dialog box
2. Combine structures for the DVH. Click the drop-down arrow in the Make new
combination field and select a structure.
3. Click the radio button next to the + sign.
4. Select a second structure. Click the same drop-down arrow and select a second
structure.
5. Type a name for the new structure combination.
7-20
Plan Review
Add Structures (cont.)
6. Click the Color button and select a color for this structure combination.
7. Click the Accept button when you are done to show the structure combination
in the Review/delete combinations field.
8. (Optional) Click the Delete button if you would like to delete the shown
structure combination.
9. Click OK when finished.
Export the DVH Values
You can export cumulative or differential DVH values of a shown DVH as a text file
(*.txt) or a comma separated values (*.csv) file.
1. Click the DVH Export button on the Output tab.
OR
Right-click in the DVH window and select Export DVH.
2. In the Save DVH File In dialog box, select a location where you want to save the
file.
3. Type/edit a file name and select a file type (*.txt or *.csv).
4. Select an Export style of Cumulative or Differential.
5. Click Save.
Monaco® 7-21
Plan Review
Add Structures (cont.)
Print or Export the DVH View
You can print or export any shown DVH view.
1. Right-click in the DVH window and select Print.
2. Type an optional report comment. Click OK to show the DVH View dialog box.
3. To print, click the Print Report button to show the Print Setup dialog box. Type
the appropriate information for your printer, and then click OK.
OR
To export to a PDF file, click the Export Report button to show the Save PDF
File In dialog box. Select a location to save the file and click Save.
Measure Dose Intensity at a Point
1. Click the Volume Cursor button on the Planning tab.
2. Position the cursor over one of the CT images and hold down your left-mouse
button to show the dose at the cursor point.
NOTES: If more than one plan is shown (Multiple Plan Mode), the dose at the
same point appears on each plan.
If more than one plan is shown and the Dose Difference or Dose
Summation is shown, the cursor shows the difference in or sum of
dose between the two plans.
7-22
Plan Review
Measure Dose Intensity at a Point (cont.)

3. Hold down your left mouse button and drag the mouse. The dose dynamically
shows at each pixel as the cursor moves over it. (You see pixel value and electron
density information for Primary Volumes.)
4. Hold down your Shift key and left mouse button simultaneously and drag
across the image. The dose and point coordinates appear at each pixel as the
cursor moves across it.
5. Click the Volume Cursor button on the Main toolbar to turn off the volume
cursor.
Monaco® 7-23
Plan Review
Set the Normalization Parameters

Use the Dose Normalization group (Figure 7-21) on the Plan Options tab to change
the normalization of your plan to absolute or percent dose. You can also change the
dose display to cGy or Gy.
1. Place a checkmark in the box to the left of Relative mode.
Figure 7-21: Dose Normalization Group
2. Type 10.00 as the dose for normalization.
NOTE: If you chose Absolute as the normalization mode, the system grays
out this field.
3. Press the Tab key. This changes the normalized dose to 10.00.
NOTE: The default is the global maximum value, which is the highest dose
value in the opened active plan. If a Monaco Plan is loaded, the
default value corresponds to the Target EUD isoconstraint.
4. Type 50.00 as the dose for normalization.
5. Press the Tab key. This changes the normalized dose to 50.00.
6. Click the drop-down arrow located to the right of Gy and select cGy or Gy as the
shown units.
7. Type 95 in the box next to the % sign. This action adjusts the isodose line that
receives this dose.
8. Click the drop-down arrow in the Norm field and select the Absolute option to
change the normalization mode to Absolute. Notice the change to the DVH
labeling and Isodose Control.
7-24
Plan Review
Show Dose Extents

If you want to see a graphical representation of the calculation volume on the
transverse, sagittal and coronal views, click on the Plan Options tab then the Show
Dose Extents button.
Measure and Interest Points Tools

The Measure and Interest
Point Tools are available in
all activities.
See the Planning Tools

section for more detailed
Figure 7- 22: Measure and Interest Points Toolbar
information on the use of
these tools.

You can click on the Dose Reference Points tab on the Planning Control to view
dose reference point information for Monaco plans in Plan Review activity. For more
information about dose reference points, see the Planning Tools section of this
training guide.
Monaco® 7-25
Plan Review
Single Plan Display and Multiple Plan Display

In Plan Review, you can show a Single Plan where the transverse, sagittal, coronal
images, and the DVH of the selected plan are shown. You can change plans when you
double click on the plan in the Workspace Control or choose Load/Activate option
from the right-mouse menu of the selected plan. The active plan appears in blue
bolded italic underlined font (Figure 7-23).
Figure 7-23: Workspace Control: Load Single Plan
You can also show Multiple Plans in Plan Review. Each image window shows the
same SPV (either transverse, sagittal, or coronal) for all plans and the DVH represents
up to three plans using solid, dashed, and dotted lines to represent the different plans.
7-26
Plan Review
Measure and Interest Points Tools
Switch from Single Plan Mode to Multiple Plan Mode

Right-click in any transverse, sagittal, or coronal window and select Multiple Plans.
This makes the Multiplan Navigation option available in the Controls drop-down
menu on the Workspace tab.
Navigation Tools in Multiple Plan Mode

1. Left-click on a transverse, sagittal, or coronal thumbnail image to change the
SPV shown in the main windows.
2. Hold down your left-mouse button and drag the T-bars on the thumbnail
images to change the shown slice in the main window.
OR
Press the upper case and lower case L key while pointing with the mouse over the
required location on one of the views in Multiplan Navigation Control. (For
more information on Quick Locator, refer to Quick Locator section in this
guide.)
3. The system shows the name of the plan, image set, and structure set at the top of
each of the three main image windows together with the Maximum Dose
information for this plan. Click the drop-down arrow next to the plan name and
select a different plan to change the plan shown in any window.
Monaco® 7-27
Plan Review
Show the Dose Difference or Dose Summation between Plans

In Plan Review, you can subtract dose to highlight dose differences between two
selected plans. You can also add plans if you would like to see a result of dose
summation of two or more plans. Follow these instructions to set up a window that
shows a dose difference or summation.
1. Select the plans you want to add or subtract in the Patient Workspace. To do
this, hold down the Ctrl key and select the plans with the mouse.
2. Right click and select <Plan X>- <Plan Y> for a subtraction plan. The system
loads the two original plans along with the subtraction plan in the lower right
window.
OR
Right-click and select Sum Plans for dose summation.
7-28
Plan Review
Modify the Dose Difference or Dose Summation Display

When you select a dose difference or dose summation, the system shows a Summation
or Subtraction control so you can adjust the isodose values shown in the difference or
summation window. Note, that the shown Dose Control is dependent on the active
plan. If a summation plan is active, then only the Summation Dose Control appears.
Below are examples of the default controls:
Figure 7-24: Summation Dose Control Figure 7-25: Subtraction Dose Control
lsoDose Summation
When you add plans together, the Summation control shows the dose range of the
summed plans. However, this range is editable when you type new values followed by
the Tab key.
You can also change how the isodoses appear. Options are Isoband, Isofill, IsoLine,
and Colorwash. The Thickness value only applies to the Isoband option. The Cutoff
value does not apply to summations.
When you show a summation plan, the DVH for the summation plan is also shown.
Therefore, you can show the DVH Statistics for a summation plan and apply reference
dose cursors. You can sum multiple plans in a single operation.
Monaco® 7-29
Plan Review
Modify the Dose Difference or Dose Summation Display (cont.)
Dose Difference
When you subtract plans, it becomes important to review the difference dose between
plans. The Subtraction control shows a default range of percentages. However, this
range is editable when you type new values followed by the Tab key. You can change
the default normalization to Absolute to see the absolute dose difference.
You can also change how the isodoses appear. Options are Isoband, Isofill, IsoLine, or
Colorwash. The Thickness value only applies to the Isoband option. The value entered
for Cutoff represents the differences that are greater or less than the absolute value.
You can only subtract two plans in a single operation.
NOTE: For summation or difference plans where the calculation grids of the
original plans are not the same, you see a warning message in the
summation or difference window.
Save the Summation or Difference Plan

You can save a Summation or Difference plan. Select File | Save
Summation/Difference Plan. This saved plan appears in the Patient Workspace
Control. This tool is useful if you want to sum (or find a difference of) more than two
plans. After you save the result of summation/subtraction, you can add/subtract
additional plans.
Figure 7-26: Patient Workspace
NOTE: You cannot export summation or difference plans.
7-30
Plan Review
Review the Patient in 3D

1. Right-click in any image window and select the View Type, 3D option. If you are
in Single Plan Mode, the 3D image appears in the selected window. If you are in
Multiple Plan Mode, the 3D image appears in all windows. The 3D view is
available at any time during the plan review process.
2. Select the Isofill, Isoband, or Isoline viewing option to view dose on the 3D
image sets. When the Isoline option is turned on for 3D, you can also see the
isolines in the BEV. Once you select one of these options, the Isodose Control
bar changes to look like this one:
Figure 7-27: Isodose Control
3. Click the All 3D On button to turn all isodoses on in the 3D view.
4. Select S for solid, T25 –T 75 for transparent, or W for wireframe in the field next
to any isodose line value under the 3D heading to turn on individual isodoses. A
dashed line in this field indicates that the selected isodose line does not appear in
the 3D view.
Monaco® 7-31
Plan Review
Review the Patient in 3D (cont.)
Convert Isodose to Structure

In Planning activity, you can create a structure from an isodose line on the Isodose
Control (Figure 7-28). The Convert Isodose to Structure button is only available if you
are in IsoLine mode or if the Isolines option is checked in ColorWash, IsoFill, or
IsoBand mode. You can DICOM export the structures created from this tool.
Figure 7-28: Isodose to Structure Option
1. Click on the Convert Isodose to Structure icon next to the isodose line for
which you want to create a structure. This action opens the Create Structure
from Isodose dialog box (Figure 7-29).
7-32
Plan Review
Convert Isodose to Structure (cont.)
Figure 7-29: Create Structure from Isodose dialog box
2. Type in a structure name in the New Structure Name option.
3. Left-click on the Structure Color field to open the Color palette and change the
color of the structure.
4. Type in a Symmetric Margin value. The range is -4.00 to 9.90 cm. The structure
in the images update in real time when you type a value.
5. Type in a value for the Minimum Volume size. The range is 0.100 cm3 to 10.000
cm3.
6. The information for the Number of Contours, Number of Non-contiguous

Volumes, Total Volume of New Structure, and Total Volume to Be Discarded
are read-only and update based on the information you type in the Symmetric
Margin and Minimum Volume options.
7. Click Cancel to discard your changes.
Monaco® 7-33
Plan Review
Convert Isodose to Structure (cont.)
8. Click OK to save the structure and close the dialog box.
NOTE: If the structure volume is smaller than the minimum volume, a

warning message about the minimum volume appears when you
click OK.
Figure 7-30: Structure Volume warning message
7-34
Plan Review
Approve a Calculated Plan
In Plan Approval, you can approve plans and type or review comments. You can see
these approval statuses and comments on XiO or Monaco.
You can approve plans in:
• Planning Activity
• Plan Review Activity
1. Right-click over the loaded plan in the workspace control where you want to
approve the plan.
OR
Click the Plan Approval button on the Planning tab.
2. The reviewer and planner can leave comments about the plan.
3. In the Plan Approval dialog box, check the Approved box to approve the plan.
4. You (the reviewer) must type a valid user name and password in the User
Validation dialog box. (To create a user name and password in User
Authorization, see Appendix A. User Authorization).
5. The plan approval status updates in Reviewer and Reviewer Date

(Figure 7-31).
Figure 7-31: Plan Approval-Reviewer and Review Date
Monaco® 7-35
Plan Review
Approve a Calculated Plan (cont.)

6. If you are ready to approve the plan, click OK.
NOTE: The plan approval status, reviewer name, and review date are
DICOM exported and listed in all reports.
7. To unapproved the plan, uncheck the Approved and re-enter your username
and password.
8. Click OK.
9. Click Done to exit the Plan Approval dialog box.
NOTE: Plan Approval is not available for Summation/Subtraction Plans.

When you approve a bias dose plan, the system only approves the
current plan.
This feature is only available when you have dose calculation abilities.
7-36
Plan Review
Rescale by Number of Fractions

You can change the Rx Dose of a calculated plan by editing the Number of Fractions
in the Physician’s Intent. When you edit the Number of Fractions, the Rx Dose, and
the total doses in all views update. The dose per fraction and MU per fraction remains
constant. This is only available when you have segments and calculated monitor units.
These options are located on the Prescription Tab (Figure 7-32).
Figure 7-32: Prescription Tab
If you have just optimized a plan and you edit Number of Fractions, Monaco will
inform you that the optimizer will be reset if you are intending to run further
optimizations. See Figure 7-33.
Figure 7-33: Number of Fractions warning message
Rescale by modifying Fractional Dose

1. In Planning activity, click on the Prescription tab on the Planning Control.
2. Type the new value in the Number of Fractions field first. Next edit the Rx Dose
(Gy) field. The Fractional Dose will update to reflect the new values entered.
3. For optimized plans, Monaco calculates the ratio of the fractional dose change
and uses this ratio to update the MU/Fx. For consistency, Monaco also updates
the Rescale dose value to equal the Rx Dose value (Gy).
4. Use the isodose curves and DVH to evaluate the new dose values.
Monaco® 7-37
Plan Review
5. The Plan report shows the rescaled number of fractions under the Normalization
heading.
6. If you change the Rx Dose for a plan which you optimized and created segments,
then the system:
• Shows a warning that the MU/Fx will update (Figure 7-34)
• Updates the dose value in the Dose Normalization panel if you are in
Absolute Dose Mode
• Updates the displayed isodose lines, if you are using the Default Isodose
template
Figure 7-34: Rescale warning message
7. Use the Reset button to return the Rx Dose and MU/Fx to the last saved status. If
you have not saved your plan, Monaco sets the values back to the status before
rescale. If you are using the Default Isodose Template, then the Isodoses and
dose value on the Dose Normalization panel are also reset. If you are using a
Custom Isodose Template, neither the isodose display nor the dose value on the
Normalization panel reset.
8. Use the Absolute Dose Mode and select the Default Isodose Template to have
edits to the Rx Dose update both the displayed isodose values and the dose value
on the Normalization panel.
Figure 7-35: Prescription Tab with Reset option
7-38
Plan Review
Practice Exercise – Plan Review Tools

This exercise lets you practice using the plan review tools available in Monaco.
It is assumed that you reviewed the section Plan Review Activity. You can use it as a
reference as you practice with these tools.
• Open Monaco and Select the Patient ID HeadandNeck
• Select and Load the three plans MonPlan1, MonPlan2 and TONSIL
• Change the Isodose Display
• Change the Dose Transparency
• Show/Review Beam Summary
• Show/Hide Structures
• Use Reference Doses, DVH cursors and DVH Statistics
• Create Structure Combinations
• Change to Multiple Plan Display
• Show/Modify a Dose Subtraction
• Show/Modify a Dose Summation
• Show/Modify Dose on a 3D image
Monaco® 7-39
Practice Exercises
Practice Exercises
Practice Exercise 1. General Operation and Navigation
Use the exercises in this section before you come to class, or use it with the
lecture below in the classroom discussion on each area described.
Practice Exercise 1. General Operation and Navigation
This exercise lets you practice the use of the general operation and navigation
tools available in Monaco.
It is assumed that you have reviewed the section General Operation and
Navigation. You can use it as a reference as you practice with these tools.
• Open Monaco and Select the Patient Fusion Prostate

• Load the Studyset CT (no cont)
• Navigate through T/S/C Images
- Use the Color-Coded T-bars
- Use the Scroll Wheel on the Mouse
- Use the Quick Locator tool
- Use the Reference Plane Indicator Toolbar
- Use the Page Up/Page Down keys (transverse images only)
• Adjust the Window and Level
- Use the Mouse
- Use the Window/Level Toolbar
- Use the Window/Level Presets
• Use the Zoom and Pan tools on transverse, sagittal, and coronal image
types
• Turn on a 3D image and practice using the Zoom and Pan tools
- Pan
- Zoom
- Rotate
- Translate
- Reset
• Select V.Fluoro Layout (to show a DRR)
- Practice using MIP
- Show/Hide Grid
- Use the DRR Volume of Interest Tool
Monaco® 8-1
Practice Exercises
Practice Exercises
Practice Exercise 1. General Operation and Navigation (cont.)
• Maximize and Restore a window
• Print Images
- Print a T/S/C View
- Print a DRR
Practice Exercise 2. Fusion, Contouring, and Beam Manipulation
This exercise lets you practice with the fusion and contouring tools available in
Monaco.
It is assumed that you have reviewed the sections Contouring Tools and Fusion
Activity. You can use them as references as you practice the use of these tools.
If you do not have Fusion or do not want to practice using fused images, you can
open the patient, skip the Fusion section and start with the Contouring section.
Fusion
• Open Monaco and Select the Patient Fusion Prostate.
• Load the Studyset CTClean as the Primary and the Studyset MR1 as the
Secondary
• Register the studysets in Fusion

- Use Manual Registration tools
- Use Auto Registration
- Use Point Registration
• Visually verify the Results

- Use the Blender Bar
- Use the Measure Tool
- Use all the Fusion Display Options
• Save the Registration
8-2
Practice Exercises
Practice Exercises
Practice Exercise 2. Fusion, Contouring, and Beam Manipulation (cont.)
Contouring
• Contour all Structures in the Prostate Patient
- Blend from the CT to the MRI during Contouring
- Draw Contours Manually (ex. Prostate)
- Change the Guide Radius
- Use the Drawing Assistant
- Mirror and Rotate a structure
- Edit Contours using Replace and Reshape
- Use the Swap Contour feature
- Use the Contouring by Shapes Tool (ex. Cord)
- Use the Paintbrush Tool (ex. Prostate)
- Use the Copy Structure tool
- Use Copy Superior/Copy Inferior (ex. Cord)
- Use Interpolate (ex. Cord)
- Use Auto Segmentation (ex. Bladder)
- Use Automargin (ex. Create a PTV around the Prostate and SV)
- Edit Structure Properties
- Delete Structures
Beam Manipulation
• Add Beams
• Move Beams
- Using the Keyboard
- Using the Mouse
· Rotate Gantry
· Rotate Collimator
· Move Isocenter
• Copy and Mirror Beams
• Turn Beam Visibility Off and On
• Delete Beams
• Edit Beam Information
- On the Beam Control
Miscellaneous
• Use the Measure Tool
• Add/Edit/Remove Interest Points and Markers
• Save the Contours
Monaco® 8-3
Practice Exercises
Practice Exercises
Practice Exercise 3. Plan Review
This exercise lets you practice with the plan review tools available in Monaco.
It is assumed that you have reviewed the section Plan Review Activity. You can
use it as a reference as you practice the use of these tools.
• Open Monaco and Select the Patient HeadandNeck
• Select and Load the three plans MonPlan1, MonPlan2 and tonsil
8-4
Treatment Couchtop Inclusion
This exercise shows you how to create, import, and remove a treatment couch within
an IMRT or QA plan.
This exercise includes these tasks:
• Import a Treatment Couch Structure
• Edit and Save a Treatment Couch
• Add Couch to a Plan, a Studyset or a Phantom
Task 1. Import a Treatment Couch Structure
You can import a scan of your couchtop just as you import a new patient. You can
import structure sets of your couchtop or create the structure in Monaco.
1. Open the software to automatically show the Patient Selection dialog box.
2. Click Import New Data.
3. Click Browse to navigate to the DICOM IMPORT DATA folder setup for this
training class and select iBeam.
4. Click OK to load the patient into the import utility.

5. Click the down arrow next to the DICOM Patient field and select iBeam.
6. Click RTSS_1. (This couchtop has contours to import.)
7. Select Installation as the Local Installation.
8. Select 0~Clinic as the Local Clinic.
9. Type NewCouch as the Patient ID.

10. Type Training Couch as the Patient Name.
11. Click Add.
12. Select DICOM3.rocboard as the CTtoED Assignment.

13. Click Import.
14. After you complete the Import, click Close to close the DICOM Import dialog
box.
Monaco® 9-1
Task 2. Edit and Save a Treatment Couch
This task shows you how to edit an imported treatment couch and save it to the
Treatment Couch Library.
1. Click Monaco Applications Menu | Open Patient to show the Patient Selection
dialog box.
2. Click the Clinic folder.
3. Select the patient name Training Couch.
4. Click OK.
5. Double-click on the studyset CT1 to load.
6. Click on Foam Core in the structure control.
7. Select the Structure Type Couch.
8. (Optional) Edit the color and density of the structure.
9. Click on Carbon Fiber in the structure control.
10. Select the Structure Type Couch. It is important to designate your structure as
such so that the system recognizes it as a treatment couch structure.
11. (Optional) Edit the color and density of the structure.
12. Click Monaco Application Menu | Treatment Couch | Save as Treatment

Couch.
13. Type the Couch Name Trainingcouch.
14. Click Save. This action saves the couch to the Treatment Couch Library.
15. Click Monaco Application Menu | Close Patient.
9-2
Task 3. Add Couch to a Plan, a Studyset or a Phantom

You can add a treatment couch to a plan or a studyset. If you add the treatment couch
to a studyset where plans already exist, this action does not force dose recalculation.
If you create a QA Plan based on a patient that has a treatment couchtop, the couchtop
does not transfer to the phantom. You must add treatment couches to phantoms in the
same way you add them to plans or studysets.
1. Click Monaco Application Menu | Open Patient.
2. Select Patient Fusion Prostate.

3. Double-click the studyset CT1 to load.
4. Click the Plan Options ribbon.
6. Click Trainingcouch.
NOTE: If treatment couch(s) already exist, click the box next to the Remove
Existing Couch Structures to remove them.
7. Click OK. This loads the couch onto the studyset and shows the Treatment
Couch Position dialog box.
8. (Optional) You can edit the couch position two ways.
(1) Use the dialog box to edit the couch position.
OR
(2) Move the couch with the mouse in any transverse, sagittal, or coronal
view.
9. Click Done. The couch is cropped superiorly and inferiorly and added to the
studyset.
NOTE: Once you click done, you cannot edit the couch again. Delete the
couch structure(s) and import the couch again.
10. (Optional) Edit the treatment couch structures properties just as you would any
structure property.
Monaco® 9-3
3D Planning
Volume II of IV Monaco Training Guide
3D Planning
Features of 3D Plans
Monaco supports static gantry and dynamic gantry 3D delivery options. You can
conform Static 3D beams when you use multi-leaf collimators or custom blocks and
apertures. The Collapsed Cone algorithm lets you to use soft, physical and motorized
wedges. You can use CT studysets and transverse MR studysets to create 3D plans.
When a 3D or 3D Static Arc plan is active, you can:
• create and edit beams

• copy and delete beams
• create and edit blocks/apertures
• define MLC shapes
• select and use wedges
• select and use stereotactic cones
• select and use electron and photon machines
• enter width, length and jaw values
• make asymmetrical and symmetrical adjustments
• rescale dose
• show dose for each beam after calculation in all views
• use the Collapsed Cone or Monte Carlo algorithm based on the treatment aid
Create a 3D Treatment Plan
You create a 3D Treatment plan when you use a stored template.
1. Start Monaco and click the Open Patient button. Monaco shows the Patient
Selection dialog box.
2. Double-click the patient you want to use. Monaco loads the patient into the
Planning Workspace.
Monaco® 1-1
3D Planning
3D Planning
Create a 3D Treatment Plan (cont.)
3. Type a Plan Name and Plan Description. The Description is optional.
Figure 1-1: New Monaco Plan window
4. Select an Anatomical Site to filter plan templates specific to an anatomical site.
5. Select the Template you want to use. This can either be one of the default templates
which come with Monaco, or one that you created and saved.
6. Select the Treatment Unit and beam parameters. You can change all of these during
planning.
7. Click OK. Monaco places the beams and starts the Treatment Plan.
8. Once you start a treatment plan, you can add, edit, and remove contours when you
use the tools on the Contouring Ribbon.
Figure 1-2: Contouring ribbon
1-2
3D Planning
3D Planning
Create a 3D Treatment Plan (cont.)
9. You can set up the couch and treatment aids when you use the tools on the Plan
Options ribbon.
Figure 1-3: Plan Options ribbon
10. You can edit ports and the plan and calculation parameters when you use the tools
on the Planning Ribbon.
Figure 1-4: Planning ribbon
11. The Planning Control has four tabs: Structures, Prescription, Dose Reference
Points, and Beams. You use the Planning Control to manipulate the beams and
treatment aids, set the contour densities, overlap properties, and type the treatment
intent.
Figure 1-5: Structures window
12. See the General Operation and Navigation section for more information on
Ribbons. See the Planning and Workflow section for more information on the
Planning Control. An overview of the Planning Control is given in this section.
Monaco® 1-3
3D Planning
3D Planning
Planning Control – Structures

You can set the display properties of the structures on the Structures tab. You can
override the electron densities of structures when you use the Force ED and Fill ED
options. You must use Forced Electron densities if you make a plan on an MR studyset.
Click the Force ED option if there is an object in the treatment that needs to maintain a
constant mass density. Click the column header to toggle the force density feature on or
off for all of the structures.
Click the Fill ED option to fill a structure with a minimum electron density.
The Relative Electron Density Field is empty until you mark either the Force ED or Fill
ED fields. It then shows the default electron density for the structure. You can type in a
new value. Monaco lets you use a large range of Relative Electron Values. Type the value
which is applicable for the structure you fill. Valid values are:
• Photon Monte Carlo from 0.010 to 15.000
• Electron Monte Carlo from 0.01 to 2.456
• Collapsed Cone from 0.01 to 2.456
Planning Control – Prescription Tab:
You can type new/update prescription information in the Prescription tab. This
information is saved with the plan. You can do the tasks below in the Prescription dialog
box:
• Update the information for the physician’s intent
• Rescale Dose
• Weight the plan’s beams
• Change the active prescription
• Add prescriptions to a plan
• Delete prescriptions from a plan
1-4
3D Planning
3D Planning
Physician’s Intent
In the Physician’s Intent area of the Prescription dialog box (Figure 1-6), you can
update relevant prescription information. If a physician’s intent exists for the plan, all of
the fields are pre-populated. You can edit the fields except for the Rx ID and X, Y, and Z
coordinates as these are non-editable fields. 3D Plans are calculated to a point which is
the Prescribe To point you define. When you edit the Rx Dose (Gy), Monaco updates the
dose distribution so the dose at the Prescribe To point equals the Rx Dose (Gy). The
Actual Dose value updates to reflect this change.
Figure 1-6: Prescription dialog box
1. Select an Rx Site from the drop-down menu. You can make the Rx Sites in the
Settings dialog box.
OR
Type in a value in the Rx Site field. When you tab out of the field, the system shows
a message and asks if you want to save your Rx Site to the list.
Figure 1-7: Rx Sites message
Monaco® 1-5
3D Planning
3D Planning
Physician’s Intent (cont.)
2. Click the drop-down arrow next to the Prescribe To drop-down menu to select an
interest point or volume. The X, Y, Z coordinate information updates when you
select a location.
a. For electrons, you can select the Depth of Beam X.
b. Type the depth in cm that is clinically related for the energy you chose to
calculate.
NOTE: If bolus is assigned to the electron beam, you must think about the bolus
thickness when you select a depth.
3. In the Physician’s Intent, the Rx Dose (Gy) field is the total dose for the Rx Site.
4. If you wish to edit the fractionation scheme of the plan after calculation, Monaco
will calculate and update the new Fractional Dose. Therefore, editing the Rx Dose
or Number of Fractions rescales the plan and updates the Actual Dose value to be
equal to the Rx Dose (Gy). Monaco also updates the monitor units as needed.
Rx ID
If you have a plan with multiple prescriptions, you can change the active prescription
from the Rx ID drop-down.
Figure 1-8: Rx ID drop-down
1-6
3D Planning
3D Planning
Add Rx
Plans may have multiple prescriptions. The prescriptions can have different delivery type,
treatment machines, modality, algorithm, energy, SSD, and isocenter location.
1. If you want to add a prescription to a plan, select Add Rx.
Figure 1-9: Add Rx button
2. The Import Template into Existing Plan window opens.
Figure 1-10: Import Template into Existing Plan
3. Select the plan options.
4. Click OK to import the template into the plan.
Monaco® 1-7
3D Planning
3D Planning
Delete Rx
You can delete prescriptions from a plan if you select Delete Rx.
Figure 1-11: Delete Rx
1. Select the prescription you want to delete in the Rx ID drop-down.
2. Select Delete Rx to delete the prescription.
Rescale Dose
There are seven options for you to choose from in the Rescale Dose drop-down menu
(Figure 1-12). This option is not available during optimization.
Figure: 1-12: Rescale Dose Drop-Down Menu
Name Description
to cover % and Structure field appears

to min dose of structure Structure field appears
to mean dose of structure Structure field appears
to max dose of structure Structure field appears
to dose at point All available points appears
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
1-8
3D Planning
3D Planning
You can reset the dose back to the original value (Figure 1-13).
Figure 1-13: Reset option for a 3D plan
Beam Weighting
You can weight beams by dose or MU in the Prescription dialog box (Figure 1-14). You
can move the slider bar or type in a value to adjust the weights.
Figure: 1-14: Prescription dialog box-Beam Weighting
1. Select a Weight beams by option: Click on the Dose or MU radio button.
2. You can type in a number in the Beam field.
3. You can type in a beam description in the Description field.
4. You can type in a Field ID.
NOTE: When you type in information in Beam, Description, or Field ID, the
beam spreadsheet information updates is real time. Any change you
make is reflected immediately.
5. Use the slider bar or type in a value in order to change the beam weights. You can
edit beam weights before or after calculation. If you want to lock a beam weight,
place a checkmark in the Lock box next to that beam.
Monaco® 1-9
3D Planning
3D Planning
Prescription: Segments Tab
You can add, edit, copy, and delete segments from a beam. The Segments tab shows when
you open the Prescription tab on the Planning Control bar. You can also do the tasks
below from this dialog box:
• Select which beam you want to work with
• Update beam weighting
• Change the field size
Figure 1-15: Segments tab
1. Select the beam you want to use from the Beam drop-down. The beam in this
drop-down is the active beam
2. Select one of the following segment options:
• Add Segments: Lets you add a segment to the current parent beam. The
jaw settings default to the parent beam’s open field size.
o Select Create and Edit Ports to create the segment.
• Copy Segment: Lets you copy an active segment. The default weight of
the new segment is zero. This segment shows last on the segment
order.
• Delete Segment: Lets you delete an active segment. When a segment is

deleted, the dose is spread equally to current unlocked segment weights.
1-10
3D Planning
3D Planning
Prescription: Segments Tab (cont.)
• Edit Segment: Click this button to make changes to a segment. The

Create/Edit Ports dialog box opens if you select an active segment. The
BEV updates with information from the active segment.
3. You can select to weight the segments by one of the following methods:
• Equal Weights: Distributes the weight of the unlocked beams equally.

The button is disabled when all segments except one are locked.
• %: Defines the percentage of MU that is assigned to a segment. The sum

of the segments weights is equal to 100% of the beam MU.
o Use the slider bar to adjust the beam weights. Move the slider bar
to the left to decrease the percentage. Move the slider bar to the
right to increase the percentage.
o Type a percentage in the number field to the right of the slider

bars.
NOTE: When you change the weight of a segment, you need to recalculate and
rescale the plan to get back to the original scaling.
Figure 1-16: Percent Weight sliderbar
• MU/Fx: Shows the Monitor Units/Fraction for the segment. You cannot
edit the field.
Figure 1-17: MU/Fx
Monaco® 1-11
3D Planning
3D Planning
• Lock: Click the check box to prevent an automatic update of the beam
weight. Remove the checkmark in the check box to let the beam weight
update automatically. You can continue to edit a locked weight and MU.
The default is not checked.
Figure 1-18: Lock Weights check box
4. The Segment column lists the segments and identifies the number of segments.
Figure 1-19: Segment Column
5. You can view the Segments Area (cm2). This shows the size of the segment area in
cm2.
Figure 1-20: Segment Area
1-12
3D Planning
3D Planning
6. Width1(cm) and Width2 (cm): Shows the left- and right-width values in
centimeters. These fields may be editable based on machine characteristics.
7. Length1 (cm) and Length2 (cm): Shows the upper- and lower-width values in
centimeters. These values may be editable based on machine characteristics.
Figure 1-21: Segment Width Values
8. Length1 (cm) and Length2 (cm): Shows the upper- and lower-width values in
centimeters. You may edit the values based on machine characteristics.
Figure 1-22: Segment Length Values
Segment Light Field Projection
You can see a light field projection of a beam or beams’ segments for segmented IMRT
and arc-based plans in the 3D view.
1. Use the 3D transparency slider bar on the Structures tab to set the External
structure’s transparency to 0%.
2. Turn on the beam or beams in the Beam Visibility dialog box you want to see in the
3D view.
3. Select the beam and click on the segment on the Segments tab to see the segment
light field projection in the 3D view.
Monaco® 1-13
3D Planning
3D Planning
Planning Control – Dose Reference Points

Use this tab to place, edit, or review Dose Reference Points for Monaco plans. Dose
Reference Points are user-defined points where you can view the dose. There is one DRP
for each beam. Dose Reference Points are user-defined locations. Monaco reports on
individual beam dose contribution at these points. Each beam contains only one DRP.
But, multiple beams may share the same DRP location. Monaco saves DRP parameters
with the plan.
Every new beam automatically has a dose reference point which defaults to the beam's
isocenter. You may edit DRP locations or add new dose reference points, but only in the
Planning activity. Monaco does not use dose reference points when calculating dose. You
may view thier locations in the Planning and Plan Review activities.
Monaco calculates dose at each dose reference point during the final dose calculation. If
you move a dose reference point, the plan dose remains valid, but Monaco recalculates
the beam dose, total dose, and parameters for each dose reference point.
Planning Control – Beams Tab

Use this tab to manipulate the beams. The Beams contains sub-tabs: General, Geometry,
Treatment Aids and Setup Beams. Use the General tab to add, remove, and edit beams.
You set the beam energy and isocenter on this tab.
Figure 1-23: Planning Control – Beams tab
Use the Geometry tab to add new beams to a plan. You can also edit the field setup and
dimensions from this tab.
Use the Setup Beams tab to set up Verification beams. You add the beams and edit their
field size, location, and setup parameters on this tab.
1-14
3D Planning
3D Planning
Planning Control – Treatment Aids

You can add, delete, or edit beams and treatment aids from the Treatment Aids button in
the Beams tab when you select Planning | Beams | Treatment Aids (Figure 1-24). You
can also see if the beam includes a Port or MLC. The headings are non-editable on the
treatment aids sheet. The editable treatment aids available on this tab include:
• Beam Number
• Description
• Wedge
• Applicator ID (Stereo and Electron Cones)
• Bolus
• Couch
Figure 1-24: Treatment Aids section of Beams tab
Wedges
You can click on the drop-down arrow in the Wedge ID column to select a wedge for a
beam. This field shows when a SIM plan, 3D and 3D Static Arc delivery modes are in use.
When you select a wedge in this column, the Angle and Orient columns populate with
the information associated with the wedge selected. The Angle column shows the angle of
the wedge. The Orient column shows a wedge’s directional image: in, out, left or right.
You can also view the wedge parameters in Settings if you have physics rights.
Monaco® 1-15
3D Planning
3D Planning
Port /MLC
These columns only appear for Sim and 3D treatment plans. The fields are checked if a
port or MLC are present on the beam. You cannot edit these fields.
Applicator ID
Click the drop-down arrow next to the beam to select an applicator ID in this column.
This field shows the cones in the drop-down list if the machine is a photon or electron
machine. This option is available for SIM plans and 3D and 3D Static Arc delivery modes.
Stereotactic applicators are not available for SIM plans.
The figure below shows an example of the applicator menu for Stereotactic Cones. Refer
to the Stereotactic Planning section of the Training Guide for more information.
Figure 1-25: Example of the Stereotactic Cone Applicator ID menu
Couch
You can place a checkmark in this column to add the couch to a beam if you imported a
couchtop into the plan.
1-16
3D Planning
3D Planning
Bolus
Once you create a bolus structure, you can assign a bolus to a beam. The calculation
engine does not take into account any Bolus structures unless you assign them on the
Treatment Aids tab of the Beam Control to the beams. See the Contouring section of the
Monaco Sim guide for more information on generating a bolus.
If the bolus is imported with anything other than Electron Density, the Density field is
blank for that structure. You must type a value on the Structures Control before the Start
Optimization option becomes available.
1. Click the Treatment Aids sub-tab on the Beams Control.
2. Click the drop-down arrow in the Bolus column for any beam.
3. Select the bolus in the Treatment Aids tab. This applies the bolus to all of the beams
for IMRT plans. For 3D plans, you can add the bolus on per beam basis. The SBD
(cm) column shows the Source to Bolus Distance when you select the bolus for the
beams.
4. (Optional): You can print the Beam Summary report to see the bolus information.
Monaco® 1-17
Planning and Workflow: Workflow Diagram, Contouring, Beam and Delivery Setup
Planning and Workflow: Workflow Diagram, Contouring,

Overview
Monaco gives you a unique approach to optimization that uses the latest
advancements in IMRT and VMAT planning. They are:
• Biological and dose-based cost functions

• Constrained fluence
• Pareto and aperture optimization
• A photon Monte Carlo dose engine integrated into the optimization
process
As an alternative to traditional dose-based approaches in IMRT optimization,

Monaco implements an intuitive biological model that takes into account the
response of tissues to dose per fraction and its particular volume effect.
When you describe the tissue-specific increase in dose tolerance with a reduction
of irradiated volume, this biological volume effect can define the shape of the
optimum dose distribution in normal tissues. You can define each tissue with its
particular volume effect. Monaco does not require you to determine weight
factors for each structure. Instead, Monaco utilizes a unique time and effort-
saving approach where it determines the weight factors for you, internally based
on your prescription.
Clinicians are able to determine prescriptions when they use not only these
biological models, but also standard dose-based models such as maximum dose,
overdose DVH, and underdose DVH.
You can plan in Monaco with any one of these five types of delivery methods:
• Step and shoot IMRT

• dMLC (Dynamic MLC)
• VMAT (Volumetric Modulated Arc Therapy)
• Dynamic Conformal Arcs
• Conformal RT
Monaco® 2-1

Overview (cont.)
Key features include:
• A comprehensive set of contouring and beam manipulation tools

• Six delivery modes: Step and Shoot IMRT, dMLC, VMAT, mArc
Dynamic Conformal Arcs and Conformal RT
• Enhanced voxel definition controls - structure layering and properties
• A spectrum of biological and dose-based cost functions
• Two optimization modes: Constrained Optimization (Normal Tissue
Priority) and Pareto mode (Target Volume Priority)
• Multicriterial optimization to tighten constraints, if feasible, during
optimization
• Several useful plan analysis tools, like constraint Sensitivities, to guide
prescription decision-making
• Bias Dose Planning
• XVMC Monte Carlo dose engine or an advanced Pencil Beam integrated
into the optimization process
When you complete this section, please go to the Practice Exercise section and
complete the exercises ‘Editing IMRT Prescription Elements’ and ‘Optimization
and Plan Evaluation’.
2-2

Monaco Workflow
Contour all Targets and OARs Fuse Images prior to Contouring*
Select Delivery Mode and Add an IMRT or 3D template
Edit/Add/Delete Beams/Sequences
No
Is the Template acceptable?
Yes
Enter/Edit Prescription
Enter/Edit Calculation Properties and

Sequencing Parameters
Do you want to
No optimize each stage?
(DCAT has only one stage if SSO is off)
Yes
Batch Optimization Optimize Fluence (Stage 1)
Edit Prescription or Parameters

Is the Optimized Plan No
Acceptable? If edits are to
any other
prescription
Yes element or
parameter
Optimize Segment Shapes (Stage 2)
If edits are to
Isoconstraints or
Multicriterial
Edit Prescription or Parameters

Is the Segmented No
Plan Acceptable?
Yes
Saving acceptable plan
Finished
Planning?
Plan Review Perform QA EXIT
Figure 2-1: Monaco Workflow
Monaco® 2-3

Contouring and Beam Manipulation

Contour all Targets and Organs at Risk (OARs)
Contouring is a very important part of the planning process. Field sizes are
smaller and more conformal in modulated plans than in traditional 3D plans, so
creating contours that actually represent the volume of the structure is
imperative. You should note that any structure for which you intend to deliver
dose or restrict dose in the prescription, you must contour and add to the
prescription.
Dose transition volumes are not required as Monaco lets you easily create dose
transition regions through use of specific user-definable properties and
parameters.
3D Auto-Margin Generation
You can also use 3D auto-margins to create non-variable or variable margins
around structures, such as creating a CTV or PTV around a GTV. If you have
more than one target, you should create a 3D auto-margin that encompasses all
targets. The structure margin is not used in the prescription. It is instead used for
isocenter placement.
Consideration of Contours outside the Patient

You may want to make a structure outside the patient contour. Use the Couch
and Bolus structure types for the structures external to the patient. For example,
you may want to contour a mask, make a bolus or account for attenuation of the
table. To do this, select Couch or Bolus in the Type drop-down list on the
Structures tab in the Planning Control. Then place a check mark by
Couch/Bolus on the Beams | Treatment Aids tab so you can take the structure
into account for the optimization and dose calculation.
For a structure in the IMRT Constraints tab, use the Do Not Store Dose option
in the Structure Optimization Properties. This only takes the attenuation into
account which in turn saves on calculation time. This requires that you use the
structure type of Internal for the structure. A constraint for the structure is not
necessary.
NOTES: (1) Refer to the Contouring Tools section for more information
about contouring tools.
2-4

Contouring and Beam Manipulation (cont.)
Beam Manipulation Tools

Beams/sequences, machine energies, and calculation algorithms are saved with
templates in Monaco. In Planning Activity, you can add/delete beams or edit
beam arrangements to suit any patient’s specific requirements. In the Planning
activity, you can add/delete beams or sequences using the Beam Control. Monaco
supports coplanar and non-coplanar beam arrangements.
It is not necessary to set a specific field size before planning. During optimization,
Monaco automatically defines the field sizes appropriately based on the target(s)
defined.
NOTE: Refer to the Planning Tools or IMRT Tools sections for more
information about beam manipulation tools.
Monaco® 2-5

Using Templates
After you complete your contouring, you start your plan. Select a template.
Monaco makes use of template-based planning for workflow efficiency. The
system provides basic DEFAULT templates. But, you can create and save your
own templates at any time.
Information saved in a template includes, but is not limited to the ones below:
• Treatment Machine Information

• Calculation Algorithm
• Calculation Parameters
• Structure Layering Order
• Individual Structure Properties
• Global Structure Parameters
• Prescription Information
• Segment Shape Properties
• Delivery Mode
• Anatomical Site
Start a Plan Using a Template
1. While in the Planning Activity, click the Plans button on the toolbar.
Or, right-click on a studyset in the Workspace Control and select New
Monaco Plan. Monaco shows the New Monaco Plan dialog box (Figure 2-
2).
2-6

Using Templates
Start a Plan Using a Template (cont.)
Figure 2-2: New Monaco Plan Template dialog box
Monaco® 2-7

Using Templates
2. Type in a Plan Name. Monaco does not allow spaces in the plan name.
3. Type in a Plan Description.
4. Select a Delivery Mode.
5. Select an Anatomical Site. When you select a delivery mode and

anatomical site, the related templates show in the Select template to
import window.
6. Select the template you want to import from the list. The description
information includes the Rx Site, Rx Dose, and number of beams.
7. Click on the Head First or Feet First radio button to select the treatment
orientation. The scan orientation information appears above. If you change
the treatment orientation so that it differs from the scan orientation,
Monaco shows a message for you to verify the information.
8. Select a Port option.
• Import Beams Only:

• Retain Template Beam Shapes:
• Auto-conform Ports:
2-8

Using Templates
9. Select the template to apply to your patient.
10. Number of Beams is a non-editable field that shows the number of beams
that are in the selected template.
11. Select the isocenter location where you want to apply the template.
Monaco automatically populates the X, Y and Z coordinates. You can also
type in X, Y and Z coordinates directly as the isocenter location. If the
template has multiple isocenters, only the first isocenter appears. However,
multiple isocenters are applied as defined by the template.
NOTE: The system saves isocenter coordinates as relative coordinate

values. It does not save them according to a "center of structure"
assigned during beam creation.
12. Monaco supports plans with multiple isocenters. You can save templates
with multiple isocenters. When you select a template that has multiple
isocenters, you have the ability to reset all the beams to a common isocenter
when you place a checkmark next to Use Common Isocenter. Monaco
automatically resets all beams to the isocenter of beam number one.
13. Select the treatment machine you want to use for this patient’s plan. You
can change the machines and energies when you import the template.
Monaco® 2-9

Using Templates
14. Select the Delivery Mode you plan to use. More detail on VMAT and
Dynamic Conformal is discussed after the Delivery Mode Table below:
Table 2-1 Delivery Mode Table
Gantry Motion Gantry MLC Motion Beam

Delivery Method while beam on Speed while beam on Intensity Dose Rate
Step and Shoot Static Constant Static Modulated Constant
Conformal RT (non-IMRT) Static Constant Static Uniform Constant
dMLC Static Constant Dynamic Modulated Variable
Constant or
VMAT Dynamic Variable Dynamic Modulated Variable
Constant or
Dynamic Conformal Arc Dynamic Variable Dynamic Uniform Variable
mArc Dynamic Variable Static Modulated Variable
2-10

Using Templates
VMAT
VMAT is a novel form of rotational IMRT where the MLC and gantry move
during radiating arc segments. The system uses variable gantry speed and
variable dose rates to achieve variable MU per degree. Compared with IMRT, the
potential advantages of VMAT include improved dose conformity, improved
normal tissue sparing and a reduction in treatment time. Planning with single
arcs and multiple arcs are supported and multiple arcs are optimized
simultaneously.
The Monaco VMAT sequencer is a sweep sequencer for fluence profiles, similar
to sliding window sequencers. The basic paradigm of the sweep sequencer is that
the leaves move from their start to their end position in a continuous,
unidirectional manner. By moving the leaves across the field from one side to the
other, and varying the leaf speeds, and thereby the gaps between opposing leaves,
the system modulates the intensity of the delivered fluence. Changing the leaf gap
is accomplished by either accelerating the leading leaf (more fluence), or the
trailing leaf (less fluence). At least one leaf moves at maximum velocity at any
given time to provide for the shortest possible delivery time.
The Monte Carlo dose engine allows for continuous arc calculation instead of
being limited to dose approximations with discrete gantry positions.
Dynamic Conformal Arcs

When delivering this type of rotational arc therapy, the gantry rotates during
treatment. The MLC conforms to the target and avoids any avoidance structures,
but the MLCs do not modulate the intensity.
Monaco® 2-11

Using Templates (cont.)
Creating a Customized Template

To customize your work environment, you have to create your own templates.
You can edit any existing template or start with the provided generic templates.
The software comes with default templates:
DEFAULT Step and Shoot, single beam

DEFAULTSNS Step and Shoot, 7 beams
DEFAULTCONFRT Conformal RT, single beam
DEFAULTVMAT VMAT, single 360 deg arc
VMATTraining VMAT, single 360 deg arc
DEFAULTdMLC dMLC, 7 beams
DEFAULTSTEREO DCAT, 4 beams
ConeLtTrigem 3D Static Arc, 7 beams
DEFAULT3DArc 3D Static Arc, 2 beams
StereoCones 3D Static Arc, 5 beams
DEFAULT3D1beam 3D, 1 beam
DEFAULT3D4beam 3D, 4 beams
These templates have two “generic” structures in the prescription, PTV and
SKIN. You must select the isocenter(s) and the machine to use with these
templates. Whenever you create a new template, you can save it when you use
File | Save Template As.
NOTE: Only users with Physics rights can overwrite an existing SIM or New
Monaco Plan template. All other users can save the template with a
new name.
2-12

Using Templates (cont.)
Deleting a Template
You cannot delete templates from within the software. If you would like to delete
a template and are not familiar with how to locate files when you use Windows
Explorer, you should call customer support for assistance. If you would like to
delete the templates yourself, they are located in the
FocalData\MonacoTemplates folder. (The location of the FocalData folder varies
from site to site. Contact your administrator if you do not know the location of
this folder).
Monaco® 2-13

Beam Tools
To start a new plan, right-click on a studyset in the Patient Workspace and select
New Monaco Plan. From here, you are able to select plan templates. After you
select a template, you can begin planning. To add, copy, or delete beams or
VMAT sequences, you can select the Tools or the Beam Control option from the
Beam Control in the Planning Activity.
Planning Ribbon – Beam Tools
Create, Duplicate, or Oppose Active Beam
Close Plan Delete Plan

Delete Active Beam
Edit Active Beam

Create new Monaco or Sim Plan
Import Template into Existing Plan
Figure 2-3: Planning Ribbon – Beam Tools
When you use the tools in (Figure 2-3), you can do these tasks:
• Start a New Plan – This option lets you create a new Sim or Monaco
plan.
• Close Plan – This option closes the currently loaded plan.
• Delete Plan – This option deletes the currently loaded plan.
• Delete QA Plan – This option deletes the currently loaded Monaco QA

plan.
• Add a New Beam – This option creates a new beam.
• Copy Beam – This option makes a copy of the active beam.
2-14

Beam Tools
Planning Ribbon – Beam Tools (cont.)
• Copy Beam Opposing – This option makes a mirror image copy of the
active beam.
• Delete Beam – This option deletes the active beam.
• Edit Beam – This option lets you move the beam with your mouse.
Monaco® 2-15

Beam Control
The four beam control tabs are:
• General
• Geometry
• Treatment Aids
• Setup Beams
You can add, edit, or delete beam\sequences as well as modify beam

properties and add setup beams. When you load a template, the beams from
the template populate in this dialog box. You can edit the loaded beams in
the Beam Control. If you want to switch the plan from a beam plan to a
sequence plan, the system groups all the like beams in the Beam Control
dialog box. You must re-enter them. This beam control is available in the
Planning activity.
NOTE: The beam control updates in real time. Any change you make is
reflected immediately. We recommend that you save your plan before
you make any updates to avoid loss of data.
2-16

Beam Control | General Tab
In the Beam Control | General tab, you can add, edit, and delete beams. You can
also edit the beam properties below in the General Tab:
• Beam
• Description
• Field ID
• Delivery
• Machine ID
Figure 2-4: Beam Control
Monaco® 2-17

Beam Control | General Tab (cont.)
Add/Edit/Delete Beams in Beam Control

1. Click Workspace | Controls | Beams.
2. To add a new beam or sequence, left click the Add New Beam button.
OR
Left-click on the words <click to add a new row>.
3. Type a unique Description for each beam.
4. Type a unique Field ID (up to five characters) that is accepted in MOSAIQ

for each beam.
5. Select a Machine, if applicable.
6. Select the Isocenter Location for the each beam. Monaco shows the
Isocenter Coordinates each beam.
Copy a Beam/Sequence
1. Left-click to highlight the beam/sequence you want to copy.
2. Click the Duplicate Beam button to show the copied

beam/sequence.
2-18

Beam Control for IMRT Plans – General Tab

Delete a Beam/Sequence
1. Left-click to highlight the beam/sequence you want to delete.
2. Click the Delete Beam button to delete the selected beam/sequence.
Renumber Beams/Sequences
1. Left-click to highlight the beam/sequence you want to renumber.
2. Type the new number in the Beam column for the current beam.
NOTE: If you type a beam number that is used in the plan or another
prescription, the 2 beam numbers switch.
Reorder Beams/Sequences
1. Left-click to highlight the beam/sequence you want to move.
2. Click the Move Beam Up OR the Move Beam Down button to

reorder the beams on the list.
Number Beams/Sequences Consecutively

You can reorder the beams/sequences in the list when you add or remove a
beam/sequence.
1. Add/remove a beam/sequence in the beam control list.
2. Left-click on the Beam heading. Monaco renumbers the beams in the list
and shows them in ascending order. The beams/sequences’ orders in the
Setup Beams tab are also updated. The setup beam number defaults to the
next consecutive number after the treatment beams.
Monaco® 2-19

Beam Control|General Tab (cont.)
Link Machine ID and/or Isocenter Location

You can plan with multiple isocenters and machines. You can save templates
with multiple isocenters and machines. You have the ability to reset all the beams
to a common isocenter. Restore the link above the Isocenter Location
column on the Beam Control dialog box, then select the desired isocenter
location for one of the beams in the Isocenter Location column. The remaining
beams’ isocenter locations update to match the isocenter location you selected.
You can assign different isocenter locations to each beam or a group of beams.
Break the link in the Isocenter Location column to modify the desired beam
isocenter locations. You can restore the link when you have set the desired
location for each beam in the list. The beams with a common isocenter link
(Figure 2-5) updates when you change the isocenter location of any beam in that
group.
Figure 2-5: Beam Control - Common Isocenter
When you check the Group Only Visible Beams box, Monaco links all the beams
that have the Visible field checked.
2-20

Beam Control |General Tab Link Machine ID and/or Isocenter Location

(cont.)
You can reset the beams to a common machine. Restore the link above the
Machine ID column on the Beam Control dialog box, then select the desired
machine ID for one of the beams in the Machine ID column. The remaining
beams’ machines update to match the machine ID you selected. You can assign
different machine IDs to each beam or a group of beams. Break the link in
the Machine ID column to modify the desired beam machine ID. You can restore
the link when you set the desired machine for each beam in the list (Figure 2-6).
Figure: 2-6: Machine ID Link
Monaco® 2-21

Beam Control |Geometry Tab

In the Beam Control for IMRT Plans-Geometry tab, you can edit the Beam,
Description, Couch, Collimator, Gantry, Arc and/or Increment values as
needed. Arc and Increment only apply to VMAT sequences.
Figure 2-7: Beam Control |Geometry
NOTE: See Arc Planning Terminology for more information about the
definition of terms and further information about sequence setup.
You can also set the Field (field size) to:
• [Auto]: The optimizer determines the field size.
• Fixed: You can type in the beam/sequence field size.
• Structure: Ex: Bladder: You can auto-conform with a margin to the

structure you select in the Field drop-down menu.
NOTE: The Asym column is only available when you select Fixed or
Structure. Uncheck the box to make the field jaws symmetric. The
defined field size is sent to the optimizer to define the maximum
extents.
2-22

Beam Control|Geometry Tab (cont.)
Split Beams
When a machine’s carriage restrictions are violated, the beams (parent beams)
could split after segmentation (Figure 2-8). These split beams (child beams) are
listed on the beam control below the parent beam. The beam names are DICOM
exported as B1S1, B1S2, etc.
Figure 2-8: Split Beams
Left-click on the Delete Parent Beams button (Figure 2-9) to remove the parent
beams. When you delete the parent beams, the optimizer resets and any changes
made to the plan restarts the plan from the beginning.
NOTE: A child beam’s field size is automatically set to Fixed. If you

recalculate the plan, the field size does not change.
Monaco® 2-23

Beam Control|Geometry Tab
Split Beams (cont.)
Figure 2-9: Delete Parent Beams
2-24

Beam Control |Geometry Tab (cont.)
Fixed Jaws
You can set fixed jaw settings for beams to avoid a machine’s carriage
restrictions. When you select [Fixed], you can define the jaws’ width.
1. Left-click in the Field column and select [Fixed] in the drop-down menu. If
you want to select [Fixed] for individual beams, remember to break the link
on the Field column.
NOTE: Since the beam control updates in real time, you can view the
jaw settings as you make changes in any of the T/S/C or BEV
views.
2. You can edit the beams’ jaw width and length and uncheck the Asym box if
desired. The system maintains the current isocenter and moves the field
borders to the symmetric field size shown in the Geometry tab on the beam
control.
Figure 2-10: Fixed Jaws
Monaco® 2-25

Beam Control|Geometry Tab
Fixed Jaws (cont.)
Monaco assigns a dose reference point (DRP) to all Fixed Jaws and Split
Fields. The dose reference point (DRP) for each beam/arc is DICOM
exported along with these:
• SSD to DRP
• Physical Depth
• Radiological Depth
• Beam Dose
2-26

Beam Control |Treatment Aids Tab

Planning Control – Treatment Aids
You can add, delete, or edit beams and treatment aids from the Treatment Aids
button in the Beams tab when you select: Planning | Beams | Treatment Aids
(Figure 2-11). You can also see if the beam includes a Port or MLC. The headings
are non-editable on the treatment aids sheet. The editable treatment aids
available on this tab include:
• Beam Number
• Description
• Wedge
• Applicator ID (Stereo and Electron Cones)
• Bolus
• Couch
Figure 2-11: Treatment Aids section of Beams tab
Monaco® 2-27

Planning Control – Treatment Aids (cont.)
Wedges
You can click on the drop-down arrow in the Wedge ID column to select a wedge
for a beam. This field appears when a SIM plan, 3D and 3D Static Arc delivery
modes are in use. When you select a wedge in this column, the Angle and Orient
columns populate with the information associated with the wedge selected. The
Angle column shows the angle of the wedge. When you change the angle for an
Elekta Motorized Wedge, the dose automatically updates. Therefore,
recalculation is not required. The Orient column shows a wedge’s directional
image: in, out, left or right. You can also view the wedge parameters in Settings if
you have physics rights.
Figure 2-12: Beams tab shows Wedge ID, Angle, and Orientation
Port
This field shows a check mark if the beam contains a Port. This field shows when
a SIM plan is in use. This field shows when 3D and 3D Static Arc delivery
modes are in use.
MLC
This field shows a check mark if the beam contains an MLC. This field shows
when a SIM plan is in use. This field shows when 3D and 3D Static Arc delivery
modes are in use.
2-28

Applicator ID
Click on the drop-down arrow next to the beam to select an applicator ID in this
column. This field shows the cones in the drop-down list if the machine is a
photon or electron machine. This option is available for SIM plans and 3D and
3D Static Arc delivery modes. Stereotactic applicators are not available for SIM
plans.
The figure below shows an example of the applicator menu for Stereotactic
Cones. Refer to the Stereotactic Planning section of the Training Guide for more
information.
Figure 2-13: Example of the Stereotactic Cone Applicator ID menu
Bolus
You can select a bolus from the drop-down for a beam in this column. For 3D
and QA plans, you can select a bolus per beam. For IMRT plans, you can select
bolus for all or none of the beams. When you select a bolus, the SBD column
populates with the skin-to-bolus distance for that beam.
Monaco® 2-29

Couch
You can place a place a checkmark in this column to add the couch to a beam
when you import a couchtop into the plan.
Add Bolus to Beams

You can assign bolus to beams in the General tab on the beam spreadsheet for
dose calculation. For IMRT plans, you must add bolus to all of the beams or
none. If you import the bolus with anything other than Electron Density, the
Density field is blank for that structure. You must type in a value before the Start
Optimization option becomes available.
1. Click the Beams tab in the Planning Control.
2. Click the drop-down arrow in the Bolus column for any beam.
3. Click the drop-down arrow to bolus in the Treatment Aids tab. This applies
the bolus to all of the beams for IMRT plans. For 3D plans, you can add the
bolus on per beam basis. The SBD (cm) column shows the Source to Bolus
Distance when you select the bolus for the beams.
4. (Optional): You can print the Beam Summary report to see the bolus
information.
2-30

Beam Control |Setup Beams Tab

In the Beam Control for IMRT plans, you can add setup static beams or arcs to
your plan in the Setup Beams tab (Figure 2-14). You can add, edit, or delete the
setup beam/sequences as well as modify the beam/sequence’s properties the same
as the treatment beams. The setup beams\sequences are DICOM exported as
SETUP.
Figure: 2-14: Beam Control for IMRT Plans-Setup Beams Tab
Edit Beam Options Using Mouse
You can use the mouse to edit specific beam options. You can click on Edit Beam
button on the Planning tab to make edits with the mouse. As you edit any of
the areas in the list below, the beam information updates in Beam Control.
 Rotate the gantry on the transverse view and sagittal view (if there is a
couch kick)
 Move isocenter position on SPVs and BEV
 Set field size and rotate collimator on BEV
 Set the start/end point for an arc
Monaco® 2-31

Edit Beam Options Using Mouse (cont.)
Print a Beam Control Report

In Planning Activity, complete these steps.
1. Click Beam Summary on the Output tab.
3. Click OK to show the Beam Summary Report.
In Plan Review Activity, complete these steps.
1. Click Beam Summary on the Planning Options tab.
2. Click the Print button in the lower-right corner of the dialog box to show a
Report Comment dialog box.
4. Click OK to show the Beam Summary Report.
2-32

Definition of Terms as They Apply to Arc Planning
Figure 2-15: Beam Control for Arc Planning dialog box
Sequence
A sequence is a single defined arc used for arc treatments. You can plan with full
or partial arc sequences (Figures 2-16 and 2-17), or with multiple coplanar or
non-coplanar sequences. (For detailed information about Beam Control, refer to
Section 6: Planning and Workflow: Workflow Diagram, Contouring, Beam, and
Delivery Setup.)
Direction
You can select the arc rotation’s starting direction on the Dir column in the arc
planning beam control. You can select CW or CCW. The default is CW.
Monaco® 2-33

Definition of Terms as They Apply to Arc Planning (cont.)
Sequence (cont.)
Figure 2-16:Full Arc Sequence Figure 2-17: Partial Arc Sequence
Gantry
The Gantry setting on the Geometry tab in the Beam Control refers to the
starting position for the sequence when planning arcs. When setting up the initial
gantry angle for a sequence, remember that treatment delivery starts in the
direction you defined in the Dir column.
Arc
The Arc setting in Geometry in the Beam Control is the total arc rotation you
desire for the sequence. For example, you can usually treat prostate plans with a
360 degree arc.
Collimator
The typical Collimator setting in Geometry in the Beam Control for arc beams is
zero (0). You can adjust this value to meet planning guidelines used in your
clinic, and to improve quality of overall treatment plan and delivery.
2-34

Increment
The Increment setting on the Geometry tab in the Beam Control dialog box
controls the number of generated static gantry positions or sectors. Using an
increment that is too large, creates fewer sectors which can produce poor quality
plans and increase treatment time. Using an increment that is too small, gives
you more sectors, but increases planning time and may not significantly improve
plan quality. This is consistent with having too few or too many beams in a
standard IMRT plan.
One method to find a reasonable increment is the “Rule of 3”. This means you
add three (3) to the number of static beams you would have used to treat this
patient. For example, if you used nine (9) beams to plan a standard IMRT plan,
consider creating 12 sectors (9+3) for VMAT. 360 deg arc/12sectors = increment
of 30.
Increment ↑ Plan Quality ↓ Treatment Time ↑
Monaco® 2-35

Sector
Prior to stage one optimization, the system divides a sequence into sectors you
use to simulate the arc during stage one optimization. You determine the number
of sectors when you divide the total arc degree by the increment. For example, a
360 deg arc with a 30 deg increment equals 12 “static” sectors to optimize. So, on
the console, you would see 12 rays created before optimization (Figure 2-18).
Figure 2-18: Console showing ray (sector) creation
Figure 2-19 shows a total arc of 360 degrees with a starting angle of 180 degrees
and an increment of 30. The system creates sectors in 30 degree increments
starting 15 degrees in front of each angle and ending 15 degrees after each angle.
In this example, the first sector starts at 165 deg and ends at 195 deg. The
treatment starts at 180, so treatment of the first sector is split. Fluence maps
generated during stage-one are computed at the increment gantry angles. The
fluence profiles extend from midline to midline of consecutive sectors.
2-36

Sector (cont.)
Figure 2-19 Full 360 Deg Arc
Figure 2-20 shows a partial 300 degree arc with a starting angle of 195 degrees
and a 33.3 increment. So, 300 / 33.3=9 sectors. For partial arcs, the first and last
sectors are only half the size as the rest of the sectors. So, 10 sectors appear below
to represent this.
Figure 2-20: Partial 300 Deg Arc
Monaco® 2-37

Sector (cont.)
The system generates fluence maps during stage-one and computes them at the
increment gantry angles.
We recommend that you plan with an even number of sectors to avoid

asymmetry of the final dose distribution. Eight to fourteen (8-14) sectors for
VMAT seem to be a reasonable range for good plan quality, depending on the
defined arc angle.
Sweep Sequencer
The basic paradigm of a sweeping leaf sequencer is that the leaves move from
their start position to their end position in a continuous, unidirectional manner.
When you vary the leaf gap, the system modulates the intensity of the delivered
fluence. Beginning with the first sector, the leaves move to the left side of the
BEV, then change direction, moving to the right side of the BEV. The leaf
movement continues to alternate between sectors. Typically, both ends of the
sweep have a small window of leaves open on one side or the other. The
minimum width of these end segments is hard coded at 5mm.
2-38

Control Point (VMAT only)

The treatment machine uses control point as starting and ending points for
movement of the MLCs. Certain Sequencing Parameters directly affect the
number of control points generated for a plan. You can see the number of control
points generated for a plan in the Console after stage-two optimization is
complete. For reasonable treatment time and plan quality, you should look for a
number of control points in the range of 75-150.
Arc Segment (VMAT only)

The system creates the arc segments during stage two optimization. Arc size and
number of monitor units vary from one arc segment to the next, but the dose rate
remains constant within each arc segment.
When you select Start on the Fluence Toolbar (Figure 2-21), the start angle of an
arc segment is represented by a solid line and the end angle of the arc segment is
represented by a dashed line (Figure 2-22). When you select End, the start angle
is dashed and the end angle is solid.
Figure 2-21: Fluence Toolbar
Monaco® 2-39

Arc Segment (VMAT only) (cont.)
Figure 2-22: Arc Segment
You can recognize arc segments on a BEV as having a uniform fluence (Figure 2-
23). Uniform color varies from segment to segment based on the range of MU for
the plan.
Figure: 2-23: BEV of Arc Segment
2-40

Dynamic Segments with Static Gantry (VMAT only)

Dynamic segments at static gantry angles (Figure 2-24) are occasionally
generated for arc plans if the number of degrees per control point for an arc
segment is less than two. This type of segment is represented by a single solid line
on the transverse view and a non-uniform fluence in the BEV (Figure 2-25).
Figure 2-24: Dynamic Segment with Static Gantry
Figure 2-25: BEV of Dynamic Segment with Static Gantry
Monaco® 2-41
3D Lung Case
3D Lung Case
Overview
This practice exercise builds on the knowledge you gained when you complete
the Fusion, Contouring, Beam, and Port Manipulation lessons. This exercise
reinforces what you previously learned and shows you how to create 3D plans in
Monaco.
This exercise and the information provided is subject to the disclaimer included
in the Overview section of Volume 1, Section 1.
NOTE: The patient used in this exercise is only available to you in the
Training database. The default templates given are only available to
get you started. However, you could follow these steps for almost any
patient and complete a 3D plan.
When you complete this exercise, you should understand the concepts below and
be able to complete the various tasks without additional supervision.
• Select a patient and open a studyset

• Contour structures
• Use Auto Margin to expand a structure
• Add an interest point in Monaco
• Set the 3D calculation matrix
• Create a new beam
• Add a treatment aid (port)
• Mirror a beam
• Edit a port
• Save a plan
• Normalize the dose display and review isodoses
• Review the plan
Monaco 3-1
3D Lung Case
3D Lung Case
Practice Exercise
Task 1. Select Patient and Open Studyset
This task includes the steps to select a patient and open a studyset.
1. Open the Monaco software to automatically show the Patient Selection

dialog box.
2. Select the patient 4DLung using one of these methods:
Double-click on the patient name.
OR
Click the name once.
3. Click the OK button. The system loads the patient information into the
Patient Workspace Control.
4. Select the CT studyset CT1 using one of these methods:
Double–click on the studyset name.
OR
Click the studyset name once, and then click the Load button. The patient
appears in the Planning activity.
3-2
3D Lung Case
3D Lung Case
Practice Exercise (cont.)
Task 2. Create Contours
Contour the following structures.
• Patient (external)
• Right lung
• Left lung
• Spinal cord
• Tumor (GTV)
You may choose from any of the contouring methods outlined in the Contouring
Tools section of this training guide. Refer to those procedures as needed.
Task 3. Use Auto Margin to Expand the Target Volume
Use the Auto Margin tool if you would like to combine structures to create a new
structure or create positive, negative, or variable margins on structures. Refer to
the Contouring Tools section of this training guide for more information on
creating 3D auto margins.
1. Click the Auto Margins button on the Contouring ribbon.
2. Type the structure name: PTV in the Structure field.
3. View the Source Selection List By Study.
4. Select Tumor (GTV) in the Structure Selection List.
5. Click the Add button.
6. Type the value 1.5 cm, to create a uniform Margin for Selected Structure.
7. Click the Create button.
Monaco 3-3
3D Lung Case
3D Lung Case
Task 4. Start a 3D Plan using Templates
This task walks you through the steps to create a 3D plan from a template.
1. Click the Planning ribbon tab.
2. Click on the drop-down arrow next to the New Plan button and select
New Monaco Plan. This opens the New Monaco Plan dialog box (Figure
3–1).
Figure 3-1: New Monaco Plan Window
3. Type in a plan name and description.
3-4
3D Lung Case
3D Lung Case
Task 4. Start a 3D Plan using Templates (cont.)
4. Select 3D Delivery.
5. Select All for Anatomical Site.
6. Select the Template: DEFAULT3D1beam (Rx Site, Rx Dose: 2.000 Gy,

Total Beams: 1).
7. The Treatment Orientation for scan CT1 is Head First.
8. Select any Treatment Unit labeled Demo. (Note: The Treatment Units in
the training data are associated to specific energies.)
9. Select the Algorithm Collapsed Cone.
10. Select an energy for the beam.
11. Select Center of PTV for the Isocenter Location.
12. Click OK to load the template and open the patient in Planning Control.
Monaco 3-5
3D Lung Case
3D Lung Case
Task 5. Create Ports
1. Click the Create and Edit Ports button. Monaco shows the Create/Edit
Ports dialog box.
Figure 3-2: Create/Edit Ports dialog box
2. The Port Type for this exercise is MLC.
3. (Optional) Type the distance the MLC leaves intrude into the portal shape, in
percentage of total beam width in the Leaf Insertion (%) field.
4. (Optional) Type a new value if you want to change the defaulted Closed Leaf
Position.
3-6
3D Lung Case
3D Lung Case
Practice Exercise
Task 5. Create Ports (cont.)
5. Left-click the Auto Conform structure drop arrow, select PTV.
6. Type 1 for the Margin (cm).
7. Click Snap Jaws to Port to conform the collimator to the port shape.
8. Click the Close button.
Task 6. Duplicate and Oppose Beam
Use the Duplicate and Oppose Beam option to copy a beam parallel opposed to
the original (active) beam. If you have a port on your beam, it will also mirror the
port.
1. Click the New Beam drop-down menu.
2. Create a posterior beam Select the Duplicate and Oppose

button.
Monaco 3-7
3D Lung Case
3D Lung Case
Task 7. Edit Beam Information
If you need to edit your beam information, you can accomplish this in two ways.
You can edit individual beams when you click the Edit Beam button, or you
can edit one or multiple beams when you click the Beams tab on the Planning
Control. You can find additional information about beam manipulation in the
Planning Tools section of the training guide.
1. Open the Beams tab in the Planning Control.
2. Edit the Description field.
3. Edit the Field ID.
4. Edit Beam Geometry.
Task 8. Add Right Posterior Oblique Beam
1. Add Right Posterior Oblique field, use the <click to add a new beam>
option.
OR
Select the New Beam button .
2. Edit Beam Information. Complete the steps in Task 7.
3. Create and Edit Port for the Right Posterior Oblique beam. Complete the
Task 5 steps.
3-8
3D Lung Case
3D Lung Case
Task 9. (Optional) Edit a Port
The port editing tools enable you to reshape the MLCs of a port or to replace the
port. Complete these instructions if you want to manually make edits to your
port.
1. Verify the active port before editing.
3. Click the Replace editing tool radio button on the Create and Edit Ports
dialog box.
4. Left-click on the area of the port you want to edit. Hold and drag your
mouse to draw the new portal segment. The mouse cursor for editing a port
is a .
5. Click and drag the yellow edit box around the port to resize the port shape.
6. Click the Reshape editing tool radio button on the Create and Edit Ports
dialog box.
7. The selected MLC for editing appears in red. The mouse cursor for editing a
port is . Click and drag a MLC leaf to the new location.
Monaco 3-9
3D Lung Case
3D Lung Case
Task 10. Add a Wedge
1. Open the Beams tab in the Planning Control.
2. Click the Treatment Aids tab (Figure 3-3).
Figure 3-3: Treatment Aids Tab
3. Click to activate the beam to which you want to add a wedge.
4. Click the Wedge ID drop-down menu.
5. Select the Wedge/Angle to use in your plan.
3-10
3D Lung Case
3D Lung Case
Task 11. Add an Interest Point
In the Tools ribbon, you can place interest points or markers. This task explains
how to create interest points in Monaco. For more information on how to place
interest points or markers, refer to the Planning Tools section in this training
guide.
1. Click the Interest Points/Markers button on the toolbar. Monaco

shows the Interest Points& Markers dialog box (Figure 3-4).
2. To place an Interest Point, left-click anywhere on a transverse, sagittal or

coronal image to place the point.
3. Type a Description for the point or marker next to its coordinates.
4. To move the point on a transverse, sagittal, or coronal image, place the

mouse pointer over the point or marker. (The mouse pointer visually
changes to look like this .) Hold down your left mouse button and drag
the point or marker to a new location.
OR
Monaco 3-11
3D Lung Case
3D Lung Case
Task 12. Enter the Prescription
This task is only required when you need to edit the prescription from a template.
This task should be less frequently used once you create and save your own
clinical templates.
1. Select the Prescription tab on the Planning Control.
2. Type Lung for RX Site.
3. Select Plan Isocenter in the Prescribe to Column.
4. Type 66 in the Rx Dose (Gy) column.
5. Type 33 in the Number of Fractions column. The Fractional Dose(Gy)

column updates with 2.0 as the value.
Figure 3-5: Prescription Control
3-12
3D Lung Case
3D Lung Case
Task 13. Dose Calculation Properties
Grid spacing determines the numbers of points calculated in the region. Grid
spacing ranges from 0.10 cm to 0.80 cm in units of 0.01 cm. To change the Grid
Spacing, complete these steps.
1. Click the Calculation Properties button. The

Calculation Properties dialog box opens.
Figure 3-6: Calculation Properties dialog box
2. Type the voxel size you want to use for Grid Spacing.
Monaco 3-13
3D Lung Case
3D Lung Case
Task 14. Calculate Dose
1. Select the Calculate button, on the planning ribbon.
Task 15. Evaluate Isodoses and DVH
1. Open the Isodoses Control (Figure 3-7).
Figure 3-7: Isodoses Control dialog box
2. Adjust the Isodose display for your plan.
3. Review the isodoses on T/S/C and 3D views.
4. Right-click on the DVH window and select Statistics from the menu.
5. To review your plan, use the DVH and DVH Statistics.
3-14
3D Lung Case
3D Lung Case
Task 16. Edit Beam Weights
2. Use the slider bar or numerical entry box to

adjust the beam weight in percentage.
Task 17. (Optional) Rescale Dose
If your plan already has calculated dose, you can adjust the dose from within the
Planning activity. Rescaling the dose is not normalization, but a change to the
dose itself.
2. Use the Rescale Dose dialog box drop-down menu to rescale the dose.
Figure 3-8: Rescale Dose dialog box drop-down menu
Task 18. Save the Plan
1. Click the Save button
OR
Type (Ctrl + S) on your keyboard
Monaco 3-15
3D Lung Case
3D Lung Case
Task 19. Save a Template
You can do this task at any time in the planning process. However, it is highly
beneficial for you to create a prescription before you save a template. You can
reuse the saved template for future plans. As you use Monaco, you need to create
new beams and prescriptions less often, as this information will upload from your
saved customized plan templates.
1. Click the Monaco Application Menu and select the Save Template As
option to show the Save Template As dialog box.
2. Type the template name and description TrainProLung.
3. (Optional) Select an Anatomical Site from the drop-down.
4. Click Save to save the template.
3-16
3D Breast Case
3D Breast Case
Field in Field Planning
You can use two tangential open fields with subfields to create a Field in Field
radiation therapy plan. The MLC subfields are constructed based on BEV projections,
conforming MLCs to isodose surfaces.
This exercise shows you how to apply the Field in Field planning technique for breast
with Monaco. This exercise contains all necessary steps to create two tangential beams
with multiple subfields. It is assumed that you are already familiar with breast
planning.
This exercise and the information provided is subject to the disclaimer included on in
the Overview section of Volume 1, Section 1.
Once you complete this exercise, you should understand these concepts and be able to
execute the various tasks without additional supervision.

• Contour Structures
• Manage Structure Display
• Edit beam Isocenter
• Create and edit photon ports
• Create Interest Points
• Manage Prescription Properties
• Display and Evaluate isodoses
• Create Subfields
• Edit Beam Weighting
• Manage MU/Fluence Display
• Save a plan
Monaco 4-1
3D Breast Case
3D Breast Case
Field in Field Planning (cont.)
Task 1. Open the Patient
1. Click the Monaco Applications menu button.
2. Select Open Patient .
3. Select the patient BreastTRN. Use one of these methods:
OR
Click the name once and click OK.
4. The system loads the patient information into the Patient Workspace Control.
5. Select the CT studyset CT1. Use one of these methods:
Double – click on the studyset name.
OR
Click the studyset name once, and then click the Load button. The patient data
4-2
3D Breast Case
3D Breast Case
Contour the following structures:

• Right lung
• Left lung
• Spinal cord
• Heart
• Lumpectomy_PTV
structure or create positive, negative, or variable margins on structures. Refer to the
Contouring Tools section of this training guide for more information on creating 3-D
auto margins.
1. On the Contouring ribbon click Auto Margins .
2. Type the structure name: Lumpectomy_PTV in the Structure field.
4. Select OP Bed in the Structure Selection List.
6. Make sure Uniform Margin is checked.
7. Type the value 1.0 cm next to Superior.
Monaco 4-3
3D Breast Case
3D Breast Case
Task 4. New Plan from Template
1. Click the drop-down arrow next to the New Plan .
• This opens the New Monaco Plan dialog box (Figure 4–1).
Figure 4-1: New Monaco Plan dialog box
3. Type a plan name and description: FIFLtBreast.
4-4
3D Breast Case
3D Breast Case
Task 4. New Plan from Template (cont.)
6. Select the Template: DEFAULT3D1beam (Rx Site , Rx Dose: 2.000 Gy, Total
Beams: 1).
7. The Treatment Orientation for this plan is Head First. The Scan Orientation is
indicated as Head First Supine.
8. Select the Treatment Unit labeled Demo Synergy – 6MV.
NOTE: The Treatment Units in the training data are associated to specific
energies.
10. Select 6.0 MV for the beam energy.
11. Select any option in the Isocenter Location column. This exercise guides you to
change the location of the isocenter in Task 5.
The Patient orientation icon shows the head pointing toward the top of the
screen.
Figure 4-2: Head First Patient Orientation Icon
Monaco 4-5
3D Breast Case
3D Breast Case
Task 5. Edit Beam Isocenter
1. Click the Planning Ribbon tab.
2. Click Edit Beam.
3. Position the mouse cursor over the central crossmark on the isocentric plan. The
mouse pointer looks like this: (Figure 4-3).
Figure 4-3: Mouse Cursor to Move Isocenter
4-6
3D Breast Case
3D Breast Case
Task 5. Edit Beam Isocenter (cont.)
4. Click and drag the crossmark to a new isocenter location close to the chest wall.
(Figure 4-4)
Figure 4-4: Isocenter Location
NOTE: You can also change the isocenter when you type the X, Y, and Z
coordinates for the new isocenter location on the beam tab in the
Planning Control. Select Beams on the Planning Control Bar |
General.
Monaco 4-7
3D Breast Case
3D Breast Case
Task 6. Edit Gantry Angle
1. Your Edit Beam button should still be selected.
2. Position the mouse cursor over the active beam’s central ray. The mouse pointer
looks like this: (Figure 4-5).
3. Left-click and move the mouse in a circular motion until you achieve your
desired medial tangent gantry angle.
Figure 4-5: Mouse Cursor to Rotate Gantry
NOTE: You can also change the Gantry, Collimator, and Couch angles by
navigating to the Planning Control. Select Beams on the Planning
Control Bar| Geometry.
4-8
3D Breast Case
3D Breast Case
Task 7. Manage Structure Display
1. Open the Structure Visibility Control. In the default location, the control
appears on the right side of your screen.
2. (Optional) If you cannot find the Structures Control, reset your controls.
3. Click the Column Header: Structure to turn all structures off. When all
structures are off, the Structure Visibility window is gray.
4. Click Breast_PTV_EVAL to show your target volume.
NOTE: You can also manage structure’s visibility on the Structures tab on
the Planning Control Bar. Select and unselect the Visible box.
Monaco 4-9
3D Breast Case
3D Breast Case
Forward Planning (cont.)
Task 8. Edit Field Size
1. Left-click in the Beam’s Eye View (BEV) to activate window.
2. Right-click and select Maximize.
3. Toggle the MLC display off. Right-click in the BEV, unselect Show MLC. Your
Edit Beam button should still be selected.
4. Position your mouse pointer over the collimator jaw position lines so that the
5. Increase the field length so that the field covers the whole target. Move the
mouse while you hold down the left-mouse button to adjust the collimator jaw
position line to the desired position.
Figure 4-6: Mouse Cursor to Edit Field Size
NOTE: You can also change the Field Size in the Planning Control when you
select Beams on the Planning Control Bar | Geometry.
4-10
3D Breast Case
3D Breast Case
Task 9. Create and Edit Port
1. Turn on your MLC display. Right-click in the BEV window and select Show
MLC. Monaco places a checkmark in the menu when the
MLCs appear.
2. Select the Create and Edit Ports button.
3. In the Create/Edit Ports dialog box, select MLC as the Port.
4. Use the mouse cursor to draw a Medial Tangent port.
5. (Optional) Edit individual MLC leafs. When you hover your mouse over the
MLCs, the selected MLC for editing appears in red. The mouse cursor for editing
a MLC is a . Click and drag a MLC leaf to the new location.
6. Close the Create and Edit Ports dialog box when the previous step is complete.
Monaco 4-11
3D Breast Case
3D Breast Case
Task 10. Duplicate and Oppose Beam to Create Lateral Tangent
1. Click the New Beam drop-down.
2. Select Duplicate and Oppose. .
Task 11. Edit Beam Descriptions in the Beam Control
1. Open the Beams tab on the Planning Control.
NOTE: You can Reset the location of the Planning Control by selecting
Workspace | Reset Controls. If the Beams tab is not visible select
Workspace| Controls | Beams. The Beams tab should then become
visible on the Planning Control Bar.
2. On the General tab of the Beam Control, edit the Beam Descriptions and Field
IDs (Figure 4-7).
Figure 4-7: Beam Description and Field ID
4-12
3D Breast Case
3D Breast Case
Task 12. Line up Superior Edge of the Fields
There are different techniques on how to line up the Superior field edge to get rid of
divergence. This is just one way to demonstrate this.
1. While looking at the 3D View change the Couch angle on the Beams tab|
Geometry to line up the superior edge of the field. The couch angle moves the
superior edge of the field superior to inferior.
2. While looking at the 3D View change the collimator angle on the Beams tab|
Geometry. The collimator angle tilts the beam edge left to right.
NOTE: You may line up the superior edge if you are going to treat a half
beam block supra clavicular field.
Figure 4-8: Zero Couch Rotation (left) and Zero Collimator Rotation (right)
Monaco 4-13
3D Breast Case
3D Breast Case
Task 12. Line up Superior Edge of the Fields (cont.)
Figure 4-9: Couch and Collimator rotation to get rid of superior edge divergence
Figure 4-10: Beam Data for Couch and Collimator Rotation
Task 13. Re-evaluate the Ports
1. Since the Couch and Collimator have moved you want to re-evaluate your ports
to make sure they are covering everything.
2. If changes need to be made select Create and Edit Ports and make the edits.
4-14
3D Breast Case
3D Breast Case
In the Tools ribbon, you can place interest points or markers. This task explains how
to create interest points in Monaco. For more information on how to place interest
points or markers, refer to the Planning Tools section in this training guide.
1. Click the Interest Points/Markers button on the Tools tab. Monaco shows
the Interest Points& Markers dialog box (Figure 4-11).
2. To place an Interest Point, select New Interest Point .
• An interest point appears on the studyset (Figure 4-12)
Figure 4-12: Interest Point
Monaco 4-15
3D Breast Case
3D Breast Case
Task 14. Add an Interest Point (cont.)
3. Type a Description for the Interest Point next to its coordinates.
4. Move the point on a transverse, sagittal, or coronal image. To do this, place the
mouse pointer over the point or marker. (The mouse pointer visually changes to
look like this .) Hold down your left mouse button and drag the point to a
new location.
OR
NOTE: Try to keep the interest point 2cm away from the field edge if you are
using it as a weight point. This will keep it out of the penumbra
region. You can use the Measure tool on the Tools tab if you need to
measure the distance. (Figure 4-13)
Figure 4-13: Measure distance for Interest Point
4-16
3D Breast Case
3D Breast Case
Task 15. Enter Prescription
1. Click the Prescription tab on the Planning Control.
2. Type LtBREAST as the Rx Site. Monaco asks if you want to add the LtBREAST
site to the list of Rx Sites.
Figure: 4-14: Add to the List of Rx Sites dialog box
3. Click Yes.
4. Select the Prescribe To point. This could be the Interest Point you just created.
5. Type an Rx Dose (Gy) of 48.6.
6. Type 27 Number of Fractions. The Fractional Dose updates to 1.8 Gy.
7. Equally Weight the Prescription dose between the Medial Tangent and Lateral
Tangent, Fields 1 and 2 in the example below (Figure 4-15).
Figure 4-15: Beam Weights
Monaco 4-17
3D Breast Case
3D Breast Case
1. Click the Planning ribbon.
2. Click Calculate .
Task 17. Evaluate Dose
1. Open Isodoses Control. The default location for this control is on the left side of
your screen. (Figure 4-16)
Figure 4-16: Isodose Control
2. (Optional) To Locate your Isodoses Control:
3. Click Workspace | Reset Controls.
OR
Click Workspace | Controls| Isodoses.
4. Adjust Isodose levels as needed.
4-18
3D Breast Case
3D Breast Case
Task 17. Evaluate Dose (cont.)
5. Review the 100% isodose line to make sure it adequately covers the breast and
does not intrude into the lung. If it does not adequately cover the breast, return
to Task 2 and increase the field sizes and/or rotate the gantry until you are
satisfied with the coverage. You may also need to scale your Prescription.
Monaco 4-19
3D Breast Case
3D Breast Case
Task 18. Edit Beam Weighting and Plan Normalization
1. Click the Prescription tab in the Planning Control.
2. (Optional) Adjust the beam weighting for the Tangent fields 1and 2 to achieve
best isodose display.
3. Rescale the Dose: 48.6Gy to Cover 97% of Breast_PTV_EVAL

(Figure 4-17).
Figure 4-17: Rescale Dose
4-20
3D Breast Case
3D Breast Case
Task 19. Display 3D Isodose for Field in Field Planning
1. Open the Isodoses Control (see task 17).
2. Pin the Isodose Control. To do this, click the thumb tack button.
3. In the first Isodose value box, type the first overdose value you want to remove.
4. Click the 3D drop- down arrow for the first isodose value box.
5. Select an option. (Figure 4-18)
Figure 4-18: Isodoses Control 3D Column
Monaco 4-21
3D Breast Case
3D Breast Case
Task 20. Manage MU/Fluence Display
1. Right-click in the BEV. Select Maximize from the submenu.
2. Right-click in the BEV. Select Show MU / Fluence from the submenu.

You should now only see the 3D dose display and MLCs on the BEV (Figure 4-
19).
• As you add new sub fields the system freezes the dose from the previous
calculation so the isodose is still visible when you add create the fields.
Figure 4-19: BEV 3D Dose Display
The above window shows the 118% hotspot in the BEV of your medial
tangent. You use this to create the first subfield.
4-22
3D Breast Case
3D Breast Case
Task 21. Create First Medial Sub-Field
1. Open and pin the Beams tab on the Planning Control Bar. (Figure 4-20)
Figure 4-20: Beams tab on the Planning Control Bar
2. Select the medial tangent field (LtMed Tang).
3. On the Planning ribbon, select Duplicate Beam from the New Beam drop-down.
(Figure 4-21)
Figure 4-21: Duplicate Beam
4. Rename the Field ID (1B).
5. Click Calculate so dose becomes visible.
6. On the Planning ribbon click Create and Edit Ports .
Monaco 4-23
3D Breast Case
3D Breast Case
Task 21. Create First Medial Sub-Field (cont.)
7. Edit the MLC’s to block the overdose region displayed as a 3D isodose. You may
allow flash around the parts of the breast where you are not doing any
modulation. (Figure 4-22)
8. Click Close on the Create/Edit Ports dialog box when previous step is complete.
Figure 4-22: BEV Blocking Hotspot
4-24
3D Breast Case
3D Breast Case
Task 22. Calculate Dose and Adjust Beam Weighting for First Medial
Subfield
1. On the Planning ribbon, click Calculate .
2. On the Prescription tab you can adjust the weight of the new sub field.
First, Lock the weight of the Lt Lat Tang Field, to prevent loss of dose from this
field. (Figure 4-23)
Next, adjust the weight for the new sub-field using the slider bar or by typing in
the weight value, until the overdose 3D isodose disappears. (Figure 4-23 and
Figure 4-24)
Figure 4-23: Locking and Beam Weighting
Figure 4-24: Beam Weight First Medial Sub Field
Monaco 4-25
3D Breast Case
3D Breast Case
Task 23. Create First Lateral Subfield
1. Edit the 3D isodose display to a value approximately 2-5% less than its current
value. (Figure 4-25)
Figure 4-25: 2-5% less hot spot Isodose
2. Open Beams tab on the Planning Control Bar.
3. Select the lateral tangent field (Lt Lat Tang).
4. On the Planning ribbon, select Duplicate Beam from the New Beam drop-down.
(Figure 4-26)
Figure 4-26: Duplicate Beam
4-26
3D Breast Case
3D Breast Case
Task 23. Create First Lateral Subfield (cont.)
5. Rename the Field ID (2B).
6. Click Calculate so dose becomes visible. (Figure 4-27)
Figure 4-27: Isodose seen on BEV
7. On the Planning ribbon, click Create and Edit Ports .
Monaco 4-27
3D Breast Case
3D Breast Case
Task 23. Create First Lateral Subfield (cont.)
modulation. (Figure 4-28)
Figure 4-28: Subfield covers Hot Spot Isodose
9. Click Close on the Create and Edit Ports dialog box when previous step is
complete.
4-28
3D Breast Case
3D Breast Case
Task 24. Calculate Dose and Adjust Beam Weighting for First Lateral
Subfield
2. On the Prescription tab you can adjust the weight of the new sub field.
First Lock the weight of the Lt Med Tang Field and LT med Tang sub field, to
prevent loss of dose from these fields. (Figure 4-29)
Next, adjust the weight for the new sub-field using the slider bar or by typing in
the weight value, until the overdose 3D isodose disappears. (Figure 4-29 and 4-
30)
Figure 4-29: Beam Weight First Lateral Sub Field
Figure 4-30: BEV
Monaco 4-29
3D Breast Case
3D Breast Case
Task 25. Calculate Dose and Adjust Beam Weighting for Remaining
Subfields
1. Alternating between the Medial and Lateral Tangent fields, repeat the same
procedure as previously described above to eliminate other hotspots until you
reach your desired isodose distribution. Be aware of the location of your
calculation point that it is not being covered by the block, otherwise you are not
able to calculate.
Task 26. Add Setup Beams
2. Click the Setup Beams tab.
3. Click <click to add a new beam>.
4. Edit the beam Description, ID, and Geometry an Anterior Posterior (AP)
setup field.
6. Edit the beam Description, ID, and Geometry to create a Left Lateral setup field.
Task 27. Save Plan
1. Select the Save tool in the Quick Access toolbar
OR
2. Select the Monaco Application button and select Save.
4-30
3D Breast Case
3D Breast Case
Create a Supraclavicular (SCV) Plan
Task 1. Add another Beam
1. Select Beams | General | Add Beams tool.
OR
2. Select Planning ribbon | New Beam tool.
Task 2. Save Plan As
1. From the Monaco Application drop-down, select Save Plan As.
a. Do this so you do not change the FIF plan but you can use the beams as
guidance for lining up the SCV field.
2. Type in a Plan Name.
a. Example-SCVplan
3. Type in a Plan Description.
a. Example- SCVplan
4. Click Save.
Task 3. Setup the Beam
1. Go to the Planning Control bar| Beams | General.
a. Type in the Beam Description (example-SCV).
b. Deliver is 3D.
c. Select the Treatment Machine.
d. Modality-Photon
e. Algorithm-Collapsed Cone
f. Evergy-6.0 MV
g. Setup-SAD
Monaco 4-31
3D Breast Case
3D Breast Case
Create a Supraclavicular (SCV) Plan (cont.)
Task 3. Setup the Beam (cont.)
2. Go to the Planning Control bar| Beams | Geometry.
a. Adjust the SCV field gantry rotation so it is off the cord.
i. Example-345 degrees.
b. Adjust the Collimator rotation to be 0.
c. Adjust the Couch rotation to be 0.
d. Adjust the Length 2 border (LL) to be 0.
Task 4. Find Isocenter Location
1. First, Unlink the Isocenter Location.
2. Take the Length 1 (UL) length of 1 of the tangent fields (Figure 4-31) and add this
to the Y coordinate of the tangent field to get the Y coordinate of the SCV field.
Figure 4-31: Upper Length Tangent Field
Figure 4-32: Y Coordinate of Tangent Field
a. Example- 10.20 + 10.20 = 20.40
4-32
3D Breast Case
3D Breast Case
Task 4. Find Isocenter Location (cont.)
3. Your beams should look similar to Figure 4-33 in 3D view.
Figure 4-33: 3D View
Task 5. Edit the Port
1. Select Create and Edit Ports.
2. The Create and Edit Ports dialog box opens.
3. Draw the SCV field in BEV according to your physician’s specifications.
a. Example Figure 4-34.
Figure 4-34: SCV BEV
Monaco 4-33
3D Breast Case
3D Breast Case
Task 5. Edit the Port (cont.)
4. Click Close.
a. Double check the port to make sure there is no overlap with the tangent
fields.
Task 6. Create a Calculation Point
1. Go to the Tools ribbon | Interest Points and Markers.
2. The Interest Points and Markers window opens.
3. Select New interest Point.
4. Type in a Description (example-SCV calc pt).
5. Move the SCV calc pt to the center of the field and to the appropriate depth for
your clinic. (Figure 4-35)
a. Use the Jump to Point to easily locate the interest point to move it.
Figure 4-35: Calculation Point for the SCV
Task 7. Create a Prescription
1. Go to the Planning Control Bar| Prescription tab.
2. Select the Prescribe to Point.
a. Example: SCV calc pt
4-34
3D Breast Case
3D Breast Case
Task 7. Create a Prescription (cont.)
3. Type in the RX Dose.
a. Example: 5040cGy
4. Type in the Number of Fractions.
a. Example: 28 fractions
Task 8. Delete Tangent Beams
1. Go to the Beams tab on the Planning Control bar.
2. Select the Lt Med Tang field.
3. Select the Delete Beam option.
4. Select the Lt Lat Tang.
5. Select the Delete Beam option.
2. Click the Calculate button.
Task 10. Evaluate Doses
1. Open the Isodoses Control.
2. Review the isodose display and adjust Isodose levels as necessary.
Monaco 4-35
3D Breast Case
3D Breast Case
Plan Summation
Task 1. Sum Plans
1. Monaco lets you combine plans regardless of dose calculation matrix variations.
Monaco creates a new, independent dose matrix for plan summation.
2. In the workspace control, left click to highlight the FIFBreast plan you created.
3. Hold down the Control key and left mouse click on the ElectronBoost plan you
created.
4. Right-click and select Sum Plans from the menu.
5. The sum plan should now appear in Plan Review and the Workspace.
Figure 4-36: Locking and Beam Weighting
Task 2. Plan Summation Review
1. Use the Multiplan Navigation control and the slice mode indicator to reveal the
area of interest.
2. Adjust the color ranges in the isodose control.
3. Review the DVH, the summed plans adopt Absolute normalization mode. Percent
normalization is not available for summation plans.
Task 3. Save the Plan Summation
1. Click the Save button.
OR
2. Type (Ctrl + S) on your keyboard.
4-36
3D Prostate Case
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 9. Calculate plan
Task 10. Save a Template
Task 13. Save Plan
Task 14. Print the Plan
Task 15. Export the Plan
Monaco 5-1
3D Prostate Case
3D Prostate Case
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:
OR
Click the name once. Click the OK button.
The system loads the patient information into the Patient Workspace
Control.
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.
5-2
3D Prostate Case
3D Prostate Case
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.
Monaco 5-3
3D Prostate Case
3D Prostate Case
Task 3. (Optional) Import Treatment Couch

1. Select the Planning Workspace.
2. Click the Plan Options tab.
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.
5-4
3D Prostate Case
3D Prostate Case
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.
Monaco 5-5
3D Prostate Case
3D Prostate Case
Practice Exercise
Task 4. Define the Scan Reference Point (cont.)
4. Type the X, Y, and Z values in the Setup Reference dialog box.
OR
Use the mouse to reposition the cross hairs in the transverse view.
5. 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.
5-6
3D Prostate Case
3D Prostate Case
Task 5. Create a New Monaco Plan from Template

This task walks you through the steps to select a template to import.
1. Click the Planning tab.
2. Click the drop-down arrow next to the New Plan button and select
New Monaco Plan in the drop-down list. This opens the New Monaco Plan
dialog box (Figure-2).
3. Type in a Plan Name and Description.
4. Select 3D for the Delivery.
5. Select All for the Anatomical Site.
6. Place a checkmark by the template named DEFAULT3D1beam (Rx Site ,

Rx Dose: 2.0Gy , Total Beams: 1).
7. Select Head First for the Treatment Orientation.
8. Select a treatment unit used in your clinic, labeled as Demo.
9. Select the Collapsed Cone Algorithm.
10. Select the Photon Energy to be used in the plan.
11. Select the Isocenter Location: Center of GTV.
Monaco 5-7
3D Prostate Case
3D Prostate Case
Practice Exercise
Task 5. Create a New Monaco Plan from Template (cont.)
12. Select OK to load the template and open the patient in Planning Control.
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.
5-8
3D Prostate Case
3D Prostate Case
Task 7. Create Anterior 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.
Figure 5-4: AP DRR and Port
Monaco 5-9
3D Prostate Case
3D Prostate Case
Task 8. Duplicate and Oppose Anterior Beam

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.
5-10
3D Prostate Case
3D Prostate Case
Task 10. Add Right Lateral Beam

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.
Monaco 5-11
3D Prostate Case
3D Prostate Case
Task 11. Create Right Lateral Port
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.
Figure 5-5: Right Lateral DRR and Port
5-12
3D Prostate Case
3D Prostate Case
Task 12. Duplicate and Oppose Right Lateral Beam

button.
3. Edit beam information. Use the steps in task 9.
Monaco 5-13
3D Prostate Case
3D Prostate Case
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.
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.
5-14
3D Prostate Case
3D Prostate Case
This task should be less frequently used once you create and save your own
clinical templates.
1. Select the Prescription tab on the Planning Control (Figure -3).
2. Type Whole Pelvis for RX Site.
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.
Monaco 5-15
3D Prostate Case
3D Prostate Case
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.
5-16
3D Prostate Case
3D Prostate Case

1. Open the Isodoses Control (Figure 5-7).
Figure 5-7: Isodoses
5. Review your plan. Use the DVH and DVH Statistics.

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

the beam weight in percentage.
Monaco 5-17
3D Prostate Case
3D Prostate Case

If your plan already has calculated dose, you can adjust the dose from within the
Planning activity.
2. Use the Rescale Dose dialog box drop down menus to rescale the dose.
Table 5-1: Rescale Dose

Name Description
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
5-18
3D Prostate Case
3D Prostate Case
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.
5. Place a checkmark by the template named DEFAULT3D1beam (Rx Site ,

Rx Dose: 2.0Gy , Total Beams: 1).
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.
Monaco 5-19
3D Prostate Case
3D Prostate Case
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
3. Auto Conform to Structure: PTV.
4. Type 1.0 (cm) for the Auto Conform Margin.
6. Activate each beam and create a por. Use these steps.
7. Close the Create / Edit Ports dialog box.
5-20
3D Prostate Case
3D Prostate Case

2. Type Prostate Boost for RX Site.
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.
1. Use the slider bar or numerical entry box to

adjust the beam weight in percentage.
Task 26. Force Electron Density

2. Check the Force ED box on the Bladder row of the spreadsheet.
3. The Relative ED for the bladder is now 1.0.
Monaco 5-21
3D Prostate Case
3D Prostate Case

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

2. Use the Rescale Dose dialog box drop down menus to rescale the dose.
OR
5-22
3D Prostate Case
3D Prostate Case
Task 31. Create Plan Summation

Monaco enables you to combine plans regardless of dose calculation matrix
variations. Monaco creates a new, independent dose matrix for plan summation.
1. In the workspace control, left-click to highlight the first plan you created.
2. Hold down the Control key and left-click on the second plan you created.
3. Right-click and select Sum Plans from the menu.
Task 32. Plan Summation Review

1. Use the Multiplan Navigation control and the slice mode indicator to reveal
the area of interest.
2. Adjust the color ranges in the isodose control.
3. Review the DVH, the summed plans adopt Absolute normalization mode.
Percent normalization is not available for summation plans.
Task 33. Save the Plan Summation
OR
Monaco 5-23
IMRT Tools
IMRT Tools
Overview
This section of the training guide specifically outlines the buttons and tools available
in the Monaco Planning workspace. Within this activity, you can optimize and
evaluate your Monaco IMRT plans. You can also print Monaco plan reports. When
you complete this section, please go to Practice Exercise 3. IMRT and QA in the
Practice Exercises section of this guide.
Planning Control
When you create a New Monaco Plan, this launches the Planning Control window
(Figure 6-1). It is an interactive window where you can make edits to the prescription,
beam properties, and IMRT constraints. You can edit some properties during
optimization. Below is an example of the tabulated contents located in the Planning
Control Window (Figure 6-1).
Figure 6-1: IMRT Planning Control Window
Monaco 6-1
IMRT Tools
IMRT Tools
Structures
You can edit the structure’s properties when you double-click on the structure name
or edit the cells in the columns. From the Structures tab, you can check the Force ED
box to maintain a constant electron density for a structure (Figure 6-2).
Figure 6-2: Planning Control | Structure Tab
Prescription
Prior to optimizing, select the Prescription tab to define all prescription relevant
information in one place. From this tab you can make a Physician’s intent, manage
beam weights, and rescale normalization details. (Figure 6-3). See the Plan Review
Activity and 3D Planning sections of this guide for more information on the tools you
can use on the Prescription tab.
Figure 6-3: Planning Control | Prescription Tab
6-2
IMRT Tools
IMRT Tools
Beams
You can use the Beams tab in the Planning Control to add new beams or to edit the
configuration of beams already in your plan. You can also edit treatment aids such as
bolus, and manage setup beams (Figure 6-4).
NOTES: If the plan contains split beams, you cannot make changes to the child
beams.
Setup beams that you create in Planning on the Setup Beam tab are not
included in the dose calculation for the given plan. Monaco does not
account for dose accumulation for setup beams. The system exports any
assigned monitor units for use during filming.
Figure 6-4: Planning Control | Beams Tab
Monaco 6-3
IMRT Tools
IMRT Tools
IMRT Constraints
Use the IMRT Constraints tab to define the IMRT target objectives and organ at risk
constraints. You have the option to choose the Pareto Mode on the IMRT constraints.
Normally, Monaco sets constraints on healthy tissue while it administers dose to target
volumes. In Pareto mode, Monaco relaxes constraints on healthy tissue while
prioritizing target underdoses on tumor volumes.
During optimization phase two, you can select the Sensitivities tab to show the
sensitivities of each constraint in relationship to each target. From this tab, you receive
indications of which structures are impeding you meeting the prescription. Use this
information to make informed decisions as to what trade-offs to make to improve
your plan. (Figure 6-5)
Figure 6-5: Planning Control | IMRT Constraints Tab
6-4
IMRT Tools
IMRT Tools
The treatment planning system computes the Dose Reference Points (DRPs) that
represent point doses to user-defined locations on a per-beam basis. You can report or
export the information represented in dose reference points to external systems for the
purpose of independent MU calculation checks or dose tracking in a record and verify
system. You can view the dose reference point dialog box in Planning and Plan Review
activities. But, you can only edit dose reference points in Planning activity.
NOTE: DRPs are saved with the plan. But, if the plan is saved as a template, DRPs
are reset to the isocenter of the first beam for the new plan where the
template is applied.
Figure 6- 6: Dose Reference Point Window
You can edit the description of each Dose Reference Point. Type a new description in
the dialog box (Figure 6-6). You can also edit the position of the dose reference points.
Simply type X, Y, and Z values in the Dose Reference Point window or use the mouse.
Monaco 6-5
IMRT Tools
IMRT Tools
Dose Reference Points (cont.)
Use the mouse to move a Dose Reference Point
1. Click the Dose Reference Points tab in Planning Control window to show the
Dose Reference Point dialog box.
2. You can edit all DRPs at once or edit individual DRPs. Toggle the Location
button to link (edit all DRPs) or unlink (edit individual DRP).
3. Click Show/Edit DRPs . The active Show/Edit DRPs button is

shown in orange.
4. In any Transverse, Sagittal, Coronal or Fluence view, place your mouse over the
selected Dose Reference point. The mouse pointer visually changes to look like
this .
5. Hold down your left mouse button and drag the point to a new location.
NOTE: DRPs default to the isocenter of each beam/sequence.
Update DRP with Prescribe to Point
To move the dose reference point to the Prescribed to point on the Prescription tab,
click Update DRP with Prescribe to Point.
NOTE: The Prescribed To and DRP locations are linked by default for 3D plans.
For IMRT plans where the Prescribed To point is a volume, the button
disables.
6-6
IMRT Tools
IMRT Tools
Dose Reference Points (cont.)
Reset All Dose Reference Points to Isocenter
If you have moved your Dose Reference Points and now want to reset them back to the
isocenter of the plan, click the Reset All to Isocenter button on the
Dose Reference Point window.
Planning Tab
The panels below are available in the Planning tab of the Planning workspace. You can
locate several tools for IMRT planning within these panels (Figure 6-7).
Figure 6-7: IMRT Planning tab Panels
NOTE: You can find a more detailed discussion of the tools launched from this
toolbar in the Monaco Planning and Workflow section of this guide.
Monaco 6-7
IMRT Tools
IMRT Tools
Planning Tab (cont.)
Planning Tab | Calculation Panel
Table 6-1: Planning tab – Calculation panel buttons, tools, and descriptions
Buttons and Tools Description

This button launches the Calculation Properties dialog
box. It shows editable calculation and global
parameters related to your plan and structures in the
prescription.
This button launches the Sequencing Parameters
dialog box. These editable parameters relate to fluence,
segmentation, and monitor unit properties of
optimized segments.
The Start Optimization button starts the optimization
for stage one or stage two. The subscript number
indicates which stage will start when the button is
clicked.
The Batch Optimization button lets you perform stage
one and stage-two optimization without pausing in
between.
The Skip Forward button lets you manually stop an
optimization by “skipping forward” to the next
converged state. Note that when you skip forward, you
prematurely end the optimization, which could lead to
an unacceptable result.
The Skip Back button has different functionalities and
depends on which stage you are in. When clicked
once, it lets you manually skip back to the last idle
state. If you are in stage one, you can click the Skip
Back button twice to reset to the initial (pre-
optimized) fluence. In stage two, you can click the Skip
Back button twice to reset the optimized segments
back to optimized fluence. You can also use Skip Back
to “PAUSE” optimization. You can make prescription
edits and then press the “start” button again.
The Reset Calculation Engine button lets you remove
fluence, segments, and dose.
6-8
IMRT Tools
IMRT Tools
Planning Tab | Fluence Panel for IMRT Plans
The tools below are available on the fluence panel when you plan IMRT, dMLC and
Conformal RT plans (Figure 6-8).
Figure 6-8: Fluence Panel – IMRT, dMLC and Conformal RT Plans
Table 6-2: Planning tab – Fluence panel buttons, tools, and descriptions

Click the up and down arrows to select the beam you
want to show in the Fluence View, or click the drop-
down arrow to the right of the field and select a specific
beam to show.
Gantry Angle is a non-editable field that shows the

angle of the gantry of the active beam.
Use the Segment Selector to movie through the

segments in the Fluence View. When the field is
highlighted, you can use the scroll wheel to movie
through the segments quickly.
The monitor units shown are the monitor units for the
segment currently shown in the fluence view.
The MU Cursor works like the volume cursor tool. But,

it shows monitor units at a selected point on the BEV
instead of dose. Click the MU Cursor button. Then,
hold down your left mouse button over the intensity
map. Monaco shows a MU value associated with the
intensity at that point.
Monaco 6-9
IMRT Tools
IMRT Tools
Planning Tab
Planning Tab | Fluence Panel for IMRT Plans (cont.)
Table 6-2: Planning tab – Fluence panel buttons, tools, and descriptions (cont.)

The range of monitor unit values for all fluence
profiles in the plan appears on the hot/cold indicator
in grayscale or color.
Click the fluence color button between the two

numbers to toggle the intensity map in the BEV
from color to grayscale.
NOTE: To turn off the intensity map and monitor unit fluence, right-click in the
BEV and select the Show MU/Fluence option to remove the checkmark.
6-10
IMRT Tools
IMRT Tools
Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans
The tools below are available on the Fluence panel when you plan VMAT and
Dynamic Conformal Arc plans (Figure 6-9).
Figure 6-9: Fluence Panel – VMAT and Dynamic Conformal Arc Plans
Table 6-3: Planning tab – Fluence panel buttons, tools, and descriptions

Click the up and down arrows to select the
sequence you want to show in the Fluence View, or
click the drop-down arrow to the right of the field
and select a specific sequence to show.
When the Gantry button is selected (orange), all

the gantry angles for the sequence appear in the
drop-down list. Only the segments for the selected
gantry angle are available in the Segment drop-
down list.
When the Segment button is selected (orange), all

the segments for the entire sequence appear in the
drop-down list. Only the starting and ending
gantry angles for the selected segment are available
in the Gantry drop-down list.
Most segments have two control points, so you can

choose to show the starting position or ending
position for that segment. Select Start or End. If the
segment is static, Static appears in this field.
Monaco 6-11
IMRT Tools
IMRT Tools
Planning Tab
Planning Tab | Fluence Panel for VMAT and Dynamic Conformal Arc Plans
(cont.)
Table 6-3: Planning tab – Fluence panel buttons, tools, and descriptions (cont.)

The monitor units that appear are the total
monitor units for the segment that currently
appears in the fluence view.
The MU Cursor works like the volume cursor tool.
But, it shows monitor units at a selected point on
the BEV instead of dose. Click the MU Cursor
button Hold down your left mouse button over the
intensity map. Monaco shows a MU value
associated with the intensity at that point. This
option is grayed out for Dynamic Conformal since
the MU is constant for each segment.
(VMAT Only) The range of monitor unit values for
all fluence profiles in the plan appears on the
hot/cold indicator in grayscale or color.
Click the fluence color button between the two

numbers to toggle the intensity map in the BEV
from color to grayscale.
NOTE: To turn off the intensity map and monitor unit fluence, right-click in the
BEV and select the Show MU/Fluence option to remove the checkmark.
This option is grayed out for Dynamic Conformal since the MU is constant for each
segment.
6-12
IMRT Tools
IMRT Tools
Planning Tab
Fluence Analysis and Visualization Tools
The fluence analysis and visualization tools below are available in the Planning tab
from the Fluence Panel.
To show the fluence image view, turn on a BEV View Type. When you have this
option selected, you can right-click in the BEV window to show these display options.
All options are accessed when you right-click in the BEV window and select them.
Show MLC – Toggle the segment display on or off.
Show MLC Edges –Toggle the segment edges on or off. Segment edges appear in light
green.
Show Leaf Outlines – Toggle the display of the leaf outlines on or off. The color of the
leaf outline changes where the leaf is blocked.
Show Leaf Interiors – Toggle the display of the leaf shading on or off. The color of the
shading changes where the leaf is blocked.
Clip Leaves at Jaw Edges – Toggle the display of the full extent of the leaves on or off.
This option limits the MLC leaf display to the jaw extents. Jaw extents appear in dark
blue.
Show Maximum Segment Extents – Toggle the segment display between showing the
segment extents of the selected segment to showing the maximum extent of all
segments.
Enable DRR/MIP – Toggle the display of the DRR image on or off.
Show MU/Fluence – Toggle the display of the Fluence on or off.
Monaco 6-13
IMRT Tools
IMRT Tools
Planning Tab | Grid Volume Panel
The Grid Volume panel has different functionality based on which activity you are in.
The functionality below is available in the Planning workspace. (Figure 6-10)
Figure 6-10: Grid Volume Panel
Volume Cursor
The Volume Cursor is a mouse tool on the Grid Volume Panel that shows you:
• Volume information, such as Hounsfield units or PET units

• Pixel and voxel electron density
• Relative electron density of secondary image sets
• Point dose information regarding the image or plan selected
NOTE: Hounsfield Units and Electron Density values for all image sets are based
on pixel resolution. All other values that appear when you use the volume
cursor are based on dose grid resolution.
6-14
IMRT Tools
IMRT Tools
Planning Tab
Planning Tab | Grid Volume Panel (cont)
Studyset and Grid Slider Bar
The Studyset and Grid Slider Bar lets you fade the display
between the primary studyset and any grid volume option selected.
You can choose the Grid Type from the drop down menu.
This lets you set which visualization tool you want to use. For example, the Cost
Function Occupancy (available only in the Planning Workspace) shows cost function
occupancy per voxel.
When you choose certain Grid Types, you can also choose to
view a Structure. The drop-down menu enables you to select a structure when VOI
Occupancy, CF Occupancy, Variation, or when you select Relax Response as the Grid
Type.
The Units button enables you to view the lowest and highest
level of monitor units within the segment.
You can find more information on use of the volume toolbar in the Monaco Planning
and Workflow section of this guide.
Monaco 6-15
IMRT Tools
IMRT Tools
Plan Options Tab
Optional Panel
The Optional Panel contains controls you can use for IMRT and VMAT planning.
(Figure 6-11)
Figure 6-11: Options Tab Panels
Fluence Statistics
The Fluence Statistics dialog box shows fluence data for each beam along with
the total and mean monitor units for entire plan. The fluence statistics (Figure 6-12)
give you information based on beam fluence generated in stage-one and stage-two
optimization. You can select Print to print fluence statistics report.
Figure 6-12: Fluence Statistics dialog box
6-16
IMRT Tools
IMRT Tools
Plan Options Tab
Optional Panel (cont.)
Show Dose Extents

transverse, sagittal and coronal views, select Show Dose Extents. This control is
available for Monaco plans.
DVH Panel
You can evaluate the Optimized or Total Dose dose-volume histograms after stage
one or stage two of the optimization when you use the tools on the DVH panel (Figure
6-13).
Figure 6-13: DVH Panel
There are two main types of dose-volume histograms you can view in IMRT Activity.
Toggle between the two DVH types. Right-click in the DVH window and select Total
Volume DVH (total volumes) or Optimized DVH (volumes used by optimizer).
The DVH Properties sets the Dose Maximum, Grid Style, Grid
Line Style, Volume Display, Volume Maximum, Line Thickness, and Resolution and
Bin width.
You can combine structures when you use the set operations
union, intersection, and difference. You can view the combined structure in the DVH
structure report, DVH graph, and in the structure control.
Monaco 6-17
IMRT Tools
IMRT Tools
Plan Options Tab
DVH Panel (cont.)
You can control the background color of the dose – volume

histogram graph when you select DVH color setup.
You can view a summary of minimum, maximum, and mean dose

when you select the DVH Statistics button.
For more detailed information on how to use the DVH tools and set the properties, see
the Plan Review Activity section of this training guide.
Dose Normalization Panel
When you use the Dose Normalization panel (Figure 6-14), you can choose to
normalize your plan in Absolute doses or Percent doses. You can also choose to show
the doses in Gy or cGy.
Figure 6-14: Normalization Toolbar
NOTE: For more information on using the normalization tools, see the Plan
Review Activity section of this training guide.
6-18
IMRT Tools
IMRT Tools
Tools Tab
Figure 6-15: Tools Tab
Click the Interest Points and Markers button, located in the Tools tab. Or,
right-click in the transverse view to show the shortcut menu, then click Interest
Points & Markers. The treatment planning system computes the Interest Points and
Markers that represent point doses to user-defined locations.
You can report or export the information represented in dose reference points to
external systems for the purpose of independent MU calculation checks or dose
tracking in a record and verify system. You can view the Interest Point & Markers
dialog box in Planning and Plan Review activities. But, you cannot use the right-click
shortcut key in Plan Review.
Editing Interest Points and Markers
Figure 6-16: Interest Point and Markers dialog box
You can edit the Description of each Interest Point when you type a new description
in the dialog box (Figure 6-16). You can also edit the position of the points when you
type X, Y, and Z values in the Interest Point and Markers dialog box or use the mouse.
NOTE: The interest point or marker’s new location may re order the list if the Y
value is lesser than the interest points and markers that are already made.
Monaco 6-19
IMRT Tools
IMRT Tools
Tools Tab
Additional Interest Point and Marker Functionality
In the Planning, Plan Review and QA activities, there is expanded functionality and
information that you can access from the Interest Point and Marker dialog box. For
example, there is a column that shows Total Dose to the interest point or marker. You
can also sample a user-defined volume instead of a point. This is useful to evaluate
Monte Carlo doses that have inherent statistical uncertainty.
To sample a volume (sphere) around interest points and markers, type a value for the
Radius of the sampling sphere. The Volume in cm3 and number of Points in the
volume sample are automatically generated and appear just below the Radius field.
Next to each interest point or marker, fields such as the Mean Dose, Min Dose, Max
Dose, Standard Deviation and # of Grid Points (dose calc grid) appear in reference to
the sample volume.
Measure Tool
The Measure Tool is available in all activities. See the Planning Tools
section for basic use of these tools.
6-20
IMRT Tools
IMRT Tools
Additional IMRT Tools
Progress Meter
Figure 6-17: Progress Meter
The progress meter (Figure 6-17) consists of three real-time graphs, designated by the
colors blue, red and green that update with each iteration during both stages of
optimization.
The red graph shows the convergence of the target objectives Target EUD(s) and the
overall target coverage of the prescribed dose. When the dotted line converges to 1.0,
all objectives applied to the targets are met during optimization.
The blue graph shows the current status of all constraints, essentially the Constraint
Violation. During constrained optimization, this graph should converge to 0.0,
meaning that all applied constraints are being met.
The green graph shows the Modulation Degree. This indicates the current total
relative degree of modulation of all beams or sequences.
Monaco 6-21
IMRT Tools
IMRT Tools
Additional IMRT Tools (cont.)
Beam Visibility Control
In IMRT activity, you can toggle individual beams or sequences and their doses on or
off from the Beam Visibility Control. The system highlights the active beam/sequence
in red. It highlights all other beams in blue.
• Click on an individual beam/sequence name to turn the selected

beam/sequence on or off.
• Click on the heading Plan/Rx/Beam to toggle all beams/sequences on or off.
• Check or uncheck the box under Dose for each beam or Rx to toggle dose on
or off.
• Click on the heading Dose to toggle all beams/sequences on or off.
• Click the Current button to turn off the visibility of all beams except the
current beam (in red).
• If you plan with Bias Dose, the base plan name appears on the Beam Visibility
Control so you can toggle the dose on or off.
• With multiple Rx(s), you can toggle each Rx(s) beams on and off if you select a
specific Rx (example Rx A).
• With multiple Rx(s), you can toggle each Rx(s) dose on and off when you
check the Dose check box next to the specific Rx.
6-22
Planning and Workflow: Calculation Parameters and IMRT Constraints
Planning and Workflow: Calculation Parameters and

IMRT Constraints
Calculation Properties
You can edit specific Calculation Parameters from the Calculation Properties dialog
box (Figure 7-1).
Figure 7-1: Calculation Properties dialog box – Monte Carlo
Figure 7-2: Calculation Properties dialog box – Electron Monte Carlo
Monaco® 7-1

IMRT Constraints
Calculation Properties (cont.)
Figure 7-3: Calculation Properties dialog box-Collapsed Cone
Calculation Parameters
Calculation Parameters are those parameters that can affect optimization, dose
calculation, or both. The Grid Settings parameters are applied to all prescriptions. The
Algorithm Settings parameters are specific per prescription.
Algorithm
This is a non-editable field in this dialog box. You can select the algorithm you want to
use in the Beam tab on the Planning Control. Monaco updates the information in the
Algorithm field on the Calculation Parameters information.
Grid Spacing
This value refers to the uniform spacing of the calculation points on a three-
dimensional grid. Keep in mind that the calculation grid is defined by and
encompasses all contoured structures and cannot be resized.
If you have small structures such as in a head and neck case, you may want to use a
grid spacing of 2mm. Understand that smaller grid spacing significantly increases
calculation time. Plans with larger structures could be set to a larger grid spacing (such
as 3mm) to increase the calculation speed. Keep in mind, when you use too large of a
grid spacing, it can lead to a poorer resolution of the optimization problem and, in
addition, to a less accurate monitor unit calculation.
7-2

IMRT Constraints
Calculation Parameters (cont.)
Calculate Dose Deposition to:
You have the option to calculate dose to Medium or dose to Water. The default value
is Calculate dose to Medium. To be consistent, select the same option in QA Activity
for your QA plan that you selected here.
NOTE: For more detailed information on this topic, see the Report of the AAPM
Task Group No. 105: Issues associated with clinical implementation of
Monte Carlo-based photon and electron external beam treatment
planning.
Statistical Uncertainty (%)
The system only uses this value during the final dose calculation when you select the
Monte Carlo Algorithm as the Secondary Algorithm. There are two options to choose
from, Per Control Point and Per Calculation.
Statistical Uncertainty Per Control Point is the percent (%) statistical uncertainty per
voxel, on a per-segment basis, that you are willing to accept for the final dose
calculation. So, the mean, per-voxel, uncertainty in a central region of the dose of a
segment is equal to the user-specified statistical uncertainty at the end of the dose
calculation.
The uncertainty is not the same in all voxels. For example, the low dose voxels in the
peripheral regions of the patient has a higher uncertainty of dose than the voxels in the
region of maximum dose (target). The relative uncertainty of the total treatment plan
is inversely proportional to the square root of the number of histories. Dose
uncertainty in the target volume for the final plan is calculated and appears in the
console after stage-two dose calculation (Figure 7-4). The uncertainty of the entire
plan is always less than the uncertainty value you typed in the Statistical Uncertainty
field since that value is per segment.
Monaco® 7-3

IMRT Constraints
Statistical Uncertainty (%) (cont.)
Figure 7-4: Console Entry for Dose Uncertainty
Statistical Uncertainty Per Control Point (CP)
The range for this field is 0.1-10.00%. The smaller the statistical uncertainty (SU), the
longer the dose calculation. Suggested values are as follows:
# of CP Planning SU QA SU
100 3% 2%
150 4% 2.50%
200 5% 3%
When you use these values, the result should be a final dose uncertainty of
approximately 1% for the plan in the central region of the target volume. We suggest
smaller statistical uncertainty values for QA, since QA devices have a limited number
of detectors to match computed dose to measured dose.
7-4

IMRT Constraints
Statistical Uncertainty Per Calculation
The percent (%) statistical uncertainty per calculation that you are willing to accept for
the final dose calculation.
The range for this field is 0.1-5.00% (per calculation). Suggested value is 1.0% per
calculation. Calculation time is faster for this options versus the per Control Point
option since the dose calculation is based on a smaller number of histories.
NOTE: When you have structures in the prescription with small volumes, (for
example, lens) we do not recommend that you use a Statistical Uncertainty
higher than 1.5 % per calculation or 5 % per control point. If you use a
higher value, it causes the system to underestimate the cost function value
assigned to that structure. Refer to the Monaco Technical Reference: Post-
Modeling Adjustment of MLC Parameters in Support Plus for additional
information.
Monaco® 7-5

IMRT Constraints
Planning Control – Structures
You can set the display properties of the structures on the Structures tab. You can
override the electron densities of structures when you use the Force ED and Fill ED
options. Click the Force ED option if there is an object in the treatment that needs to
maintain a constant mass density. Click the column header to toggle the force density
feature on or off for all of the structures.
Figure 7-5: Structures
Click the Fill ED option to fill a structure with a minimum electron density.
The Relative Electron Density Field is empty until you mark either the Force ED or Fill
ED fields. It then shows the default electron density for the structure. You can type in a
new value. Relative Electron Density values can be:
• Photon Monte Carlo from 0.010 to 15.000
• Electron Monte Carlo from 0.01 to 2.456
• Collapsed Cone from 0.01 to 2.456
7-6

IMRT Constraints
IMRT Constraints: Structure
Introduction
The key to IMRT Treatment planning is to enter a carefully planned prescription. It is

important to use a logical thought process and the tools to make a great treatment
plan. Monaco makes it easy. It has a user-friendly prescription panel (Figure 7-6).
Click on the IMRT Constraints tab on the Planning Control to see the IMRT
Constraints dialog box. The Constraints tab is where you type in your prescription.
Right-click on any Cost Function

on the IMRT Constraints page to
get this menu.
Right-click on any Structure

on the IMRT Constraints page
to get these menus.
Figure 7-6: IMRT Constraints dialog box and Right Mouse Click Options
Monaco® 7-7

IMRT Constraints
Introduction (cont.)
You may find it useful to view the IMRT Constraints dialog box on the Planning
Control during optimization to view the Isoeffect and Relative Impact updating
during optimization and to make edits to the interactive fields, if necessary.
You can change some of the IMRT Constraints dialog box fields during optimization.
You can only change others when the system is idle (not optimizing or calculating) or
converged. During the optimization, you can change the Enabled and Multicriterial
status and the Isoconstraint values.
7-8

IMRT Constraints
IMRT Constraints: Structure (cont.)
Structure
This column lists all the structures that are in the optimization. The assigned color of
each structure appears to the left of each structure name. The system lets you plan with
up to 31 structures. You should list the structures (layer them) in order of their
importance so that voxels are prioritized and defined appropriately when structure
overlaps exist. You can also assign unique structure properties to individual structures.
You can read more details about structure layering and structure properties and their
global parameters in the sub-sections.
Structure Mismatch
Since you use templates to start planning, occasionally you might have a structure
mismatch. This means that the structure name in the template does not exist in the
currently loaded patient’s structure set. A structure mismatch is easy to recognize since
the structure name appears in red on the IMRT Constraints dialog box and say
‘Mismatch in structure names’ at the bottom. It is also easy to resolve when you select
another structure name from the drop-down list, or delete the structure altogether.
Figure 7-6 shows an example where the structure PTV and SKIN do not have a match
in the current studyset.
Structure Layering
The layering order determines how the optimizer treats the voxels in the volume
where the structures overlap. It does not imply that one structure’s objectives or
constraints are more or less important. The structure that is listed higher in the
layering order ‘owns’ the voxels in an area of overlap with another structure even if
there is no cost function assigned to it in the prescription. You can also assign voxels
of overlapping regions completely to one structure when you use the structure
properties.
To edit the structure layering on the IMRT Constraints dialog box, left-click a
structure name to highlight. Click the up or down arrow buttons to move

that structure up or down in the layering order.
Monaco® 7-9

IMRT Constraints
Structure Layering (cont.)
The images below illustrate examples of layering order applied to two overlapping
structures. These voxel priorities represent the default behavior, but can be overridden
by individual cost functions with an additional parameter.
Figure 7-7 PTV higher in In this example, the PTV

layering order 'owns' the voxels in the
PTV
than Rectum overlap region. The cost
function(s) assigned to the
rectum is only applied to
the volume in blue.
Rectum
Figure 7-8
In this example, the Rectum higher in PTV
Rectum 'owns' the voxels layering order
in the overlap region. The than PTV
cost function(s) assigned
to the PTV is only applied
to the volume in yellow.
Rectum
Figure 7-9 PTV2 higher in In this example, you need

to list the PTV2 higher in
PTV2 layering order the layering order than
PTV1. If not, its cost
than PTV1 functions will be
PTV1 overridden by the cost
functions of PTV1 since
PTV1 totally encompasses
PTV2.
7-10

IMRT Constraints
IMRT Constraints: Structure (cont.)
Structure Optimization Properties and IMRT Prescription Parameters
Monaco has powerful structure definition tools that let you define voxel priorities and
physical properties for each structure in the prescription. In other words, you can
determine which voxels a cost function will be applied to within a selected structure.
NOTE: Prescription Parameters are applied across all structures where the
associated structure property is assigned. For example: When you set the
Minimum CT Number, that value is applied to all structures where Clear is
applied. If the value is changed, it is changed for all structures.
You can designate very specific properties for each individual structure. You can use
these properties alone or in combination with each other. Instead of creating
additional contouring to alter how the cost function is applied to those structures, you
could simply apply a specific structure optimization property to accomplish the same
goal. The uses and limitations of these properties are defined here.
To view the structure optimization properties (Figure 7-10) for a specific structure,
right-click on the structure name in the IMRT Constraints dialog box and select the
Properties option.
To edit the Prescription parameters (Figure 7-11), click on IMRT Parameters on the
IMRT Constraints tab. These parameters are specific per prescription.
Monaco® 7-11

IMRT Constraints

(cont.)
Figure 7-10: Structure Optimization Properties
Figure 7-11: IMRT Prescription Parameters
7-12

IMRT Constraints

(cont.)
Clear all Voxels below the Minimum CT number
Apply this property when you want to identify and exclude all voxels in a structure
whose values fall below a user-defined Hounsfield number during the optimization.
Type the minimum Hounsfield value in the Minimum CT Number in the IMRT
Prescription Parameter dialog box. You typically use the Clear property for targets
containing air voxels.
This property is sometimes used in combination with the Fill property. Fill is always
done before Clear, when used in combination. Fill is applied to set a minimum
electron density for all voxels that belong to the structure. Then, the Clear property
removes all the voxels in the structure below the selected Hounsfield number entered.
The voxels where “Clear” is applied are not taken into account during the
optimization, but those voxels are accounted for during the final dose calculation. This
field is ignored if you are planning on an MR studyset.
Clear and Fill Example:
It is practical to remove air density voxels from structures so the optimization

algorithm does not artificially inflate the dose to the structure when it tries to deliver
dose into an area of very low density. This could lead to hot spots elsewhere. You may
also want to set a minimum density for that structure used in the dose calculation.
Monaco® 7-13

IMRT Constraints

Clear all Voxels below the Minimum CT number (cont.)
In this head and neck case, the contoured target volume includes air voxels. If the
structure is divided into voxels based on the selected grid spacing and electron density,
this slice may look like the image in (Figure 7-12). The purple voxels represent CT
values in the range of air (0.1). The yellow voxels represent ED values in the range of
0.4, since they border air voxels. The blue voxels represent voxels with an ED of 1.0 or
greater. Use Fill to apply a minimum density 0.5 (-500 HU) to all of the voxels with a
density below 0.5. See (Figure 7-13) where it changes the purple and yellow voxels to
green. When Clear (-200 HU) is applied to the filled voxels, you get an altered structure
volume represented in (Figure 7-14).
NOTE: Clear is applied to total voxels. See Figure 7-14.
Figure 7-12: Figure 7-13: Figure 7-14:

Voxelized Structure Application of Fill Application of Clear
NOTE: This is an artistic rendering of the application of Fill and Clear. These color
maps do not appear on your screen.
7-14

IMRT Constraints

(cont.)
Display Total Volume DVH
Apply this property when you want to designate that the volume shown in the DVH
during optimization (for the selected structure). This always pertains to the entire
volume of the structure, regardless of any overlap with higher priority structures. It is
not necessary to select this property for the first item in the Structure Layering list
since the volume of the DVH always pertains to the total volume. When you select this
property, it has no bearing on voxel sharing only the optimized DVH display.
Auto Flash
Typically, when a target is superficial or lies in the build-up region just beneath the
patient surface (like a breast or neck), it is difficult to sufficiently cover the target with
the prescribed dose due to the rapid fall off of dose at the surface. In some cases, the
target volume could move outside of the treatment field due to breathing.
Select the Auto Flash option to create a flash margin of voxels that extends beyond the
target volume, with the specified margin, in the direction of the skin surface (Figures
7-15 and 7-16). Monaco automatically opens the jaws, when needed, to cover the
“virtual target” when it is near the surface of the patient so that the prescribed dose is
better achieved to superficial targets. Users can type a specific margin value (0.0-2.5
cm) in the Auto Flash Margin in the IMRT Prescription Parameter dialog box.
Monaco® 7-15

IMRT Constraints
Auto Flash (cont.)
Figure 7-15: Coronal View of Breast Tangent Figure 7-16: Coronal View of Breast Tangent
Fluence without Auto Flash Fluence with 1.0 cm Auto Flash
Do Not Store Dose
This option is only available when a cost function is not assigned to the selected
structure and Display Total Volume DVH is not checked. When selected, dose is
attenuated through the structure and does not store dose for this structure in memory.
This option might be useful once you contour the table or an immobilization device
and want to account for attenuation through it, but do not need to track the dose
delivered there.
7-16

IMRT Constraints

(cont.)
Avoidance
This option only applies to organs at risk. You control it with the IMRT Prescription
Parameter| Avoidance Margin option. Check this box if you want to apply an
avoidance margin to your organ at risk. See the section on Avoidance Margin-IMRT
Prescription Parameter for more information.
Surface Margin – IMRT Prescription Parameter
You can apply Surface Margin to a structure’s cost functions to limit the cost
function’s effect in the build-up region at the patient surface. The range for the surface
margin value is 0.00 to 1.00.
NOTE: See the section Understanding the Cost Function Parameters for more
information on how to use Surface Margin.
Beamlet Width – IMRT Prescription Parameter
You use the beamlet width during stage one and stage-two optimization. In stage-one,
you use it to define the resolution of the fluence map. In stage-two, you use it during
segment shape optimization to fine tune the segment shapes in step and shoot IMRT.
In general, the smaller the beamlet width, the finer the fluence grid. This fine fluence
grid is an advantage since this lets the optimizer define sharper gradients where
necessary. The recommended beamlet width is 2mm. Beamlet length is automatically
determined by the MLC leaf width.
Monaco® 7-17

IMRT Constraints

(cont.)
Target Margin – IMRT Prescription Parameter
You can alter the fluence profiles created for target structure(s) when you change the
target margin. A target margin is always applied when you create fluence profiles. The
default value is Normal. But, you can tighten or widen the margin when you select a
different option.
Avoidance Margin – IMRT Prescription Parameter
You can alter the fluence profiles created for an OAR structure(s) when you change
the avoidance margin. Avoidance margins are optional, mainly for use with the
Dynamic Conformal Arcs delivery mode. It is only applied when you turn it on in the
Structure Optimization Properties for an OAR. The default value is Normal (8 mm).
But, you can tighten or widen the margin when you select a different option.
Avoidance margins are hard constraints for dynamic conformal arcs. The system
assigns voxels to avoid during the rotational delivery by the value of the margin
assigned.
See the section on Structure Optimization Properties for more information.
Figure 7-17: Avoidance Margin: Dynamic Conformal Arc
7-18

IMRT Constraints
IMRT Constraints: Cost Functions
Cost Function Overview
In general, all IMRT optimizers seek to minimize a composite cost-function,

comprised of the sum of the cost functions that may be objectives or constraints. This
column lists all the cost functions applied to each structure in the prescription. A cost
function relates an inhomogeneous dose distribution to a single value. You can use
this value to define a penalty for violating an objective or constraint. The system
evaluates this penalty - value during optimization.
In constrained optimization, the only contribution to the objective function is given by

the objectives. Therefore, the value of the composite cost function in Monaco is a
measure of the violation of the target prescription.
Objective
Objectives are anatomy-specific functions that establish dose and/or biological

response goals. When used in combination with constraints, the objective is always
limited so that constraints are met. You must loosen constraints in order to improve
objectives.
Constraint
Constraints are anatomy-specific functions that must be met. They are often referred
to as hard constraints. When used in combination with objective functions,
constraints are met regardless of the effect on the objectives and may limit the dose to
the target volume (objectives).
EUD (Equivalent Uniform Dose)
EUD is a homogeneous dose that, when applied to an organ, has the same clinical
effect as any given, inhomogeneous dose distribution. The concept of EUD assumes
that any two dose-distributions are assumed equivalent if they cause the same
radiobiological effect.
Monaco® 7-19

IMRT Constraints
IMRT Constraints: Cost Functions (cont.)
Application of Objectives and Constraints
Monaco gives you a set of biological and DVH based cost functions to use during
optimization. Most are considered constraints. For constrained optimization,
constraints must be met for the optimization to converge. The cost function primarily
used to designate targets is considered an objective. An objective is treated like a goal
and may not be met during optimization if the constraints are too restrictive. When
you apply the Pareto optimization mode, you place priority on underdose constraints
to targets over constraints you apply to organs at risk.
When you use biological cost functions, this takes advantage of the biological volume
effect of structures. The biological volume effect indicates that higher doses may be
tolerated when the irradiated volume is reduced. When you use a biological cost
function as opposed to a physical (dose-based) cost function, each structure is
equipped with its particular volume effect, as opposed to the optimizer treating all
structures as if they had the same dose response mechanism.
To view the Properties dialog box for each cost function, right-click on any cost
function and select Properties.
7-20

IMRT Constraints
Required Cost Function Parameters
Target Penalty
This physical cost function is the ‘objective’ version of the Quadratic Underdose
constraint for targets (Figure 7-18). The isoeffect is a DVH based physical parameter.
The Target Penalty is a quadratic penalty which starts at the threshold dose. You can
configure the dose and reference volume. You must use at least one of the two target
objectives (Target EUD or Target Penalty) in your prescription. This is a non-EUD
based objective. It does not add hot spots to the target to compensate for cold spots. As
a result, it produces steeper dose gradients after target threshold doses are met.
Monaco does not show sensitivity values for the Target penalty because there is no
direct relationship between iso-effect and objective function value. A change to the
objective function may not change the reported iso-effect. Therefore, Monaco cannot
report sensitivity, which is a change to the iso-effect.
Figure 7-18: Required parameters for the Target Penalty constraint
Figure 7-19: Target Penalty a Prescription of 72 Gy.
Monaco® 7-21

IMRT Constraints
Required Cost Function Parameters (cont.)
Target EUD
This biological cost function is an objective (not a constraint) and is the primary cost
function for targets. This cost function defines a structure as a target volume. It
expresses the probability that a target cell survives a given dose. The field size for each
beam or sequence is automatically designed to encompass the target volume.
Figure 7-20: Required Parameters for Target EUD
This cost function requires that you to type in a Prescription, which is an EUD
(Equivalent Uniform Dose) prescription. If the dose distribution in the structure is
homogeneous, the EUD is close to the mean dose, which, in the case of a target, also
represents the desired prescribed dose. If severe cold spots exist, it is close to the
minimum dose and depends on cell sensitivity. Type the actual prescribed dose for the
structure. This value is the desirable effective dose for this structure.
This cost function also requires you to type in the Cell Sensitivity for the target
structure. When you increase the cell sensitivity, you increase the penalty paid for cold
spots within the selected structure. Figure 7-21 graphs the changes in the penalty for
low doses when the cell sensitivity is altered. In difficult cases, higher values of the cell
sensitivity effectively increases the pressure to deliver dose to cold spots. Cell
sensitivity and tumor cell density may become more important in future planning
when functional imaging is available for treatment planning. Until then, it is
reasonable to use the default cell sensitivity value of 0.50 for most cases.
7-22

IMRT Constraints
Target EUD (cont.)
Target EUD
25
Increasing Penalty for Cold Spots
20
15
Cell Sen.
10 =0.1
Cell Sen.
=0.25
5
Cell Sen.
=0.5
0
65 67 69 71 73 75 77 79
Dose (cGy)
Figure 7-21: Changing Cell Sensitivity
Monaco® 7-23

IMRT Constraints

Serial
This biological cost function is the preferred constraint for serial OARs. For some
organs, high doses are harmful even if they are limited to small volumes. These organs
are considered serial structures. Examples of serial structures are spinal cord and
bowel. It implements the critical volume model of normal tissue complications where
it sees the organ as a chain. It breaks when one link breaks. Consequentially, it applies
large penalties for hot spots even if they are small in volume. The serial cost function is
the biological equivalent of a maximum dose penalty.
Figure 7-22: Required Parameters for Serial
The isoconstraint is the Equivalent Uniform Dose (EUD), where value is similar to an
acceptable maximum dose when the k value is large (ex. 12) and is equivalent to the
mean dose when the k value is equal to 1. The EUD is the dose that causes the same
damage if applied uniformly to the entire volume of the organ. The isoconstraint is the
value you should change during optimization if you when you meet your desired
prescription goal for the selected OAR.
This cost function requires one value that is the Power Law Exponent (k) volume-
effect parameter. In general, when you use a small k value, a large volume-effect is
assumed. This means that low dose volumes and high dose volumes are approximately
equally weighted. When you use a large k value, there is less tolerance for excessive
damage to small volumes of the assigned structure. In this case, low dose volumes
receive a very small weight relative to high dose volumes. Figure 7-23 graphs the
changes in the weight (penalty) of a dose in the overall EUD calculation when the k
value is altered. k values are typically set once and not changed during optimization.
When you select a particular k value, you essentially select a complication model based
on the desired outcome for the selected structure.
7-24

IMRT Constraints
Serial (cont.)
NOTE: It may be helpful for you to learn how Monaco re-samples the patient to
create voxelized structures for optimization. This effects how cost
functions, in particular, the Power Law Exponent for the Serial are applied
to the structures. For detailed information, see the Monaco Patient Model
section of this guide.
Figure 7-23: Effect of Various Power Law Exponents
Figure 7-24: Comparison of Three Serial DVH Curves
Monaco® 7-25

IMRT Constraints
Serial (cont.)
Figure 7-25 demonstrates a comparison of three serial DVH curves for the structure
rectum. A k-value of 12 gives you the best curve for the rectum without significantly
softening the shoulder on the PTV.
As a rule of thumb, you can derive a clinically significant power law exponent for serial
structures when you use this equation:
k = 0.15 x D 50
The D 50 value is the dose that causes a complication in 50 percent of all patients.
Unfortunately, this is not a well-established clinical quantity. In general, it is better to
overestimate k as this prevents potentially perilous hot spots. The table below gives
examples of common k values used to return clinically acceptable results. Results may
vary based on the contour and location of the structure.
Serial OAR Common k Common

Value Isoconstraint
Values (Gy)
Rectum 12 64
Bladder 8 60
Spinal Cord 12-14 29-36
Brainstem 12-14 36-40
Optic Nerve, Chiasm 12 -16 32-48
Heart 6 21-24
Eye 2 25
Inner Ear 12 38
Mandible, Mouth, Larynx 8 40-46
Parotid Gland 1 22
Brain 1 12
Plexus 5 55
Figure 7-25: Examples of common k values for delivery of 2 Gy/fraction
7-26

IMRT Constraints
Serial (cont.)
NOTE: It is important that you research the effect of the Power Law Exponent to
determine the k value and isoconstraint that is most effective for use in
your clinic.
The length of the weight arrows

corresponds to where and how hard the
Serial cost function is working to meet the
constraints of the OAR.
Figure 7-26: How the serial cost function controls the DVH curve
Figure 7-26 demonstrates the effect of the Serial cost function on a DVH curve. Notice
that the cost function does not affect only one point along the curve. It actually affects
the entire curve in varying degrees and particularly works on the tail to decrease hot
spots.
Monaco® 7-27

IMRT Constraints
Parallel
This biological cost function is the preferred constraint for parallel OARs. It is the
biological equivalent of the DVH constraint. Some organs tolerate very high dose
values in small sub-volumes, if the rest of the organ is spared. Consider these organs
parallel structures. Examples of parallel structures are lungs, parotids, kidneys and
liver. This model implements the critical volume model of normal tissue
complications where it sees the organ as a rope: it breaks when a certain number of
strands break.
Figure 7-27: Required parameters for the Parallel Cost Function
This cost function requires that you assign three parameters. The first parameter is the
Reference Dose (EUD) whose value is analogous to the dose that is only just
acceptable for the majority of the structure, and at which a clear dose response begins
to show. For lung, this would be around 20 Gy. If the organ were to be irradiated
homogenously with the reference dose, 50% of the organ would be lost.
The second parameter is the isoconstraint, which is the Mean Organ Damage to the
structure in %. The Mean Organ Damage is the biological equivalent to the fraction of
the volume of the structure that can be sacrificed. You can divide the function of any
organ into a large number of sub-volumes (aka functional sub-units, tissue-repair-
units) that all work in parallel (Figure 7-28).The effect of radiation is assumed to
knock out sub-volumes, and thereby reduce the function of the organ.
Consequentially, the function is degraded on a continuous scale.
7-28

IMRT Constraints
Parallel (cont.)
Because each subvolume has a continuous dose-response (that is, each sub-volume can
lose function on a continuous scale), 50% of the organ function can be lost in two
extreme ways. Either by irradiating 50% of the organ volume to a dose that obliterates
function, or by irradiating the entire organ to a dose that obliterates 50% of the
function of each sub-volume. The total damage to the organ is therefore the mean of
the functional losses of all sub-volumes.
The isoconstraint is the value you should change during optimization if your desired
prescription goal for the selected OAR is not being met.
The third parameter is the Power Law Exponent (k). This value changes the shape of
the dose response curve and determines how responsive the structure is to the
Reference Dose and Mean Organ Damage values entered. A higher k value translates
to a steep dose response that often translates into a pronounced kink in the DVH. k
values are typically set once and not changed during optimization. When you select a
particular k value, you are essentially selecting a complication model based on the
desired outcome for the selected structure.
Figure 7-28: Functional Units (voxels)
Monaco® 7-29

IMRT Constraints
Parallel (cont.)
Figure 7-29 demonstrates the shape of the cost function curve when you alter the k
value. Figure 7-30 demonstrates the effect on the parotid when you alter the k value.
Note that there are no significant differences between the plans for the target
structures. The difference between the global max doses for all three plans was
negligible.
Parallel Cost Function

Dref =20
Increasing Complication
k=2
Probability
k=3
k=4
Inflection
point
0 20 40 60
Reference Dose
Figure 7-29: Effect of Various Power Law Exponents on one functional unit (voxel)
7-30

IMRT Constraints
Parallel (cont.)
Figure 7-30: Comparison of Parallel DVH Curves
Monaco® 7-31

IMRT Constraints
Parallel (cont.)
Based on historical data, you can derive a clinically significant power law exponent for
parallel structures when you use this equation:
k = 0.15 x D ref
Below are examples of common k values used to return clinically acceptable results.
Parallel Ref Dose Common Mean Organ

OAR (Gy) k Value Damage (%)
Lung 20 3 20
Parotid 26 3.9 40
Kidney 14 2.1 20
Liver 30 4.0 33
NOTE: It is important that you research the effect of the Power Law Exponent to
determine the k value and isoconstraint that are most effective for use in
your clinic.
7-32

IMRT Constraints
Required Cost Function Parameter
Parallel (cont.)
The length of the weight

arrows corresponds to
where and how hard the
Parallel cost function is
working to meet the
constraint of the OAR.
Figure 7-31: How a parallel cost function controls the DVH curve
Figure 7-31 demonstrates the effect of the Parallel cost function on a DVH curve.
Notice that the cost function does not affect only one point along the curve, it actually
affects the entire curve in varying degrees and particularly works on the middle of the
DVH curve.
Monaco® 7-33

IMRT Constraints

Conformality
This physical cost function is a constraint that you can only use with OARs. The
purpose of the Conformality cost function is to shape the high dose volume tightly
around one or several target volumes. The farther away from the target a voxel is
located, the higher the cost function penalizes high doses. You can use this instead of
the Quadratic Overdose cost function. The rationale that you use this cost function is
that it is more acceptable to have a higher dose closer to the target than it is to have
high doses distant from the target. The Conformality cost function does not restrict
the optimum dose.
The Conformality cost function uses local importance weights that depend on the
distance of a voxel to the nearest target volume and the dose prescribed to this voxel to
modify the local effectiveness of the cost function.
1 V
 D(i ) 
F= ∑ f  D (i) 
N i =1  0 
Where D 0 (i) is an estimate of the desired dose at point i. D 0 (i) depends on the distance
of point i from the nearest target volume voxel, and the prescription dose to that voxel.
f is a local penalty function
N is the normalization factor
Using a decay function of
1
g ( Ri ) =
4 R
i
Where R i is the distance of point i from the edge of the target volume, gives a final cost
function of:
k
1 V  4 Ri D(i ) 
F=
N
∑ 



i =1  D p ( ji ) 
7-34

IMRT Constraints

Conformality (cont.)
D p (j i ) is the dose in the current dose distribution. You only have to define one
parameter, k.
The Conformality cost function does not require you to define an absolute iso-
constraint for the prescription, which would be difficult to determine. Instead, it
estimates a feasible measure of dose conformality for each case, and then requires you
to prescribe how much more or less conformal the dose distribution should be than
this estimate. Hence, the cost function only requires you to define a relative iso-
constraint (Figure 7-32 Conformality dialog box).
Figure 7-32: Conformality dialog box
The Relative Isoconstraint ranges from 0.01 to 1.00. Values less than 0.5 can start to
restrict target coverage. Monaco applies a stronger penalty to voxels when you use a
lower value for the Relative Isoconstraint. The default distance Monaco applies the
Conformality Cost function is 4cm from the edge of the target. When you select
Optimize over all voxels in volume , Monaco applies the cost function up to 8.0 cm
from the edge of the target. You can also select Multicriterial to make this a secondary
objective.
Monaco® 7-35

IMRT Constraints

Quadratic Overdose
This physical cost function is a constraint you can use with either targets or OARs to
limit high doses in the structure to which it is applied. It is most often used in
conjunction with the Target EUD objective to limit hot spots in the target. The
rationale that you use this cost function is that sometimes a maximum dose limitation
should not be enforced strictly while a small, yet controlled hot spot is permissible. In
general, penalizing hot spots in IMRT may cause problems with associated cold spots
in a target volume, so that a certain violation of the maximum dose limitation appears
acceptable.
Figure 7-33: Required Parameters for Quadratic Overdose
This cost function requires you to assign a parameter that is the Maximum Dose
beyond which a penalty is incurred. Figure 7-34 graphs the shape of the Quadratic
Overdose cost function curve. The isoconstraint is the (Root Mean Square) RMS Dose
Excess the amount of violation of the prescription you are willing to accept. This value
is comparable with the positive dose-variance above the reference dose you are willing
to accept.
Figure 7-34: Quadratic Overdose Constraint
7-36

IMRT Constraints
Quadratic Overdose (cont.)
This cost function plays an essential role for targets. Without a dose-limiting cost
function, the Target EUD objective is bound to push the dose up to values higher than
the prescription. A quadratic overdose cost function is ideal to prevent this (that is, if
the Maximum Dose is set to the prescription dose in the target volume, and the RMS
Dose Excess to a moderate value to control target hot spots). For example, 70 Gy/ 1 Gy
is a commonly used practical value.
The root mean square of a set of values is determined when you use this equation:
∑ D( x) 2
D represents the voxel dose in excess of the Maximum Dose and n represents the total
number of voxels. Only dose values above the Maximum Dose are considered.
Calculating a Root Mean Square for Dose Excess
Consider a simple structure divided into four voxels. The Maximum Dose prescription
is 70 Gy and the RMS Dose Excess is 2 Gy. The dose above 70 Gy appears in each
voxel.
If the root mean square of the Maximum Dose, plus the dose excess is greater than 72
Gy, the constraint is not met and the optimizer must try harder to reduce the dose
excess.
Monaco® 7-37

IMRT Constraints
Quadratic Overdose (cont.)
= 2.65 Gy
2.65 Gy is greater than the RMS Dose Excess of 2 Gy (or

72.65 Gy is greater than 72 Gy), so the optimizer has to
keep working to lower the excess to 2 Gy.
NOTE: For further application of quadratic overdose, refer to the Planning

Suggestions section under the Prescription heading.
Quadratic Underdose
This physical cost function is a constraint that implements a quadratic penalty for
underdose. Therefore, it implies that its structure is a target volume. You should
handle this constraint with caution. It may result in an infeasible configuration of the
optimization problem. Use this in conjunction with Pareto Mode to shift priority from
OAR constraints to Target objectives.
Figure 7-35: Required Parameters for Quadratic Underdose
7-38

IMRT Constraints
Quadratic Underdose (cont.)
This cost function requires a parameter that is the Minimum Dose allowable in a
target. The isoconstraint is the RMS (Root Mean Square) Dose Deficit the amount of
violation of the prescription you are willing to accept. It is analogously applied as the
RMS Dose excess. Figure 7-36 graphs the shape of the Quadratic Underdose cost
function curve. This isoconstraint works like an objective, may not be met when you
apply contradictory constraints.
The root mean square of a set of values is determined when you use this equation:
∑ D( x) 2
D represents the voxel dose below the Minimum Dose. n represents the
n
total number of voxels. Only dose values below the Minimum Dose are considered.
NOTE: The same concept as RMS dose excess applies to RMS dose deficit. See the
Quadratic Overdose section for an example of how a root mean square is
calculated.
Monaco® 7-39

IMRT Constraints
Quadratic Underdose (cont.)
Quadratic Underdose
Minimum Dose = 70 Gy
400
350
300
250
Penalty
200
150
100
50
0
-50 50 55 60 65 70 75 80 85 90
Minimum Dose
Figure 7-36: Quadratic Underdose Constraint
7-40

IMRT Constraints
Maximum Dose
This physical cost function is a constraint you can use with either targets or OARs. It
is effectively a hard barrier. This penalty kicks in “all at once” whenever voxels cross
the maximum dose threshold, so it can be troublesome. It may be preferable to use the
Quadratic Overdose constraint with a small RMS Dose Excess (0.1 Gy) in most cases.
Figure 7-37: Required Parameters for Maximum Dose
The isoconstraint is the maximum tolerated dose, Maximum Dose, which is not
exceeded anywhere (any voxel) within the structure. Figure 7-38 graphs the shape of
the Maximum Dose cost function curve.
Figure 7-38: Maximum Dose Constraint
Monaco® 7-41

IMRT Constraints
Overdose DVH
This physical cost function is the equivalent of a DVH constraint for an OAR. When
you add more than one DVH constraint to a structure, the values for dose and percent
(%) volume (Figure 7-39) must be consecutive so that they create a single continuous
curve.
Figure 7-39: Required Parameters for Overdose DVH Constraint
This constraint requires two parameters: the Objective Dose and the Isoconstraint
Maximum Volume. When you apply this cost function, it keeps the volume that
receives more than the objective dose below the isoconstraint, which is given as a
percentage of the total volume. For example, use this constraint if you want no more
than 50% of a structure to receive a dose in excess of 60 Gy.
7-42

IMRT Constraints
Overdose DVH (cont.)
The constraint
controls only a
single point.
Figure 7-40: How an Overdose DVH Constraint Controls the DVH Curve – both
DVH curves are effectively equivalent for this DVH constraint.
Monaco® 7-43

IMRT Constraints
Underdose DVH
This physical cost function is the equivalent of a DVH constraint for targets. If you
add more than one DVH constraint to a structure, the values for dose and % volume
(Figure 7-41) must be consecutive so that they create a single continuous curve. You
should handle this constraint with caution. It may result in an infeasible configuration
of the optimization problem if used together with dose limiting constraints.
Figure 7-41: Required Parameters for Underdose DVH Constraint

It requires two parameters, the Objective Dose and the isoconstraint Minimum
Volume. When you apply this cost function, it keeps the volume that receives less than
the objective dose above the isoconstraint, which is given as a percentage of the total
volume. For example, use this constraint if you want at least 80% of a structure to
receive a dose of at least 50 Gy.
Figure 7-42: How an Underdose DVH Constraint Controls the DVH Curve
7-44

IMRT Constraints

Optional Parameters
Each cost function has its own set of optional parameters. Not all optional parameters
are available for each cost function. You do not have to use the optional parameters to
optimize a plan. However, when used appropriately, they could increase your chances
of creating a better plan.
Figure 7-43: All Optional Parameters
Shrink Margin
When you apply IMRT Constraints to structures close to the target volume, this may
cause an underdose of the target because the dose gradient gets pushed in. Therefore,
it is often desired to limit the effect of the constraint on the target. For example, you
could apply a Quadratic Overdose to the unspecified normal tissue to ensure
conformality. You can specify this shrunken margin for any structure (OARs or other
competing targets) to avoid the application of IMRT Constraints to the voxels near the
compromised (objective) target. Essentially, the application of a shrink margin moves
the dose gradient out of the target and into the OAR or competing target.
You can apply this optional parameter to all cost functions, except Target EUD, Target
Penalty, Quadratic Underdose, Underdose DVH, and Conformality. Use shrink
margin when you have competing cost functions that are immediately adjacent to each
other or overlapping. Competing cost functions could be a target and an OAR
(constraint), or a target and the dose limiting constraint of a second target. The shrink
margin values are based on the fact that Monaco determines the shrink margin size
based on multiples of the grid spacing. Example: If you have 0.3 cm grid spacing and
select a 0.5 cm shrink margin, Monaco uses a 0.6 cm shrink margin because it rounds
up to the closest multiple of the 0.3 cm grid spacing.
Monaco® 7-45

IMRT Constraints
Optional Parameters
Shrink Margin (cont.)
Figure 7-44 shows a head and neck case where a 0.6 cm shrink margin was applied to
the quadratic overdose cost function of the unspecified tissue defined by the patient
external contour. The purpose of this is to enable the voxels near the targets and other
OARs to have a “transition zone” between competing cost functions. The cost function
for the unspecified tissue is only applied to the area shaded in red during optimization.
Notice that the applied margin only shrinks away from target structures.
Figure 7-44: Application of Shrink Margin/OAR Structure
7-46

IMRT Constraints
Optional Parameters
Shrink Margin (cont.)
Figure 7-45 shows a head and neck case where GTV is inside CTV. It depicts applying
a shrink margin to a Quadratic Overdose cost function of the CTV to create a dose
gradient between CTV and GTV. The Quadratic Overdose cost function for CTV will
be applied to the area shaded in red only. The area between the two structures that is
not shaded in red has no penalty (not used by the constraint) applied to it, so it should
provide better coverage to GTV.
Figure 7-45: Application of Shrink Margin/Target Structure
NOTE: For further application of shrink margins, refer to the Planning

Suggestions section under the Prescription heading.
Monaco® 7-47

IMRT Constraints
Optional Parameters (cont.)
Surface Margin
This optional parameter applies to the Target EUD, Underdose DVH, and Quadratic
Underdose cost functions. Each of the cost functions that Surface Margin applies to
penalizes for underdoses. Its application lets the cost function essentially ignore the
low dose in a structure where it intersects the buildup region.
When you select this option, Monaco applies the Surface Margin in the IMRT
Prescription Parameter dialog box to the selected cost function.
You should use Surface margin on superficial targets. When you select a surface
margin for a particular cost function, that cost function only applies to voxels inside
the structure (with the exception of the voxels that lie within the surface margin
distance). The Surface Margin distance value range is 0.00 to 1.00 cm from the patient
surface.
7-48

IMRT Constraints
Optional Parameters
Surface Margin (cont.)
The example in Figures 7-46 and 7-47 shows the cost function occupancy where a 0.5
cm surface margin was applied and the same cost function occupancy without surface
margin. Only the voxels shaded in red are optimized.
Figure 7-46: Surface Margin of 0.5 cm Figure 7-47: No Surface Margin Applied
Applied to Target EUD Cost Function
Monaco® 7-49

IMRT Constraints
Optional Parameters
The effects of Surface Margin are shown in Figure 7-48. Two plans that show a
comparison of the dose distribution to a superficial brain target:
NoSurfMargin - No Surface Margin was applied
SurfMargin - Surface Margin was applied
NoSurfMargin-SurfMargin – Shows the dose difference between the two plan
Figure 7-48: Application of Surface Margin
7-50

IMRT Constraints
Optional Parameters
The DVH in Figure 7-48 shows that for this case:
The target coverage does not vary much from plan to plan (see NOTE below).
The dose to the patient (unspecified tissue) structure increases significantly for the
plan that does not use surface margin. This also shows well in the subtracted plan.
NOTE: If the target contour is drawn out to the patient’s surface and surface
margin is applied, the dose that intersects the target and the buildup region
may have a significantly lower dose when surface margin is applied. You
must consider this when you determine the acceptable percent coverage to
the target.
The benefits when you use Surface Margin (Figure 7-48) are:
• Decreased MU/fx for fields that flash over the surface of the patient
• Decreased Total MU/fx for the entire plan
• Decreased Global Max dose for the entire plan
When you draw a target in the buildup region and you do not apply Surface Margin,
fields that flash over the patient surface attempt to compensate for the low dose in the
buildup while trying to bring the target dose closer to the prescription.
This can be a problem as demonstrated in Figure 7-49. Notice the difference in the
Relative MU value for the same voxel in the two images.
Monaco® 7-51

IMRT Constraints

Optional Parameters
Figure 7-49: Comparison of BEV With and Without Using Surface Margin
7-52

IMRT Constraints
Optional Parameters (cont.)
Optimize Over All Voxels in Volume
You can apply this optional parameter to any cost function. It is recommended that
you apply this option to a Serial cost function. Due to the volume-effect of the serial
cost function, you will typically want to apply the constraint to the entire volume of
the structure.
When you select the option to “Optimize over all voxels in volume” on the
prescription panel for a specific cost function and a specific structure, you are making
the decision that the cost function applies to the total volume of the structure,
regardless of the structure layering. If there is overlap with another structure, the cost
functions for both structures are applied to the overlapped voxels.
When you use Optimize over all voxels on a parallel cost function where the structure
overlaps or is very close to a target, often gives little improvement to your plan since
the parallel cost function does not “work hard” on limiting hot spots.
Figure 7-50 and 7-51 shows a head and neck where the GTV, CTV and PTV overlap
the Parotid. Figure 7-50 shows the cost function occupancy of the Parallel cost
function on the parotid when Optimize Over all Voxels is applied. In this case, in the
area where the targets and parotid overlap, both the target cost functions and the
parotid cost function are applied. Figure 7-51 shows the cost function occupancy of
the Parallel cost function on the parotid when Optimize Over all Voxels is not used. In
this case, the Parallel cost function on the parotid is only applied to the voxels shaded
in red.
Monaco® 7-53

IMRT Constraints
Optional Parameters
Optimize Over All Voxels in Volume (cont.)
Figure 7-50: Parallel Cost Function Figure 7-51: Parallel Cost Function
Occupancy with Optimize Occupancy without Optimize
Over all Voxels Over all Voxels
Multicriterial
This optional parameter applies to Parallel, Serial, and DVH cost functions. When
applied, the cost function becomes a secondary objective. It actually tries to achieve an
even lower dose (tighten the constraint) to the selected OAR as long as it can still meet
the target objective.
NOTE: See the Monaco Planning and Workflow section for a more detailed
explanation of multicriterial. Also, see the Planning Suggestions section
under Optimization for further application of multicriterial.
7-54
Monaco Training Guide
Monaco Cost Functions Quick Reference
Optimize
Cost Reference Total Shrink Surface
Function Type Applied To Isoconstraint Dose Multicriterial Volume Margin Margin Notes
Dose at a
specified This is the objective version of the
Target reference Quadratic Underdose constraint.
Penalty Objective Target volume Prescription YES YES
Biological Cost Function. Cost
function for Targets. No Penalty for
Target EUD Objective Target Rx Dose (EUD) YES YES hot spots.
Biological Equivalent of Overdose
DVH Constraint.
Constraint
or Reference Reference Dose is the dose that when
Secondary Mean Organ Dose applied uniformly to an organ, 50%
Parallel Objective OAR Damage (%) (EUD) YES YES YES of that organ will be damaged (TD 50 ).
Constraint
Biological Cost Function.
or EUD
This applies large penalties for hot
Secondary Equivalent
spots.
Serial Objective OAR Uniform Dose YES YES YES
RMS
Root Mean You most often use this with Target
Quadratic Square Maximum EUD to reduce hotspots in the target.
Overdose Constraint Target OAR Dose Excess Dose YES YES
RMS When you use this cost function, it
Root Mean could cause the plan to be infeasible
Quadratic Square Minimum due to the powerful nature of the
Underdose Constraint Target Dose Deficit Dose YES YES constraint.
Constraint You use this to shape the high dose
or volume tightly around a target
Secondary volume without being too restrictive
Conformality Objective OAR Dose Decay YES YES to the optimum dose.
55
Monaco® 7-55
Optimize
Cost Reference Total Shrink Surface
Function Type Applied To Isoconstraint Dose Multicriterial Volume Margin Margin Notes
This acts as a hard barrier on each
voxel of the applied structure.
Maximum Maximum Quadratic Overdose preferred over
Dose Constraint Target OAR Dose YES YES this constraint.
Constraint
or
Physical DVH Constraint for OAR
Overdose Secondary Maximum Threshold
DVH Objective OAR Volume Dose YES YES YES
Underdose Minimum Threshold Physical DVH Constraint for Targets

DVH Constraint Target Volume Dose YES YES
56
7-56

IMRT Constraints
IMRT Constraints: Other
Rescale Dose
You can rescale dose on the Prescription tab on the Planning Control. You have
seven options to choose from in the Rescale Dose drop-down menu (Figure 7-52).
This option is not available during optimization.
Figure: 7-52: Rescale Dose Drop-Down Menu
Name Description
to mean dose of structure Structure field appears
to max dose of structure Structure field appears
to dose at point All available points appear
to relative isoline You can type a value for the % isoline in the
number field that appears
to absolute isoline You can type a value for the cGy or Gy isoline in
the number field that appears
Monaco® 7-57

IMRT Constraints
Rescale Dose (cont.)
1. Type a value in the box next to Gy.
2. Click the drop-down arrow to the right of the to… field.
3. Select a rescale option from the drop-down menu.
4. Select and/or type values associated with the rescale option.
Enabled
This field lets you manually turn cost functions off or on during the optimization
when you place or remove the checkmark in the box. If the optimization is close to
completion, it is possible that it will finish before the change takes place. The Status
field indicates whether the cost function was on or off during the optimization.
Bias Dose (only shows for Bias Dose Plans)
To make a Bias Dose Plan, you can right-click on the plan and select New Bias Dose
Plan. Then select the CT set it is based off of. (Figure 7-53)
Figure 7-53: New Bias Dose Plan
58
7-58

IMRT Constraints
Bias Dose (only shows for Bias Dose Plans) (cont.)
If you have multiple prescriptions, you can use the Bias Dose option in the IMRT
Prescription Parameters dialog box. Figure 7-54)
Figure 7-54: Bias Dose Plan option for Multiple Prescriptions

Then you can enable or disable the Bias Dose option on the IMRT Constraints
options. This field lets you select which cost functions you want to apply to Bias Dose
during the optimization of the composite plan.
Typically, you leave Bias Dose for the target cost functions unchecked. In addition,
you type the prescription for the current plan for the target(s) and the prescription for
the composite plan for the organs at risk. This lets the system create well-defined
target dose(s) for the current plan and take into account the total dose limitations of
the organs at risk. (Figure 7-55)
Figure 7-55: Enable and Disable Bias Dose on IMRT Constraints
Monaco® 7-59

IMRT Constraints
IMRT Constraints: Other (cont.)
Status
This field shows the status of the cost function in the optimization. The status levels
are:
On — the optimizer is using the cost function.
Off — you manually turned the cost function off so it is not used during the
optimization, or the optimizer turns the cost function off since the constraints were
not affecting the objective cost function. The latter usually occurs when the constraint
prescriptions are considerably higher than the current dose distributions.
Offending — the constraint value is unreasonably high and causes numerical

problems. Verify that the prescribed constraint is what you intended, or relax the
prescription.
Infeasible —the values you typed in for the cost function are not reasonable. The
optimizer may attempt to change the value of the isoconstraint for a few iterations, but
it stops trying if the solution does not get closer to feasible. Make reasonable changes
to the prescription or isoconstraint and optimize again, if necessary.
Manual Weighting
The Manual field lets you select which cost functions you want to manually weight.
The Weight column shows the actual weights used by the optimizer during
constrained optimization. You can check manual weighting for a cost function while
the others are still controlled by the optimizer. You can also click on the Manual
heading to turn on all cost functions for manual weighting.
Typically, you leave the manual weighting unchecked during optimization. You can
turn on manual weighting for all cost functions for the final calculation in order to fine
tune constraints based on the DVH results.
60
7-60

IMRT Constraints
Isoeffect
The isoeffect is defined as the equivalent effect of a given dose distribution for each
individual complication or cost function. In some cases, the isoeffect is an equivalent
uniform dose (EUD). This volumetric dose represents the homogeneous dose to some
reference volume that causes the same effect as the given dose distribution. In other
cases, the isoeffect is the percentage of maximum damage or destroyed fraction of the
organ volume. Monaco calculates the isoeffect for each cost function for you and
continuously updates them on the IMRT Constraints dialog box during optimization.
Isoconstraint
The definition of the isoconstraint is the maximum permissible total effect for each
individual complication or objective. The isoconstraint value you type in may be a
dose or percent volume. This depends on the cost function selected. The isoconstraint
is the accepted upper limit of the isoeffect for any cost function treated as a constraint.
For objectives, the isoconstraint is interpreted as a desired value, but may not be
reachable. Typically, the isoconstraint is a value typed in by you. However, there are
two cases when Monaco may change the isoconstraint value. One case occurs when
multicriterial is turned on. Monaco lowers the isoconstraint, if possible, to achieve a
secondary objective. Another case may occur when a cost function is infeasible.
Monaco may try to change the isoconstraint of the offending cost function in an
attempt to gain feasibility.
Reference Dose
This value may be a Minimum or Maximum Dose of a physical constraint. It

designates the dose value at which the physical penalty becomes active (relevant for
Quadratic Overdose/Underdose and DVH constraints).
Monaco® 7-61

IMRT Constraints
Multicriterial
You can treat constraints such as Serial, Parallel, and Overdose DVH cost functions as
secondary objectives when you select the multicriterial option. This action changes the
constraint to a secondary objective that improves only after the “primary” target
objective(s) is/are met. If the optimizer can still reach the target objective without
being compromised by prescribed constraints, it begins to tighten the value of the
isoconstraint for the Serial, Parallel or Overdose DVH constraint. This means that
Monaco attempts to get the OAR dose as low as possible. This option does not take
any effect if the target objectives cannot be met, that is, because some constraints are
dose limiting.
The example in Figure 7-56 shows the difference in dose to the rectum if you use dose
points (solid green line), Serial (dotted green line) or Serial with Multicriterial (dashed
green line). Notice that the dose to the target for each plan is not compromised for
better rectum avoidance.
Figure 7-56: Comparison of methods to limit dose to Rectum
NOTE: For further application of multicriterial, refer to these sections:
 Cost Functions, under the Optional Parameters heading

 Planning Suggestions, under the Optimization heading
62
7-62

IMRT Constraints
Relative Impact
The relative impact is an indicator that shows how hard the optimizer is working on a
particular constraint at any given time during the optimization. The indicators are:
Blank- Cost function is an objective or is not being used (inactive) by the optimizer.
Relative impact is 0.
+ Relative impact of the cost function on the optimizer is greater than 0 but less
than 0.25.
++ Relative impact is greater than 0.25 but less than 0.5.
+++ Relative impact is greater than 0.5 but less than 0.75.
++++ Relative impact is greater than 0.75 but less than 1.0. This always represents the
most dose limiting constraints.
Optimization Modes
The system offers two optimization modes: Constrained (Normal Tissue Priority) and
Pareto (Target Volume Priority).
Constrained Optimization Mode
Constrained mode lets you place priority on normal tissue constraints. All normal
tissue constraints are met at the risk of not meeting the target objective.
Example of Constrained Optimization:
If you use an underdose volume constraint on a target and a constraint on an OAR is

not being met because of it, the underdose volume constraint on the target will be
relaxed first so the OAR constraint may be met.
Monaco® 7-63

IMRT Constraints
Optimization Modes (cont.)
Pareto Optimization Mode
Pareto mode lets you place priority on constraints used to set minimum doses on
targets, for example, Quadratic Underdose, or Underdose DVH. Target doses are met
at the risk of not meeting the normal tissue constraints.
Example of Pareto Optimization:
If you use an underdose volume constraint on a target and a constraint on an OAR is

not being met because of it, the constraint on the OAR will be relaxed first so the
underdose volume constraint on the target may be met.
NOTE: When you use Pareto Mode, it may cause the prescription for conflicting
OARs to become infeasible.
Exercises
Go to the Practice Exercise section of the Training Guide to complete the following
exercises:
• Editing IMRT Constraints
• Adjustment to Serial Power Law (k)
• Adjustment to Parallel Power Law (k)
64
7-64
Planning and Workflow: Optimization and Sequence Parameters
Optimization
This section discusses the optimization of Monaco plans. In Dose Based

Optimization, beamlet intensities are weighted to achieve a desired dose
distribution. In Evidence Based Biological Optimization, beamlet intensities are
weighted via biological models such that the calculated dose distribution yields a
known tissue response1. Monaco uses both dose based and biological cost
functions.
After you type the prescription information into the system, it is time to begin the
optimization process. Monaco uses a two-stage process of optimizing dose
distributions. Generally, in stage one, the “ideal fluence” distribution of beams is
optimized to meet a user-defined prescription for a single set of beams. In stage
two, the ideal fluence distribution is translated into a set of segments where the
shapes and weights are optimized based on the same prescription.
Because Monaco uses a combination of objectives and constraints to calculate the

objective function during optimization, all targets and organs at risk should
appear on the IMRT Constraints page when you optimize.
NOTES: You must have at least one objective and one constraint defined in
your prescription before you can begin optimization.
You must apply some cost function to the “patient contour” structure
and, in most cases, list it as the last structure in the layering order.
It may be useful for you to understand how Monaco re-samples the patient to
create voxelized structures for optimization. This effects how cost functions are
applied to the structures. For detailed information, see the Monaco Patient Model
section of this guide.
On occasion, you may want to batch the optimization process such that both
stage one and stage two are performed to completion without a pause in between.
You can do batch optimization when you click the Batch Optimization button
instead of the Start Optimization button.
NOTE: If you skip forward or skip back during a batch optimization, you
may have to skip forward or backward twice. This depends on the
phase of the batched optimization when you selected the skip option.
Monaco® 8-1 8-1

Optimization (cont.)
Step and Shoot IMRT Delivery Mode
Stage One – Fluence Optimization

Stage one of the optimization process works as follows:
1. When you start the Initialization process, the system creates the dose
calculation cube around all defined structures and calculates the structure
volumes using cubic voxels.
2. The system projects the union of all target volumes, plus defines the margin
as the Target Margin on the IMRT Calculation Properties dialog box, in a
BEV.
3. Beamlets for each beam are created. Beamlet width is user defined. The
beamlet length is the length of the individual MLC leaves.
4. Monaco uses an enhanced pencil beam algorithm to calculate the open field
dose. Then, the fluence optimization begins in which the weights (fluence)
of all individual pencil beams are varied simultaneously.
5. The system then solves an unconstrained problem using a conjugate

gradient algorithm.
8-2
Stage One – Fluence Optimization (cont.)
6. After the unconstrained optimization finishes, if necessary, Monaco

changes each cost function’s relative weight to make the optimizer meet the
isoconstraints and restarts the unconstrained optimization problem.
7. Stage 1 optimization continues until all the constraints are met or the
weighting hits a pre-determined threshold, at which time the constraint is
identified as infeasible.
When Monaco evaluates the effects of individual constraints on prescribed

objectives, it gives you information on the potential to improve the plan by
relaxing specific constraints. In other words, after the optimization, Monaco gives
feedback for each target volume and defines which constraint should be relaxed
in order to improve target coverage. This feedback appears on the Sensitivities
tab of the IMRT Constraints dialog box. Constraints which limit the dose to
targets have high values in sensitivity, as opposed to constraints that are inactive
or do not limit the dose to the target which show low values.
Serial, Parallel, and DVH Constraints can also be set as “multicriterial” or in

other words, set as secondary objectives. These constraints are subsequently
tightened throughout the optimization process as long as they are not the
limiting constraints to the objective.
NOTE: See the Plan Analysis Tools section for information on the tools
available during and after stage one optimization.
Stage Two – Aperture Optimization and Dose Calculation

After you complete the fluence optimization, you can do any of these tasks:
• Review the optimized results
• Make edits to the prescription
• Re-optimize stage one
• Directly launch into the second stage of optimization where you optimize
the apertures (segment weights and shapes)
Monaco® 8-3 8-3

Optimization
Stage Two – Aperture Optimization and Dose Calculation (cont.)
You can only select Pencil Beam for stage 1 of optimization. You must use Monte
Carlo dose algorithm for stage 2.
Segmentation of IMRT plans often introduces an unwelcome reduction in the

quality of dose distributions. When you apply fluence smoothing constraints, and
include the technical limitations of the MLC in the optimization problem,
Monaco can overcome this limitation and deliver efficient step-and-shoot beams
with fewer segments and MUs – directly translating to faster QA and less time
required for patients on the treatment couch.
8-4
Optimization
Stage two of the optimization works as follows:
1. Monaco extracts and loads the Fluence weight profiles into a static
sequencer where segments are extracted and refined.
2. Monaco optimizes the beamlet and segment weights and uses the
constrained optimization where the Minimum MU/Segment is evaluated
and segments are refined.
3. When the problem is solved to the best of its ability, the optimizer
converges if Segment Shape optimization is not checked. If it is checked, the
optimizer determines if another round of refinement and optimization is
allowed or needed. This is called Smart Sequencing. If the optimizer
decided another round could be useful, it will send the problem back to the
static sequencer mentioned in step 1 and continues through step 4. The
secondary algorithm is used during the final iteration.
4. The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot
Beamlets to guide the segment shape changes made during Segment Shape
Optimization. Monaco creates a large number of Pilot Beamlets if you use
large highly modulated treatment fields, multiple VMAT arcs and a small
arc increment. When a large number of Pilot Beamlets, which are stored in
memory, are created they can use all the RAM the system has. This slows
the process exponentially. Disabling this option removes the creation of
pilot beamlets from the SSO process. Pilot beamlets do not affect
performance for the majority of treatment plans. You should only disable
them if the plan takes a long time to converge.
NOTE: Use the Windows Task Manager to check the RAM utilization
of your system if you suspect the plan is taking too long to
converge.
Monaco® 8-5 8-5

Conformal RT Delivery Mode
Stage One – Optimization

1. While in the Initialization Process, the system creates the dose calculation
cube around all defined structures and calculates structure volumes using
cubic voxels.
2. The system projects the union of all target volumes, plus the margin defined
as the Target Margin on the IMRT Calculation Properties dialog box in a
BEV.
3. The system uses an enhanced pencil beam algorithm to calculate the open
field dose.
4. The system then solves an unconstrained problem using a conjugate

gradient algorithm.
5. After the unconstrained optimization is done, if necessary, Monaco changes

each cost function’s relative weight to make the optimizer meet the
When you evaluate the effects of individual constraints on prescribed objectives,

Monaco gives information on the potential to improve the plan by relaxing
specific constraints. In other words, after the optimization, Monaco gives
targets have high values of sensitivity, as opposed to constraints that are inactive
or do not limit the dose to the target which shows low values.
8-6
Optimization
Conformal RT Delivery Mode
Stage One – Optimization (cont.)
You can also set Serial, Parallel, and DVH Constraints as “multicriterial,” or in
tightened throughout the optimization process as long as they do not limit
constraints to the objective.
After you complete stage one optimization, you can do any of these tasks:
• Review the optimized results
• Make edits to the prescription and re-optimize stage one
• Directly launch into the second stage of optimization where you calculate
the final dose with the Monte Carlo algorithm
Monaco® 8-7 8-7

dMLC Delivery Mode

cube around all defined structures and calculates the structure volumes
with cubic voxels.
2. The system projects the union of all target volumes, plus the margin defined
BEV.
3. The system creates beamlets for each beam. Beamlet width is user-defined
and the beamlet length is the length of the individual MLC leaves.
field dose. Then, the fluence optimization begins in which the weight’s
(fluence) of all individual pencil beams is varied simultaneously.
5. The system then solves an unconstrained problem with a conjugate

gradient algorithm.
6. After the unconstrained optimization is done, if necessary, Monaco changes

each cost function’s relative weight to make the optimizer meet the
When you evaluate the effects of individual constraints on prescribed objectives,

Monaco can give information on the potential to improve the plan by relaxing
specific constraints. In other words, after the optimization, Monaco gives
targets have high values of sensitivity, as opposed to constraints that are inactive
or do not limit the dose to the target which show low values.
8-8
Optimization
dMLC Delivery Mode
Stage One – Fluence Optimization (cont.)
You can also set Serial, Parallel, and DVH Constraints as “multicriterial,” or in
tightened throughout the optimization process as long as they are not the
limiting constraints to the objective. The optimizer works to maintain the target
dose coverage at the same time.
Monaco® 8-9 8-9

Optimization
dMLC Delivery Mode (cont.)

The sequencing algorithm used for dMLC is called the Sweep Sequencer, and is
the same as used for the basis of VMAT sequencing. It is similar in nature to
sliding window sequencers, but different in that it has significant improvements
to improve delivery efficiency and minimize loss of dose quality.
The basic paradigm of the Sweep Sequencer is that the leaves move from their
start to their end position in a continuous, unidirectional manner. When you
move the leaves across the field from one side to the other, vary the leaf speeds
and thereby the gaps between opposing leaves, the system modulates the intensity
of the delivered fluence. Changing the leaf gap is accomplished by either
accelerating the leading leaf (more fluence) or the trailing leaf (less fluence). At
least one leaf moves at maximum velocity at any given time to provide for the
shortest possible delivery time.
1. Starting with the optimized fluence profiles from stage 1, the system
converts each profile to a series of leaf trajectories (that is, leaf position as a
function of MU). All trajectories are synchronized to arrive at the same MU
count for all leaf pairs. Monaco uses the beamlet width to sample these leaf
trajectory positions.
2. You translate the leaf trajectories into piecewise linear movements between
control points. You can control the coarseness of this decomposition, or
total number of control points when you use the parameter, Max # Control
Points / Beam. In general, the system inserts a control point whenever a
single leaf changes velocity.
3. The system does weight optimization on resulting segments and repeats the
optimization until it converges.
4. If you leave SSO checked, segment shape optimization combines segments

and re-weights them in order to create better plan quality and more
efficient delivery times.
8-10
Optimization
dMLC Delivery Mode
NOTE: Use the Windows Task Manager to check the RAM use of your
system if you suspect the plan is taking too long to converge.
Monaco® 8-11 8-11

VMAT Delivery Mode

cubic voxels.
2. The system projects the union of all target volumes and defines the margin
BEV.
3. The system calculates a number of static sectors that the optimizer uses to
create rays based on the Arc and the Increment you selected.
4. The system creates beamlets for each sector. Beamlet width is user-defined
and the beamlet length is the length of the individual MLC leaves.
field dose. Then, the fluence optimization begins in which the weights
(fluence) of all individual pencil beams are varied simultaneously.
6. The system then solves an unconstrained problem. It uses a conjugate

gradient algorithm.
7. After the unconstrained optimization completes, if necessary, the system

changes each cost function’s relative weight to make the optimizer meet the
8. Stage one optimization continues until all the constraints are met or the
weighting hits a pre-determined threshold, at which time, the constraint is
8-12
Optimization
VMAT Delivery Mode (cont.)

1. Stage two takes each fluence map and sequences it in such a way that it is
spread over the original sector that it represents. The system determines leaf
trajectories based solely on the Target Dose rate entered. If segment shape
optimization (SSO) is checked, the Target Dose Rate option is not available.
In this case, the sequencer controls the target dose rate to make sure it is
optimally set for the given plan.
NOTE: Use the Windows Task Manager to check the RAM use of your
system if you suspect the plan is taking too long to converge.
3. The system converts optimized fluences into a deliverable arc sequence with
multiple control points.
4. The system optimizes gantry positions. They are not necessarily equally
spaced.
5. Monte Carlo dose calculation takes place.
6. The system optimizes Segment Weights.
Monaco® 8-13 8-13

Optimization
VMAT Delivery Mode (cont.)
7. If you leave SSO checked, segment shape optimization combines segments

and re-weights them in order to create better plan quality and more
efficient delivery times.
NOTE: VMAT is available for Apex MLC when used with MCS 3.0.
Apex MLC cannot be used with a variable dose rate, so VMAT
with Apex is only available with Constant Dose Rate. The
Monaco VMAT segmenter is used, but the dose rate is not
modulated during Apex VMAT delivery.
Dynamic Conformal Arc Delivery Mode
Aperture Optimization and Dose Calculation

Dynamic Conformal Arc calculation only has one stage unless you check
Segment Shape Optimization (SSO) in the sequencing parameters dialog box.
The optimization process works like this:
cubic voxels.
8-14
Optimization
Dynamic Conformal Arc Delivery Mode
Aperture Optimization and Dose Calculation (cont.)
2. The system calculates a number of static sectors that the optimizer uses to
create rays based on the Arc and the Increment you selected.
3. Monte Carlo dose calculation takes place.
4. The system projects the union of all target volumes and defines the margin
as the Target Margin. Then, it removes any OARs that are set as Avoidance
with the Avoidance Margin specified on the IMRT Calculation Properties
dialog box in a BEV.
5. Arc weight optimization continues until it meets the best solution or the
weighting hits a predetermined threshold. At that time, the constraint is
6. The Sequencing Parameters: Dyn. Conformal Arc Delivery dialog box has a
Constant Dose Rate check box. By default, Monaco uses a constant Monitor
Unit per Degree of gantry rotation. Deselect the Constant Dose Rate check
box to vary the Monitor Unit per Degree of gantry rotation. This option is
not available (grayed out) for all add-on MLCs (Apex, all micro-MLCs).
7. When you select Segment Shape Optimization for Dynamic Conformal Arc
delivery, you can change the initial segment shapes to better meet the
prescription. (Refer to the VMAT SSO and Pilot Beamlet information in
this section for detailed information).
NOTE: When you use an Apex treatment unit while planning, if you
check SSO for a Dynamic Conformal Arc delivery plan, the
resulting plan may be undeliverable because the minimum dose
rate is violated.
Monaco® 8-15 8-15

Editing the Sequencing Parameters
This section introduces the sequencing parameters and how they apply to each
delivery mode. Before or after stage-two optimization, you have the opportunity
to edit the sequencing parameters. Click the Sequencing Parameters button
to view and edit the sequencing parameters for each type of delivery mode
(Figures 8-1 through 8-6). Table 8-1 shows which sequencing parameter applies
to which delivery mode. If you edit the sequencing parameters after stage two, the
system intelligently decides how far back to go in the calculation, which depends
on the parameter that was changed.
8-16
Editing the Sequencing Parameters (cont.)
Figure 8-1: Sequencing Parameters for Step and Shoot Figure 8-2: Sequencing Parameters for VMAT
Figure 8-4: Sequencing Parameters for Conformal RT
Figure 8-3: Sequencing Parameters for dMLC
Figure 8-5: Sequencing Parameters for DCA
Figure 8-6: Sequencing Parameters for mArc
Monaco® 8-17 8-17

Table 8-1: Sequencing Parameters for all Delivery Mode
Delivery Mode
Step and Shoot Conformal

Sequencing Parameter IMRT dMLC VMAT RT DCA mArc
Segment Shape
Optimization X X X X X
Min. Segment Area X
Pilot Beamlets x x x x x
Max Number of Segments
per Plan X
Max Number of Arcs
(Elekta and Varian) X X
Max # Control Points/Beam X
Max# Control Points/Arc X X
Target Dose Rate X* X* X*
Min Segment Width X X X X
Fluence Smoothing X X X
Min MU/Segment X X
Park Leaf Gap Under Jaw X
Max Sweep Efficiency X
Allow Move Only Segments X
Constant Dose Rate X X
Min. MU per Dynamic CP X
* Target Dose Rate for VMAT, dMLC, and VMAT is only available when you
uncheck SSO.
8-18

Segment Shape Optimization
When you check this option, you enable the system to do segment shape
optimization before it calculates the final dose. Segment Shape Optimization
includes smoothing, sequencing (clustering) and optimization of beam weights
and shapes. You can use segment shape optimization to refine the segment
shapes and apply it after the initial sequencing of the segments. It works the same
for these delivery modes: Step and Shoot IMRT, VMAT, dMLC, DCA, and mArc.
It is turned on by default and is highly recommended in order to give better plan
quality and decrease delivery times.
Segment Shape Optimization Characteristics
Optimization Time Increases
Plan Quality Increases
Delivery Time Decreases
Segment # Decreases
MU May Increase
Figure 8-7: Segment Shape Optimization Characteristics
Monaco® 8-19 8-19


Min. Segment Area (cm)
This value represents the smallest segment field area (cm2) you are willing to
accept in your plan. Use the default value of 0.5 for IMRT plans. You need to use
1.0 for VMAT SSO.
Max. # of Segments per Plan

Enter the maximum number of segments you want in the plan. If you do not have
a value saved in your plan template, this field defaults to 250 segments. This
parameter controls the maximum number of segments so that no new calculation
yields more segments than the value of this parameter.
Max. Number of Arcs (Elekta and Varian machines)

This value is the max number of rotations per arc that you want to use for an
Elekta or Varian VMAT plan. The recommended value is 2 for complex plans.
Max. # Control Points/Beam

This value represents the maximum number of control points per beam that you
are willing to accept for a dMLC plan.
Max. # Control Points/Arc

This value represents the maximum number of control points that you are willing
to accept for each VMAT arc.
VMAT Specific information:

When you use Elekta VMAT to plan, you can determine the value for max
number of control points per arc based on how complex the plan is. When you
use SSO, we recommend a range of 100-150 for highly complex plans. For simple
plans, you can use around 75-100 control points per arc.
When you use a Varian machine to plan VMAT, you can do simple plans in a
single arc rotation. When you have a more complex plan, more rotations are
necessary due to the linac limitations.
8-20

Target Dose Rate
This value is the desired dose rate you want to use to deliver a dMLC plan. SSO,
which is defaulted to ON, controls the Target Dose Rate for VMAT, dMLC. If the
segment shape optimization (SSO) is left on, the Target Dose Rate option is not
available. In this case, the sequencer controls the target dose rate to make sure it
is optimally set for the given plan. If SSO is turned off, Monaco uses Target Dose
Rate for VMAT and dMLC so that it knows the maximum possible distance the
gantry can travel between control points based on the machine’s available dose
rate. Monaco is sensitive to the Target Dose Rate and control point input you
type in. Therefore, we recommend that you keep SSO checked for VMAT, dMLC,
and mArc.
Recommended Ranges for Non-SSO VMAT:
• Elekta Specific Information: You must use a higher target dose rate for
simple plans. For more difficult plans, you must use a lower target dose
rate. The recommended range for all plans that use Elekta machines is
120-360.
• Varian Specific Information: When you use a higher target dose rate,
the number of rotations increases. It is possible that the number of
rotations can increase up to the defined maximum that you set. For
simple plans, we recommend you use a Target Dose Rate at Max (600)
which typically causes a total of 2 rotations. For complex plans, we
recommend a target dose rate of approximately 400, which typically
causes a total of 3 rotations.
We highly recommend that you use SSO which controls the dose rate
and results in better plan quality.
Monaco® 8-21 8-21


Min. Segment Width (cm)
This is the minimum distance between opposing MLC leafs you are willing to
accept. The recommended value is 0.5 cm.
Fluence Smoothing
The fluence smoothing parameter controls the smoothing of the fluence in stage
one of the optimization. Fluence smoothing options are Off, Low, Medium and
High. If you select Off or Low, this could cause the generation of too many
segments. If you select High, this could cause the fluence to be too smooth which
can degrade the final result. Medium is a recommended starting point.
Smooth ↑ Plan Quality ↓ Control Points ↓
8-22

Target Dose Rate (cont.)
Min. MU/Segment
This is the minimum Monitor Unit value you will accept for any segment the
system creates.
Park Closed Leaf Gaps Under Jaw

When planning using MLC models that allow interdigitation, the system
automatically creates more efficient segments by placing closed leaf gaps inside
the fluence map. The system optimizes dose leakage through the gaps and
contributes to the total dose delivered by the plan.
To override this feature, select the Park Closed Leaf Gaps Under Jaw option. The
closed leaves are instead parked under the jaw. This can add additional time to
the delivery in particular for beam modulator.
Max Sweep Efficiency

When you use Max. Sweep Efficiency, you can improve the MU efficiency during
sequencing of dMLC beams without negatively affecting plan quality. It positions
some leaf pairs further apart at the start or end of a sweep pattern and thereby
minimizes the overall leaf travel. For example, when you use the Max. Sweep
Efficiency option on a typical prostate plan, you can reduce the total number of
MU by 100 or more, with only a slight reduction in dose quality. The
recommended setting for this option is checked (on).
Monaco® 8-23 8-23


Allow Move Only Segments (dMLC Only):
When you check this option, you allow Move Only Segments for Elekta or Varian
linacs. Move Only Segments are segments without fluence that move the leaf
carriage to the next beam segment. Once the leaf carriage is in the starting
position for the next segment, the dose turns back on.
When you uncheck this option, the dose remains on during the entire beam
delivery. Your plan quality can decrease if you uncheck this option.
NOTES: This option was added in 3.10. Prior to 3.10, Monaco always allowed
move only segments.
ARIA Customers: If you check this option for dMLC planning

(recommended), you must set the machine “Field X” operation limit
motion mode to dynamic or multiple static segment in ARIA in order
to approve the treatment plan in RT Chart. Failure to do so could
potentially cause validation of fields to fail with this message
“ERROR: The fields below are large fields, but the defined machine
does not support them.”
Constant Dose Rate

The Constant Dose Rate option is only available for those Varian machines that
support constant dose rate. It is also available for MLCi/MLCI2, and Apex MLC
on Agility. When you check the Constant Dose Rate option, the system uses a
constant dose rate for your DCA or VMAT plan.
Min. MU per Dynamic CP

The Min MU per Dynamic CP is only available for mARC plans. This variable
gives you extra control over the plan quality. For simple single arc Prostate or
single lesion plans, you can increase this value to 3 or 4 to keep the level of plan
modulation down and improve the delivery efficiency. Siemens recommends a
minimum of 2.
8-24
Beam Splitting
For machines that are capable of splitting beams, beam splits are listed in Beam
Spreadsheet and appear in all T/S/C and BEV views. Monaco simply creates
segments with different jaw settings that avoid the carriage restriction. An
optional approach is to use the “Fixed Jaw” setting on the beam spreadsheet. You
can define the field sizes for each beam that does not violate the carriage
restriction. Monaco retains the resulting fluence and segments inside this jaw
setting.
Generally, this is how Monaco determines when to split beams.
1. First, it determines a set of potential carriage groups.
2. Next, it generates all segments that can be delivered without splitting.
3. It splits up the remaining fluence into segments. It starts from the side
where the leaves would appear at the most retracted positions. These
segments are split at the carriage group edge. No feathering is applied.
4. Finally, if carriage groups are present with few segments that could be
redistributed to other carriage groups, it deletes these. The jaw positions of
the carriage groups are shrunk to fit at the end.
5. Beam splitting is triggered by the combination of MLC parameters, like

maximum protrusion from neighboring leaf, minimum leaf tuck, etc. The
split beams are exported as separated beams with different jaw settings. The
beam names in the DICOM export appear as B1S1, B1S2, etc.
Exercises
Go to the Additional Cases section of the Training Guide to complete the “Optimization and Plan
Evaluation” exercise.
Monaco® 8-25 8-25

Planning and Workflow: Plan Analysis and Evaluation
Plan Analysis Tools
There are many tools available to analyze and modify your plan during and after
each optimization stage. You can only use some tools during or after a particular
stage. You can use some others at any time. Options that are only available
during or after a particular stage are noted in each section.
Showing the Console during Optimization
During optimization, you can optionally show internal status messages from the
optimizer. You can view the patient name, patient ID, studyset, plan name and
server name on the console title bar (Figure 9-1).
On the Workspace tab, click on the drop-down arrow below Controls and select
Optimization Console.
OR
Press Alt | C your computer keyboard.
When you save a plan, the log file is saved, each information line is time stamped
and you can recall it when you reopen the plan. You have the option to:
• Save the current file as a plain text file
• Print the saved file
• Email the file information
There are three view options at the top of the Console log:
• Auto Update
• Auto Scroll
• Always On Top
When the Auto Update and Auto Scroll boxes are checked, the Console log
automatically moves down when a new line is read. When you enable the Always
on Top option, the Console log stays on top of all other open windows.
Monaco® 9-1
Plan Analysis Tools
Showing the Console during Optimization (cont.)

At the bottom of the Console window in Message Filter, you can type in
keywords to filter through the messages in the console log.
Figure 9-1: Optimization Console
9-2
Plan Analysis Tools
Console Messages after Stage Two
Below are some useful messages that appear at the end of stage-two optimization.
Figure 9-2: Console Messages after Stage Two
Number of Segments/CP
This is the number of segments generated for a beam plan, or the number of
control points generated for a VMAT plan.
Number of Monitor Units
This is the total number of monitor units generated for this plan.
Monaco® 9-3
Plan Analysis Tools

Console Messages after Stage Two (cont.)
Estimated Total Delivery Time
The estimated total delivery time is, as it says, an estimate and does not include
the time individual machines need rotate the gantry to a new angle for beam
plans or to ramp up and beam on intermittently during a dynamic treatment. So,
this estimate may be close to the actual treatment time, or may be off by quite a
bit (this depends on the complexity of the treatment that is to be delivered).
Regardless, the Estimated Total Delivery Time is always shorter than the actual
delivery time.
Minimum # of MU for ideal delivery
This value is calculated based on the fluence profiles after sequencing and
depends only on the degree of modulation of the plan. This value is always lower
than the actual number of monitor units that the plan needs to deliver. Monaco
uses this value to calculate the estimated total delivery time. You can control this
value when you change your prescription and allow more dose to your organ at
risk or a less homogenous target dose.
Estimated MU efficiency
The estimated monitor unit efficiency shows how Monaco compares the efficient
the plan’s actual monitor units to the monitor units for the ideal delivery.
Therefore, the higher the efficiency the lower the total monitor units for the plan.
To increase the MU efficiency of the plan, lower the Minimum Dose Rate
Segment Shape Property.
Efficiency ↑ Total MU ↓ Min Dose Rate ↓
9-4
Plan Analysis Tools (cont.)
Evaluating Sensitivities
After each stage of optimization, use the Sensitivities information on the IMRT
Constraints dialog box to make informed decisions as to what prescription
trades-offs you can make to improve your plan. Guided by the Sensitivities tool,
you can easily solve the conflicts between target goals and dose-limiting
constraints.
After optimization, the Sensitivities tab is available on the IMRT Constraints

dialog box.
Figure 9-3: IMRT Constraints dialog box-Sensitivities tab
Sensitivity values of constraints appear for each target. When you place your
mouse cursor over any sensitivity value, Monaco shows the relationship of the
constraint to each objective. Each constraint represents a row, each target
objective a column. Along a target’s column, you can find the entry with the
highest value, which corresponds to the constraint limiting that target’s coverage
the most. Monaco links the changes of a constraint to a potential gain of EUD to
a target.
Another use for this tool is to assess the low sensitivity values. Very low
sensitivity values identify structures do not conflict with the target dose goal. This
indicates that changes made to the prescription for these structures will probably
have little to no effect on the dose to the target.
Once you determine what constraint you need to loosen, edit the Isoconstraint
value and re-optimize.
NOTE: Sensitivities are volume based. Therefore, small local hot or cold spots
may not be obvious when you use this table.
Monaco® 9-5
Plan Analysis Tools
Evaluating Sensitivities (cont.)
Point Sensitivity
You can use the mouse to determine the sensitivity of each constraint at a
particular point in the target(s). Higher values on the organs at risk indicate that
a change to the isoconstraint for that structure makes the most impact at that
point in the target(s).
With the sensitivities dialog box in view, click your mouse on any point inside the
target(s) on a transverse, sagittal, or coronal view. Point coordinates appear on
the bottom-right corner of the IMRT Constraints dialog box.
9-6
Using the Progress Meter
The progress meter (Figure 9-4) shows the convergence of the target structure(s)
objectives (red) and the max of all constraint violations (blue) applied to any
structure. It also shows the degree of modulation of all beams and sequences in
the plan (green). The graph updates with each iteration during the optimization.
Figure 9-4: Progress Meter
Target EUD(s)
Target EUD(s) demonstrates the average over all target objectives of the current
Target EUD(s). This means 1.0 indicates that on average, 100 percent of the
prescribed EUDs are achieved for the target(s). If the Target EUD(s) completed
above the 1.0 line, this indicates that the prescription to the target(s) was met, but
there may be hot spots. If the Target EUD(s) completed below the 1.0 line, this
indicates the prescription to the target(s) was under-achieved. Target EUD(s) is
calculated using the equation: Isoeffect/Isoconstraint. If there is more than one
target, then the average of all the targets isoeffects and isoconstraints are used in
the equation.
Monaco® 9-7
Plan Analysis Tools
Using the Progress Meter (cont.)
Constraint Violation
Constraint Violation (CV) calculates the maximum of all constraint cost

functions. If a constraint cost function equals zero, it is either inactive or the
isoconstraint has been reached (the isoeffect is smaller than or equal to the
isoconstraint). Therefore, you can use the maximum value of the CV to
determine convergence. A high value indicates that either the constraint is
violated or its current impact on the result is too large and has to be lowered in
order not to excessively reduce the target objectives. In the latter case, the CV
may show a large value even if all constraints are satisfied. (A slack constraint is
denoted as inactive).
You can determine a proper convergence (meeting all constraints) when the
objective function has been minimized and the CV equals zero.
NOTE: The range on the vertical axis of each graph changes during
optimization.
Modulation Degree
The modulation degree indicates the current total relative degree of modulation
of all beams and sequences. Monaco calculates this relative value. It divides the
total monitor units of all beams or sequences by the sum of [(Segment Area x
Segment MU)\Total Beam Area]. In general, more complex plans should have a
higher degree of modulation than simpler plans.
9-8
Using the Volume Cursor
These are the general instructions to view the volume cursor information.
1. Click the Volume Cursor button on the Planning tab.
2. Position the cursor over one of the CT or MR images and hold down your
left mouse button to show the cursor information (Examples shown
below).
P: Shows Hounsfield Units (CT only) and pixel Electron Density

information about the Primary Volume.
S: Shows relative pixel ED of the Secondary Image Volume.
D: Shows Dose or Raw Dose value at that point. You only see this when
you load a secondary image and you select isodose lines as the dose display
option.
G: Shows Grid Volume information, such as % Voxel Occupancy, Electron

Density Variation and Sensitivity values.
3. Hold down your left mouse button and drag the mouse. The cursor
information updates dynamically at each pixel as the cursor moves over it.
4. Press the Shift key and simultaneously hold down your left mouse and
drag across the image. The coordinates also dynamically update at each
pixel as the cursor moves across it.
5. Click the Volume Cursor button on the Planning tab to turn off the
volume cursor.
Monaco® 9-9
Grid Volume Toolbar
Figure 9-5: Planning Tab- Grid Volume Group
This section discusses the grid type options available in the Planning activity. Use
the volume cursor on the Main toolbar to show the information below in a
tooltip in any transverse, sagittal, or coronal view.
NOTE: The options below are voxel representations based on the calculation
grid resolution.
Dose
When you select this option, the calculated dose appears on the image set. You
can use the volume cursor to show the dose to a point. The range of dose color
values appears on the Grid Volume toolbar. You can edit the dose range and
values on the Isodose Control. You can use the Slider Bar to transition the
opacity of the dose shown on the primary image set.
9-10
Plan Analysis Tools
Grid Volume Toolbar (cont.)
Dose Raw
When you select this option, the un-interpolated dose returned from the
optimizer appears. Voxel size represents the actual calculation grid resolution.
The range of raw dose color values appears on the Grid Volume toolbar. You can
edit the dose range and values on the Isodose Control. You can use the Slider Bar
to transition the opacity of the dose that appears on the primary image set.
NOTE: You can only see Raw Dose when the dose display option selected is
not Isolines.
Electron Density
When you select this option, the electron density per voxel appears. The range of
electron density color values is editable on the Grid Volume toolbar. You also see
any density overrides, if assigned. You can use the Slider Bar to transition the
opacity of the electron dose grid that appears on the primary image set.
VOI Occupancy
When you select this option, the percent of 3D voxel occupancy for the selected
Volume of Interest (VOI) appears. Therefore, you must also select a Structure
drop-down option. The range of percent VOI occupancy color values is editable
on the Grid Volume toolbar. You can use the Slider Bar to transition the opacity
of the VOI occupancy grid that appears on the primary image set.
CF (Cost Function) Occupancy
When you select this option, the voxels assigned to a selected cost function
appear. Therefore, you must also select a Cost Function drop-down option. This
is a particularly useful tool to visualize the voxel occupancy where cost functions
compete. The range of percent CF occupancy color values is editable on the Grid
Volume toolbar. You can use the Slider Bar to transition the opacity of the cost
function occupancy grid that appears on the primary image set.
Monaco® 9-11
Plan Analysis Tools
CF (Cost Function) Variation
When you select this option as your secondary volume, along with a particular
structure’s cost function, the relative impact of that cost function on a voxel by
voxel basis appears for that structure. The cost function variation shows you
which voxels are most affected when you change the cost function parameters for
a given structure.
Consider the examples below. The first is a serial cost function variation on the
rectum (Figure 9-6). The higher penalty area appears in orange. The lower
penalty area appears in blue. There is essentially no penalty where there are no
colored voxels within the structure.
Figure 9-6: Cost Function Variation- Serial
9-12
Plan Analysis Tools
Grid Volume Toolbar

CF (Cost Function) Variation (cont.)
The second example is a parallel cost function on a parotid (Figure 9-7). The
highest penalty (appears in Red) is being applied to the voxels receiving the
Reference Dose entered in the prescription for that structure and cost function.
The lower penalty area appears in blue. There is essentially no penalty where
there are no colored voxels within the structure.
V
O
L
u
m
e
Ref Dose
Figure 9-7: Cost Function Variation- Parallel
The range of variation color values is editable on the Grid Volume toolbar. You
can use the Slider Bar to transition the opacity of the cost function variation grid
as it appears on the primary image set.
Monaco® 9-13
Plan Analysis Tools
CF (Cost Function) Relax Response
When you select this option and an associated Cost Function drop-down option,
you see the predicted, incremental change of the dose distribution if a given
constraint were to be relaxed by some small amount. Relaxing some constraints
can increase dose in some areas, but at the same time, can decrease dose in
others. This tool gives a visual representation of this effect. The range of color
values is editable on the Grid Volume toolbar. You can use the Slider Bar to
transition the opacity of the cost function relax response grid as it appears on the
primary image set.
CF Sensitivities
When you select this option and an associated Cost Function drop-down option,
the area that is most sensitive to changes made to the selected cost function
appear. You can use the volume cursor to show the percent sensitivity the
selected cost function has on a voxel (Figure 9-8). The higher the percent value,
the more sensitive the voxel is and therefore would be affected more if you made
a change to the selected cost function’s prescription. The range of color values is
editable on the Grid Volume toolbar. You can use the Slider Bar to transition the
opacity of the cost function relax response grid as it appears on the primary
image set.
Figure 9-8: CF Sensitivities
9-14
Plan Analysis Tools
Dose Uncertainty
When you select this option (only available at the end of stage 2 optimization),
the dose uncertainty per voxel appears. Dose uncertainty is greater the farther
away a voxel is from isocenter. The range of dose uncertainty color values is
editable on the Grid Volume toolbar. You can use the Slider Bar to transition the
opacity of the dose uncertainty grid as it appears on the primary image set.
Evaluating the Isodoses and Dose-Volume Histograms
You can evaluate the fluence-optimized isodoses and dose-volume histograms

before you continue with the second stage of optimization. Or, you canreview
them after the stage two optimization. You can evaluate the isodoses on the
transverse, sagittal, and coronal images or in a 3D view.
There are three types of dose-volume histograms you can review.
• Total Volume DVH
• Optimized DVH
• Optimized Total DVH.
Right-click in the DVH window to select these options.
Total Volume DVH
This DVH shows all structures that are turned on in the structure control list.
It uses the default grid resolution to calculate the DVH for the graph.
The volumes of the structures that appear are total volumes. Structures that
overlap belong to both volumes.
Monaco® 9-15
Grid Volume Toolbar

Total Volume DVH (cont.)
When the plan includes Bias dose, you can toggle the Total Volume DVH to
show the DVH dose based on the Composite plan or the Current plan when you
check/uncheck the Base plan dose on the Beam Visibility Control.
Optimized DVH
This shows the DVH dose based on the Current plan.
This DVH shows only the structures used in the prescription.
It uses the dose grid resolution of the optimized plan to calculate the DVH for
these structures. The volumes may be compromised based on the assigned
structure properties.
Optimized Total DVH (Bias Dose Plans only)

This shows the DVH dose based on the Composite plan.
This DVH shows only the structures used in the prescription.
It uses the dose grid resolution of the optimized plan to calculate the DVH for
these structures. The volumes may be compromised based on the assigned
structure properties.
NOTE: DVH statistics in the Planning activity always shows the total volume
DVH, not the Optimized DVH structure volumes.
9-16
Evaluating Intensity Maps and Monitor Units
To evaluate the intensity map and point MUs, you must first show the fluence
view. In Planning and QA activities, you can show the fluence view when you
right-click inside the lower left image window and select Show Fluence View. The
Planning Activity section also describes other fluence view options. At the end of
stage one or two, you can review the intensity map for each beam/sequence.
Review Segments and Monitor Units per Segment
Once the constrained aperture optimization is complete, you can review the
segments created in a BEV window (Figure 9-10).
Figure 9-10: Example of a Static Segment in a BEV
Toggle through the beams or sequences and segments. Use the controls on the
Fluence group on the Planning tab.
For more information about the Fluence group on the Planning tab, see the
IMRT Tools Section of this training guide.
Monaco® 9-17
Using the Fluence Statistics
The fluence statistics gives information regarding monitor units per fraction for
each beam/sequence (Figure 9-11).
The Area of the fluence appears per beam/sequence. Take the square root of this
value to derive the blocked equivalent square of the fluence map.
The point-wise Minimum, Maximum and Mean MU for each beam/sequence

appear here along with the Standard Deviation. Use these values to determine
dose delivery efficiencies.
The mean fluence is the sum of the fluences of the segment in MU weighted by
their area, divided by the total area covered by all segments of this
beam/sequence. Monaco can interpret this as the MU of this segment if it is an
un-modulated field.
A larger standard deviation typically translates to a more modulated

beam/sequence with more monitor units required to deliver the treatment, and
therefore a longer beam on time. Total MU per beam/sequence is also shown.
The Total number of Monitor Units and Mean Monitor Units for the entire plan
also appear at the bottom of this dialog box.
Figure 9-11: Fluence Statistics dialog box
9-18
Monaco Planning Suggestions
The planning suggestions reviewed here are general suggestions for planning in
Monaco. You can find any VMAT specific planning suggestions in the VMAT
Planning section of this guide.
Workflow
The instructions below show you the basic workflow to create a plan in Monaco. See
the Monaco Planning and Workflow section of this training guide for a flowchart
diagram of this process.
1. Carefully Contour all required targets and OARs. If multiple targets exist, create
a structure around them all to use for isocenter placement.
2. Add a template to your patient from the Planning Activity. Use one of the
default templates to create a new template from scratch. Edit the template
properties and save, as necessary.
3. If you need to make edits to the beam arrangement, add or delete beams or
sequences, you can edit them in Planning activity .You can also make edits to the
beam plans in Planning activity.
4. Resolve any structure mismatches and edit the IMRT Constraints, Calculation
Properties, IMRT Parameters, and Sequencing Parameters as necessary.
5. Do the fluence optimization (Stage 1).
6. Use plan analysis tools to evaluate your plan.
7. Make adjustments to the parameters and prescription (constraints) as necessary.
8. Re-optimize the fluence and repeat evaluation until you have an acceptable
optimized plan.
9. Do the segment optimization (Stage 2).
10. Use the plan analysis tools to evaluate your final plan.
11. If the plan is not acceptable, make edits to the properties and/or prescription
(constraints) as needed.
12. Once you have an acceptable final plan, save and print any desired images and
reports.
13. Create a QA plan.
Monaco® 10-1
Cap Bolus
You can create a “cap” bolus in Monaco. You must have a few slices above the first
patient slice of the CT scan in order to create the “cap” structure.
NOTE: You must create a bolus structure type in order to activate the Bolus icon.
1. Type a name in the Structure field on the Contouring tab.
2. Click on the Bolus icon to open the Generate Bolus dialog box.
3. You can modify the description in the Bolus Description option.
4. Select a structure in the Base Structure drop-down list.
5. Type a value in the Thickness (cm). The default value is 1.00.
6. Type a value for the Relative ED. The default value is 1.00.
7. You can put the top and bottom points to define the bolus in any of the T/S/C or
BEV views.
8. In the transverse view, put the bolus start and end points at the same location on
the base structure (Figure 10-1).
Figure 10-1: Placing Start and End Point in the Same Location
10-2
Cap Bolus (cont.)
9. In the Bolus dialog box, click Generate to make the bolus. The bolus is formed
around the skull to create a “cap” (Figure: 10-2).
Figure 10-2: Cap Bolus
Templates
You can create templates when you save any completed plan. Use the File drop-down
menu and select the Save Template As… option.
NOTE: You can save a Sim template with mixed energies. Only the machine for
beam 1 shows on the Template dialog box when you apply the template to
a new patient. But, mixed energies are applied.
Machine Energy
Typically, you use low to medium machine energies for planning (6-10 MV). You can
also plan with multiple machine energies. There may be cases when a higher energy is
desired or required. Keep in mind that when planning with Monte Carlo, if you use a
higher energy, it can increase the calculation time. Higher energy particle showers take
more time to calculate than low energy showers.
Monaco® 10-3
Standardize Planning
Make use of standard sets of anatomical site names and templates for recurring
treatment setups and prescriptions. When you use templates, it is important for
contour names to be consistent from patient to patient. Monaco indicates structure
name mismatches, so you can correct these before you begin optimization.
Status Messages
Status messages appear throughout the planning process at the bottom of the window.
These messages are informative, such as Mismatch in structure names when the
prescription does not reflect the structures available for the patient. Or, status
messages, such as Press start to begin stage 1.
DVH & Statistics Resolution

The resolution for the Optimized DVH is based on grid spacing. Optimized DVH also
takes into account Structure Optimization Properties such as Total Volume DVH and
overlapped volumes.
The Total Volume DVH resolution has a default value of 0.2 cm. We suggest that you
set the resolution for the Total Volume DVH to be the same as the grid spacing of
your plan. You should always base the final plan evaluation on the Total Volume
DVH.
Setup Beams for Portal Imaging

You can create setup beam plans in Planning independent of your plan. Start a New
Simulation Plan centered on the same isocenter as in the plan. You can arrange setup
beams and print or export DRRs. You can save these plans as templates for future use.
10-4
Calculation Region Volume

The Calculation Region Volume encompasses all structures listed on the IMRT
Constraints dialog box. Monaco requires for patient contours to be contiguous. If you
desire a smaller calculation region, you can delete contours from the superior and
inferior slices. The system generates DRR images for the extent of the CT slices, even if
patient contours do not exist.
Applying Structure Optimization Properties to a Non-Optimized Structure

Often, you may have a structure that you do not want to optimize (for example, you
have contoured the table or an immobilization device and you want to account for the
attenuation, but do not want to store the dose to that structure in memory).
Add the structure to the prescription and on the structure optimization properties
dialog box. Select the option Do Not Store Dose. You do not need to select a cost
function for this structure. The optimizer uses the structure for dose attenuation
purposes, but does not optimize or store dose for this structure. If the non-optimized
structure overlaps an optimized structure, layering order is important. You can use the
voxel visualization tools to verify the cost function occupancy of each structure.
NOTE: If you select the structure property, Display Total Volume DVH, the
option for Do Not Store Dose is not available for that structure.
Target Coverage
If you do not have good target coverage superiorly and inferiorly after optimization,
make sure your grid spacing is at least as small as, or slightly smaller than your CT
slice spacing.
You cannot influence the overall target dose homogeneity by target dose penalties
alone. If the target dose is not homogenous enough, either reduce normal tissue
sparing, or add more beams or sequences.
Monaco® 10-5
IMRT Beam Arrangement

• For non-concave targets, any standard arrangement that one would use for
regular 3D planning should suffice, since the modulation improves on the
dose distribution. Five (5) evenly spaced beams is a good place to start.
• For concave targets, you are more likely to require more beams in order to
shape the dose distribution around the target. Seven to nine (7 to 9) beams
usually work.
• At least fifteen (15) degrees of separation between beams is a general rule of

thumb for beam independence.
• Use a BEV to find beam angles that yield the best separation between target
and critical structures.
• In general, the more beams you use, Monaco generates fewer total segments.
Prescription
General Suggestions
• For best results, add all targets and dose limiting organs at risk to the
prescription panel at once and assign cost functions.
• You must have at least one objective and one constraint in order to optimize.
• You must use at least one of the two target objectives (Target EUD or Target
Penalty) in the prescription.
• For very small structures (example, optic chiasm, optic nerves), you may want
to create a 1-2 mm expansion margin and use this structure in the
prescription. While in plan evaluation, you should evaluate the actual
structure instead of the expanded structure.
10-6
Prescription
Tips When Creating Target Volume Prescriptions
• Target volumes may extend to the patients surface. Application of the Auto
Flash feature with a 5-7 mm margin may improve the coverage.
• To make sure you have a uniform dose distribution in the target, apply a
Quadratic Overdose penalty on the order of 0.8 to 1.1 Gy above the
prescribed dose. In general, the smaller the target volume, the smaller the
isoconstraint value for the Quadratic Overdose.
• When you have overlapping or close target volumes with different

prescriptions, you can apply a Shrink Margin to the Quadratic Overdose cost
function of the target with the lowest dose to achieve a transition dose
gradient between the two structures (highlighted in yellow below).
• Due to the higher dose gradient in the area where higher dose and lower dose
targets abut (highlighted in yellow), unacceptable cold spots in the lower dose
target could occur in areas further away from the high dose target. When you
have overlapping or close target volumes with different prescriptions, consider
increasing the isoconstraint of the Target EUD to the lower dose target(s)
about 2 Gy to make sure that you received an acceptable dose gradient
throughout the lower dose target.
Figure 10-3: Transition Area
Monaco® 10-7
Prescription
Tips When Creating Target Volume Prescriptions (cont.)
• When you have overlapping or close target volumes with different

prescriptions, it may be useful to apply a second Quadratic Overdose penalty
to the target with the lower dose with a 0 cm Shrink Margin. Assign a
prescribed dose to the lower dose target that is equivalent to or slightly lower
than the prescription of the highest target dose and assign an Isoconstraint
value of 0.1 Gy. This enables you to have an appropriate dose gradient inside
the lower dose target and keeps the hot spot inside the target with the highest
dose.
• Understand that when you use EUD cost functions, it is possible that resulting
cold spots in a target may be compensated by hot spots in another area of the
target. This is the nature of EUD usage. Smaller isoconstraint values on the
quadratic overdose cost function for the target can help to limit the range of
hot to cold voxels. If the target is large, you may want to split the target into
two separate structures and use the same prescription for both.
• To avoid the incidence of EUD generated hot spots in the target, you can use
the “Target Penalty” dose objective option. Because it is a non-EUD based
physical dose objective, you can achieve lower hot spots.
Tips When Creating Organ at Risk Prescriptions
• You can add a Serial cost function to a parallel OAR in addition to a Parallel
cost function to reduce hot spots in that structure.
10-8
Prescription (cont.)
Avoid Hot Spots in Unspecified Tissue
Occasionally, hot spots are created near a target volume, but not inside. To avoid any
hot spots created near a target, but not inside, try the prescription tip below:
Apply a Quadratic Overdose penalty to the structure defined as the patient with a
Maximum Dose equal to 2/3 of the highest target volume prescription. Type an
Isoconstraint value of ~0.3 Gy above the max dose. Apply a Shrink Margin to this
cost function on the order of 1.5 cm to control the dose just beyond the target volume.
Figure 10-4: Target with Margins
If you still have a hot spot that is in normal tissue and not in the target, you can apply a
second Quadratic Overdose penalty to the patient structure with a Maximum Dose
equivalent to the target prescribed dose, a small Prescription.
Isoconstraint value, and zero (0) cm Shrink Margin. The first cost function controls
the doses 1.5 cm beyond the target. The second cost function works to control any
high dose that tries to escape the margins of the target volume.
You can use the application of additional Quadratic Overdose penalties on the patient
structure to further conform the dose.
Monaco® 10-9
Controlling Mean Dose in OARs
If you need to reduce mean dose, you can add an additional Serial Cost Function to
the structure with a k value of 1. This serial cost function effectively controls the mean
dose in the structure.
Figure 10-5: Serial Cost Function
Controlling Maximum Dose
One thing to remember when you use EUD to plan is that when you have a complex
prescription, it may be difficult to control the absolute maximum dose to a certain
point. So, occasionally, you may need to include a Maximum Dose cost function in
your prescription.
Normally, a Serial cost function is able to sufficiently control the hot spots in an OAR.
Occasionally, the maximum dose you are willing to accept is exceeded. In this case,
you could apply a Maximum Dose cost function together with the Serial cost function
to limit the dose to the OAR.
10-10
Using Biological Cost Functions to Control Dose
You can use a serial cost function with a high Power Law (k to control high doses in an
OAR, for example, to prevent a rectal fistula. If the high dose region of an OAR
overlaps a target volume, you can use Optimize Over All Voxels so the cost function
can work in the high dose region. You can apply an additional Serial cost function(s)
with a lower EUD Dose and a shrink margin to help create a steep dose gradient.
For structures, such as lung and parotids, you can apply a Serial cost function with a
Power Law (k) of 1 to distribute the penalty equally throughout the volume in order to
control the mean dose. In this case, you should apply a shrink margin if the OAR
overlaps with a Target Volume to avoid cold spots in the Target Volume.
Parallel cost functions act similarly to DVH point dose constraints, but with the
benefit of working on the OAR volume rather than just a specified point. Use them to
prevent side effects associated with lower radiation doses. You can also use the Parallel
cost function to prevent such side effects as, for example, Parotid: Salivary Gland
function and Rectum: Diarrhea.
Monaco does not limit you to use a single dose constraint for OARs. There may be
multiple dose ranges to control per OAR. Therefore, it may be useful to apply multiple
cost functions, Serial and/or Parallel. You can control the high and low dose regions as
well as the mean dose when you use multiple cost functions together. When you use
the appropriate Power Law Exponent values and Shrink Margins, they help direct the
penalty towards specified doses within OAR volume so you can achieve optimal plan
quality.
Monaco® 10-11
Bias Dose
• Divide the Base dose prescription by the Total dose prescription to get a
multiplier to apply to each OAR prescription for your base plan. When you
lower your OAR goals for the base plan, this helps to achieve better coverage
and fewer infeasible results when you create the composite plan. Next,
increase the OAR prescription values on the Bias Dose plan to 100% of the
goal doses. Then, back them off as needed to achieve final dose goals.
• Multiple Overlapping targets: For improved results, remove any targets from
your IMRT Constraints prescription that are entirely encompassed by another
target in your prescription when you create the composite plan.
10-12
Optimization
DVH Statistics
After you optimize one time, the system activates the DVH Statistics button. For
future optimizations, you can keep the DVH Statistics dialog box open. The system
updates reference doses when you refresh. The DVH Statistics always shows the Total
DVHs, not Optimized DVHs.
Sensitivity Analysis
Make use of the sensitivity analysis tool to determine what to change in your
prescription when the optimization is not acceptable. You can use this tool after either
stage of optimization.
Multicriterial
The most effective time to use multicriterial is when you have an isoeffect on the target
structure(s) that is higher than the isoconstraint. This typically means your target and
OAR are well separated from each other, and the target(s) coverage is not significantly
affected by a tighter constraint on the OAR.
As you optimize, pay attention to the isoeffect value and the DVH of the target(s). If
you apply multicriterial to an OAR and compromise the target coverage more than
you are willing to accept, you should turn off multicriterial and set the isoconstraint of
the OAR to a value that, when optimized, creates acceptable coverage to the target(s).
Consider using the multicriterial option when you plan dose escalation protocols
where you want to increase the dose to targets and keep OAR(s) dose at acceptable
levels. You can also consider its use when you are re-treating a patient and a physician
agrees to accept compromised target coverage as long as the OAR’s dose can be kept at
as low a dose as possible.
Monaco® 10-13
Troubleshooting an Optimization Failure
• Check the Logfile. Click the Monaco Application button and select the Log
Files| Log…. Review the latest entries on the General Logfile for possible clues
that show the failure.
• Check the Optimization Console. Click the Workspace tab and click the
Controls drop-down| Optimization Console option. Review the information
on the console for possible causes that show a failure.
• One common problem is incorrect structure layering. Verify that you have the
“patient contour” last in the structure layering. Also, verify if you prescribed to
a structure that is completely encompassed by another structure (for example,
CTV and PTV). Make sure the one with the highest dose prescription is listed
above the other in the layering.
• Another common problem occurs when there is no CT-to-ED file assigned to

the patient. If you use a CT studyset, Monaco requires a CT-to-ED file for
optimization and dose calculation. If you use an MR studyset, you must
manually set electron density values for your structures.
10-14
Plan Analysis
Fluence Statistics
Make use of the fluence statistics after either stage of optimization to evaluate plan
delivery efficiencies. Consider this example: We created three plans with superficial
targets and used the same number of beams and beam arrangements. However, one
plan used Auto Flash, another used surface margin, and the third plan used neither.
The fluence maps and corresponding fluence statistics for beam one of each plan
appear below with comments.
Auto Flash ON
Fluence Statistics
A plan using Auto Flash produces reasonable monitor units

per fraction and a small standard deviation. The fluence is
slightly hotter in the buildup region as shown on the left side
of the fluence map. Application of this tool gives a uniform
distribution in the buildup region.
Figure 10-6: Auto Flash ON
Monaco® 10-15
Plan Analysis (cont.)
Surface Margin ON
Fluence Statistics
A plan using Surface Margin produces reasonable

monitor units per fraction and a small standard
deviation. The fluence is fairly homogeneous.
Figure 10-7: Surface Margin On
Neither Margin ON
Fluence Statistics
A plan using neither of these tools produces a large

number of maximum monitor units and a large
standard deviation. The fluence is very hot in the
buildup region as shown on the left side of the fluence
map. Without the proper application of structure
optimization properties or global parameters, you
could produce plans that create too many monitor
units per fraction and therefore inefficient beam-on
times.
Figure 10-8: Neither Margin On
10-16
Performance
Grid Spacing
Use smaller grid spacing (0.3 cm or less) when the structures are smaller (example,
H&N). Use larger grid spacing (0.4 cm) when the structures are larger (example,
Prostate). Calculation time increases with smaller grid spacing.
Statistical Uncertainty per Calculation vs. per Control Point
If you use Statistical Uncertainty per Calculation, it results in a faster calculation than
the per Control Point option.
It is possible to decrease calculation times for VMAT plans if you use a higher Statistical
Uncertainty per Calculation value for initial planning. For the first iteration of stage 1 and
stage 2, the user selects a higher Statistical Uncertainty than what is recommend for
clinical use. When the final plan is calculated, the user can change the Statistical
Uncertainty per Calculation to a lower, more clinically acceptable value. The segmented
plan automatically begins a re-calculation and returns the new results. The user then
selects Skip Forward when it becomes available to return the “segmentation complete”
message. The recommended values are 2-3% per plan for initial planning followed by 1%
for the final calculation.
Please note that as a consequence of using a higher statistical uncertainty, the user
must review all aspects of the plan which includes dose distribution and DVH to make
sure the plan is acceptable. If you use a higher Statistical Uncertainty, dose to small
structures can be affected.
Pilot Beamlets
The Pilot Beamlets option is available if you select SSO. Monaco uses Pilot Beamlets to
guide the segment shape changes made during Segment Shape Optimization. Monaco
creates a large number of Pilot Beamlets if you use large highly modulated treatment
fields, multiple VMAT arcs and a small arc increment. When a large number of Pilot
Beamlets, which are stored in memory, are created they can use all the RAM the
system has. This slows the process exponentially. Disabling this option removes the
creation of pilot beamlets from the SSO process. Pilot beamlets do not affect
performance for the majority of treatment plans. You should only disable them if the
plan takes a long time to converge.
Monaco® 10-17
QA Plan
Multiple QA Plans
If multiple QA plans already exist and you want to create a new QA plan, select a new
QA Plan ID from the bottom of the drop-down list.
Show Coronal Slice at Measured Depth
Use the measure tool on the transverse image to measure the depth from the surface to
where you took your actual measurement. Select the plane icon tool and drag it to the
end of the measure tool. This creates a coronal image at measured depth that you can
export for comparison.
10-18
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
The exercise in this section reviews the general process of planning a Step and Shoot,
dMLC or Conformal RT patient in Monaco. There are many ways to complete an
IMRT plan in Monaco. This is just one suggested method of IMRT treatment
planning. This exercise does not include contouring.
This exercise and the information provided is subject to the disclaimer included in the
Overview section of Volume 1, Section 1.

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

1. Open the Monaco software to automatically show the Open Patient Selection
dialog box.
2. Select the patient Fusion Prostate. Use one of these methods:
OR
The system loads the patient information into the Patient Workspace Control.
OR
Click the studyset name once, and then click the Load button.
The patient shows in the Planning activity.
11-2
Prostate IMRT Case
Prostate IMRT Case
Task 2. Start an IMRT Plan

This task walks you through the steps to select an IMRT Template.
2. Click on the drop-down arrow next to the New Plan button and select New
Monaco Plan in the drop-down list. This opens the New Monaco Plan dialog
box. (Figure11-1).
4. Select dMLC or Step and Shoot IMRT for the Delivery.
Monaco® 11-3
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 2. Start an IMRT Plan (cont.)
6. Place a checkmark by the template named DEFAULTSNS (Rx Site , Rx Dose:

Gy , Total Beams: 7).
8. Select TRNElekta80 for the treatment unit or a treatment unit type used in your
clinic.
9. Select 10.0 MV as the energy.
10. Select the Isocenter Location: Center of PTV.
11. Select OK to load the template and open the patient in Planning Control.
11-4
Prostate IMRT Case
Prostate IMRT Case

arrangements from a template. This task should be less frequently used once you create
and save your own clinical templates.
2. (Optional) Use the <click to add a new beam> option to add additional beams.
Change to the Geometry tab to edit the Gantry, Collimator, and Jaw parameters.
Label the applicable beams. Refer to the Planning Tools section of this training
guide for more information.
This task is only required when you need to edit the prescription from a template. This
task is less frequently used once you create and save your own clinical templates.
2. Type Prostate for RX Site.
5. Type 41 in the Number of Fractions column. The Fractional Dose (Gy) column
updates with 1.8 as the value.
Monaco® 11-5
Prostate IMRT Case
Prostate IMRT Case
1. Click the IMRT Constraints tab on the Planning Control.
2. Verify there is not a mismatch in structure names. For example, if the external
contour is labeled “skin” in the template and the external contour is labeled
“patient” in the plan, the mismatched structure name appears red in the IMRT
Constraints tab.
3. Use the provided Plan Scoring Criteria to add and edit cost functions. For this
exercise, we provided suggested cost functions and explanations of their use for
each structure. Note that the IMRT Constraints used in this exercise are only an
example. You can use other combinations of cost functions to produce similar
results.
NOTE: If you do not want any planning hints, skip this section and go
directly to the Plan Scoring Criteria table.
PTV - For target structures, a Target EUD or Target Penalty is always required.
The target cost functions designate the target as an Objective. Neither target cost
function penalizes high doses. You need to use the Quadratic Overdose cost
function to make sure the global max dose is not exceeded. This also gives you a
more homogeneous dose within the target structure.
The Isoconstraint value for the Target EUD/Target Penalty cost function is the
target prescription 73.80 Gy.
• If you use the Target EUD you can use 73.80 Gy for the reference dose
and 0.5 for the cell sensitivity to meet the prescription criteria. In this
exercise, the target volume does not extend to the patient surface. You do
not need to select the Optional Physical Parameters, Surface Margin.
11-6
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 5. Enter the IMRT Constraints (cont.)
For the Quadratic Overdose, you can use 75.00 Gy for the maximum
dose, and 2.00 for the RMS dose excess to meet the prescription criteria.
• If you use the Target Penalty, you can use 73.80 Gy for the Prescription
and 98% for the Minimum Volume.
- For the Quadratic Overdose, you can use 75.00 Gy for the
maximum dose and 2.00 for the RMS dose excess to meet the
prescription criteria.
NOTE: You use an RMS of 2.0 in this exercise to decrease the calculation
time. You should determine what prescription and RMS to use for
your clinical plans based on your clinical experience and goals.
RECTUM - For this organ at risk, use of the Serial cost functions is applicable
since the rectum is a serial structure. In some cases, like this one, you might need
to meet or exceed the prescription criteria for two serial cost functions. For the
first serial model, use a power law exponent of 12 with an EUD of 60.00 Gy and
check Optimize Over All Voxels in Volume to keep hot spots to a minimum
throughout the entire structure. Since the target and rectum volume are so close
and even overlap in some areas, we suggest that you add a second serial cost
function to this structure. Use a lower EUD and power law exponent, such as
45.00 Gy and 5 and use a Shrink Margin of 0.4 cm. The second serial cost
function lets you further reduce the dose in the area of the rectum where the
voxel doses do not compete with the target.
BLADDER - For this organ at risk, use of the Serial cost function is applicable
since the bladder is a serial structure. Use a power law exponent of 8 and EUD of
around 55.00 Gy to reasonably meet the prescription criteria. In addition, use a
Shrink Margin of 0.4 cm so as not to include the hot voxels that surround the
target. Since the bladder is filled with contrast, apply an electron density of 1.0 to
the structure. Click the Structures tab. Check Force ED and verify the relative
ED is 1.0. When you apply this property to the structure, the density value you
use overrides the “false” high density of the contrast in this patient.
Monaco® 11-7
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Patient - When you plan IMRT, you should take into consideration dose to all
unspecified tissue and apply a cost function to keep the dose to a minimum. You
apply the Quadratic Overdose cost functions to the patient contour for this
purpose. In some cases, you may need more than one quadratic overdose cost
function to meet the prescription criteria. For the first quadratic overdose, use a
Maximum Dose of 45.00 Gy and an RMS Dose Excess of 0.50 to keep the dose to
the unspecified tissue to a reasonable minimum and keep the femur doses low.
Since the unspecified tissue of the patient and the targets abut, it is good practice
to add a shrink margin to the patient structure so the optimizer does not try to
limit dose in the transition area between the target and the unspecified tissue. In
this case, consider a Shrink Margin of 1.2 cm. For the second Quadratic
Overdose cost function, consider a higher Maximum Dose of approximately
73.80 Gy with a small RMS dose excess like 0.3. Use a Shrink Margin of 0.4 cm
on this cost function. The second cost function lets you control the high doses in
the unspecified tissue better. The small RMS dose excess value limits the
possibility of a prohibitively high dose voxels in the unspecified tissue.
Rt and Lt Femur - You could contour and add these structures into the IMRT
constraints tab. But, if you look at the dose to the unspecified tissue (patient),
which includes the femurs, the % dose of 45.00 Gy is well below 5%.
4. Layer the structures appropriately. Highlight the structure you want to move and
click the up or down arrow on the IMRT Constraints tab in the planning control
window. Targets are typically at the top and the patient skin surface contour at
the bottom.
11-8
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
5. Review the plan scoring criteria.
Target Structures
PTV 95% is at or above 73.80 Gy
and
Max dose < or = 81.18 Gy (110%)
Organs at Risk (OAR)

BLADDER no more than 60% > 40 Gy
and
no more than 40% > 60 Gy
RECTUM no more than 50% > 40 Gy
and
Rt Femur no more than 5% > 45 Gy
Lt Femur no more than 5% > 45 Gy
Figure 11-3: Planning Score Criteria example
Monaco® 11-9
Prostate IMRT Case
Prostate IMRT Case
Task 6. Edit Calculation Properties

This task lets you set up the calculation properties. Grid Settings are global settings and
algorithm settings are per prescription.
1. Click the Calculation Properties button on the

Planning tab to open the Calculation Properties dialog box.
2. For this practice exercise, Monte Carlo Photon populates as the algorithm.
3. For this practice exercise, use a Grid Spacing of 0.4 cm. The shrink margin values
used in the exercises are based on the fact that Monaco determines the shrink
margin size based on multiples of the grid spacing.
4. Select Calculate dose to Medium.
5. Use a Statistical Uncertainty per Calculation of 2%.
6. Click OK when you complete your edits.
NOTE: You use a Statistical Uncertainty of 2.0 in this exercise to decrease the
calculation time. You should determine what prescription and
Statistical Uncertainty to use for your clinical plans based on your
clinical experience and goals.
11-10
Prostate IMRT Case
Prostate IMRT Case
Task 7. Edit IMRT Parameters

This task lets you set up IMRT Parameters for each prescription (Rx).
1. Click IMRT Parameters on the IMRT Constraints tab.
Figure 11-4: IMRT Parameters button
2. Use Minimum CT Number: Use with Clear option of -200.
3. Leave the default value for Flash Margin because Flash margin is not used for
prostates.
4. Use a Beamlet width of 0.3 cm.
5. Use the drop down arrow and click Normal (8mm) for Target Margin.
6. Use the drop down arrow and click Normal (8mm) for Avoidance Margin.
Monaco® 11-11
Prostate IMRT Case
Prostate IMRT Case

1. You can do this task at any time before stage one or stage two of the
optimization.
2. Click the Sequencing Parameters button on the

Planning tab.
3. Type/Edit properties when necessary. If you have SSO turned on, we recommend
you select Pilot Beamlets.
4. Click OK when you complete your edits, or Cancel if you made no edits.
Task 9. Save an IMRT Template

You can do this task at any time while in the planning process. However, it is highly
beneficial for you to create a prescription before you save an IMRT template.
2. Type the template name and description TrainPro1.
3. (Optional) Select Pelvis from the Anatomical Site drop-down.
11-12
Prostate IMRT Case
Prostate IMRT Case

This task starts the optimization process. The system automatically gives feedback
during optimization on the IMRT Constraints dialog box, the console and the progress
meter. You can manually update the dose, DVH and fluence during the optimization
process.
1. Show the IMRT Constraints dialog box (if it is not shown).
2. Show the Console using one of these methods:
Select the Workspace tab. In the Visibility Panel, select the Controls
drop-down menu and select the Optimization Console option.
OR
Press the Alt and C keys on your computer keyboard.
3. Click the Start Optimization button located on the Planning tab, to start
stage one of the optimization processes.
NOTE: After you create the rays (beamlets), you can see the IMRT
Constraints and progress meter start to update with each iteration.
Monaco® 11-13
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 10. Optimize Fluence (Stage 1) (cont.]
4. (Optional) If you would like to stop the optimization and move to the end of
stage one prematurely, click the Skip Forward button. Understand that this
action does not result in fully optimized fluence.
OR
(Optional) If you would like to stop the optimization and go back to the start of
stage one, click the Skip Back button. This action removes the current
display of fluence and lets you start the optimization again at stage one.
5. Once stage one of the optimization completes, the system shows a dialog box
with the message “Full Fluence Modulation Complete”. Click OK to
acknowledge.
11-14
Prostate IMRT Case
Prostate IMRT Case

After stage one, you have many tools available to evaluate the optimized fluence and
dose. Among these tools are Sensitivity Analysis, DVH Statistics, Fluence Display
Tools, and isodose curves on the SPV and 3D images. This task references the location
in the Monaco training guide where detailed information is located about the use or
functionality of these tools. You can use any or all for evaluation at this time.
1. Use the Sensitivities analysis to evaluate this information. The Sensitivities tab is
on the IMRT Constraints window. Refer to the Monaco Planning and
Workflow section: Plan Analysis Tools for more detailed information.
2. Click the Plan Options tab and use the DVH tools to evaluate the plan. The
DVH panel contains DVH Statistics, DVH Properties, and Structure
Combination.
OR
Right-click in the DVH window to use the DVH tools.
Refer to the Plan Review Activity section to change the DVH Display,
Properties, and Statistics.
3. Use the Fluence Statistics to evaluate. Select the Plan Options tab and click the
Fluence Statistics button. For more information, refer to the IMRT Tools
section in this guide.
Monaco® 11-15
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 11. Evaluate Optimized Fluence and Dose (cont.)
4. Use the isodose curves on the SPV and 3D images to evaluate. For more
information on evaluating isodose curves, refer to the resources below in this
guide:
• General Operation and Navigation section

• Image Navigation and View Types
• Planning and Workflow: Plan Analysis, Evaluation, and Review

If you determine that you need to make changes to the prescription to meet prescribed
goals, you may have to re-optimize. When you apply the changes, notice if the start
button on the toolbar changes from to . If so, the changes you made require
re-optimization. Evaluate again. Use the tools described in task 10. You may re-
optimize and evaluate several times before you calculate in stage 2.

Once the optimized plan meets the prescription goals, you must optimize the segment
shapes and calculate the final dose. Both of these actions happen in stage 2 of the
optimization.
1. (Optional) Verify that the Sequencing Parameters that appear are your desired
settings. Change them, if necessary. (See Task 7.)
2. (Optional) Show the IMRT Constraints dialog box and the Console. (See Task
9.)
3. Click the Start Optimization button to start stage 2 of the optimization.
11-16
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 13. Optimize Segment Shapes/Calculate Dose (Stage 2) (cont.)

stage two prematurely, click the Skip Forward button. Understand that this
action does not result in a fully optimized plan.
OR
(Optional) If you would like to pause stage 2 of the optimization, click the Skip
Back button. This action removes the current display of fluence and lets
you start the optimization again at stage one.
5. Once stage two of the optimization completes, the system shows a dialog box
with the message “Segment Shape Optimization Complete”. Click OK to
acknowledge.

Once the system calculates the plan, you can evaluate and use the same tools used to
evaluate the optimized plan (see Task 10). If you choose to make changes to the
prescription at this time, the system determines if the change necessitates that you start
again at stage 1, or start at stage 2, or continue from its current state.
Monaco® 11-17
Prostate IMRT Case
Prostate IMRT Case
Task 15. Save Plan

Save the plan when satisfied that it meets the prescribed goals.
NOTE: You can save optimized plans after stage 1, but optimized dose is not
preserved.
1. Save the plan. Use one of these methods:
Click the Save button on your Quick launch Bar.
OR
(Ctrl +S) on the keyboard saves the active plan.
OR
Click the Monaco Application Menu button and select a Save option.
11-18
Prostate IMRT Case
Prostate IMRT Case

There are many documents and images that offer support. You can print or export
them for patient files. This task references the location in the training guide where
detailed information appears about each type of print job.
Subtask 1. Print or Export IMRT Reports
For more detailed information on how to print, see the section General Operation
and Navigation.
1. Click the Output tab.
a. Select an option on the Individual Report panel to print.
b. Type a report comment, click OK.
c. Click the Print button on the preview window to print the image
shown.
OR
a. Select Customized Report to select a set of reports to print.
b. Click the Template drop down arrow and select a saved template.
c. Select Print.
Monaco® 11-19
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Task 16. Print the Plan (cont.)
Subtask 2. Print Single Plane View, 3D Image or DVH Graph
You can print or export the DVH graph from the Output tab. For more information,
see the General Operation and Navigation section, Printing Options.
1. Select the Output tab.
2. Select Print Views on the Reports panel.
3. Select the applicable view to print.
4. Type a report comment.
5. Click OK.
6. Click the Print button on the preview window to print the image shown.
11-20
Prostate IMRT Case
Prostate IMRT Case
Practice Exercise
Subtask 3. Print DRR/BEV
You can print DRR/BEV images to paper or film and scale appropriately when
calibrated. For more information, see the General Operation and Navigation section,
Printing Options.
1. Click the Print Views drop down arrow in the Reports panel on the Output tab.
a. Select the applicable view to print.
b. Type a comment, as needed, in the Report Comment dialog box.
c. Click OK.
d. Select the Print icon .
e. Edit and/or verify Print Setup information.
f. Click OK.
OR
2. Right-click on any DRR/BEV image.
a. Select the Print option in the mouse menu to show the DRR Print dialog
box.
b. Type the applicable information for location and scaling.
c. Click OK to print the image.
Monaco® 11-21
Prostate IMRT Case
Prostate IMRT Case

Once you complete an IMRT plan, you can create a QA plan for verification. For more
information, see the IMRT QA Activity section.
1. On the Planning tab, select the New Plan drop-down arrow . Select New QA
Plan.
OR
In the Workspace dialog box, click on the prostate IMRT plan ID that you just
created and select New QA Plan from the mouse menu.
2. Select the TrainingClinic: Prostate: MonacoPhantom study set. This is the

studyset to use to create the QA plan.
3. For this exercise, you want to maintain the original beams angles. Do not Reset
Beams to Nominal Angles.
4. Select Monte Carlo as the Algorithm.
5. For this practice exercise, type 0.3 cm for the Calc Vol Grid Spacing.
8. Click OK to show the Setup QA Plan dialog box.
9. Select the isocenter Center of patient.
10. Click OK to show the phantom in IMRT QA activity.
11. Click the Start Dose Calculation button. Once the system completes the
calculation of the QA plan, the Optimization Console indicates: Dose Calculation
Completed.
11-22
Prostate IMRT Case
Prostate IMRT Case
Task 18. Edit QA Plan Beam Weights (Optional)

Beam weights in QA are automatically scaled to one fraction. If necessary, you can edit
the beam weights to accommodate your QA process.
1. Click the Beams tab of the Planning Control.
2. Edit the Total MU for each beam individually.

The system saves QA Plans with their associated IMRT patient plans.
1. Save the QA plan. Use one of these methods:

Click the Save button.
OR
Click the Monaco Application drop-down menu and select the Save option.

If you use a third party software to compare planned versus measured dose profiles,
you can export those planes when you use the Dose Export Tool. Skip this step for the
practice exercise. For more information, see the IMRT QA activity section of this
training guide.
Monaco® 11-23
Prostate IMRT Case
Prostate IMRT Case

For more detailed information on how to print QA plan information and images, see
the section General Operation and Navigation.
Subtask 1. Print QA Plan Reports
1. Click the Output tab and select Individual Reports or Customized Reports to
print.
OR
Right-click on the loaded QA plan in the Patient Workspace Control. Select an

Individual Report to print.
OR
Select Customized Report to select a set of reports to print.
NOTE: You can save Customized Reports as a template. Refer to the General
Operation and Navigation section of this guide for more
information.
Subtask 2. Print QA Plan Images
You can print images with dose on the phantom just as any single plane view image.
3. Select the necessary view to print.
11-24
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
The exercise in this section reviews the general process of planning a VMAT patient in
Monaco. There are many ways to complete a VMAT plan in Monaco. This is just one
suggested method. This exercise does not include contouring.

Task 2. Start a VMAT Plan using a Template
Task 3. Add VMAT Sequences in Planning Activity
Task 5. Enter IMRT Constraints
Task 8. Save a VMAT Template
Task 14. Save Plan
Task 17. Edit QA Plan Beam Weights
Monaco® 12-1
Prostate VMAT Case
Prostate VMAT Case

1. Open the Monaco software to automatically show the Open Patient Workspace.
2. Select the patient Fusion Prostate. Use one of these methods:
OR
The system loads the patient information into the Patient Workspace Control.
3. Select the CT studyset CT1 using one of these methods:
OR
Click the studyset name once, and then click the Load button.
The patient shows in the Planning activity.
Task 2. Start a VMAT Plan using a Template

This task walks you through the steps to select a template.
1. Click on the drop-down arrow next to the New Plan button on the
Planning tab to choose a plan type.
2. Select New Monaco Plan in the drop-down list. This opens the New Monaco
Plan dialog box.
3. Type in a plan name and description: ProstateVMAT.
12-2
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 2. Start a VMAT Plan using a Template (cont.)
4. Select VMAT for the Delivery.
6. Place a checkmark by the template named DEFAULTVMAT (Rx Site:, Rx Dose:

Gy, Total Beams:1).
7. Select Head First as the Treatment Orientation.
8. Select the Center of PTV for the Isocenter Location.
9. Select a Treatment Unit associated with a machine type used in your clinic.
10. Select 6.0MV as the Energy.
11. Click OK to load the template and patient into the planning activity.
Task 3. Add VMAT Sequences in Planning Activity

You can only add VMAT sequences in IMRT activity. Once you create and save your
own clinical VMAT templates, you use this task less frequently.
1. Click on the Beams tab in the Planning Control.
2. Verify this beam information in the Geometry tab:
Description: Seq1
Couch: 0
Collimator: 0
Gantry Start: 180
Arc: 360
Increment: 30
NOTE: For more information on Arc and Increment definition and use, see
the section Arc Planning Terminology in this guide.
Monaco® 12-3
Prostate VMAT Case
Prostate VMAT Case

You only use this task when you need to edit the prescription from a template. Once
you create and save your own clinical templates, you use this task less frequently.
2. Type Prostate for Rx Site.
5. Type 41 in the Number of Fractions column. The Fractional Dose (Gy) column
updates with 1.8 Gy as the value.

1. Click the IMRT Constraints tab on the Planning Control.
NOTE: Verify there is not a mismatch in structure names. If the structure

names do not match, the mismatched name is red in the Structures
column on the IMRT Constraints tab.
2. Use the Plan Scoring Criteria to add/edit cost functions we gave you. For this
exercise, we gave you suggested cost functions and explanations of their use for
each structure. Note that the IMRT Constraint values used in the exercise are
only examples. You can use other combinations of cost functions to produce
similar results.
NOTE: If you do not want any planning hints, skip this section and go
directly to the Plan Scoring Criteria table.
12-4
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
PTV - For target structures, a Target EUD or Target Penalty is always required.
The target cost functions designate the target as an Objective. Neither target cost
function penalizes high doses. You need to use the Quadratic Overdose cost
function to make sure you do not exceed the global max dose. This also gives you
a more homogeneous dose within the target structure.
The Isoconstraint value for the Target EUD/Target Penalty cost function is the
target prescription 73.80 Gy.
• If you use the Target EUD, you can use 73.80 Gy for the reference dose
and 0.5 for the Cell Sensitivity to meet the prescription criteria.
- For the Quadratic Overdose, you can use 75.00 Gy for the
maximum dose and 2.00 for the RMS dose excess to meet the
prescription criteria.
• If you use the Target Penalty, you can use 73.80 Gy for the Prescription
and 95% for the Minimum Volume.
- For the Quadratic Overdose, use 75.00 Gy for the maximum dose
and 2.00 for the RMS dose excess to meet the prescription criteria.
NOTE: You use an RMS of 2.0 in this exercise to decrease the calculation
time. You should determine what prescription and RMS to use for
your clinical plans based on your clinical experience and goals.
RECTUM - For this organ at risk, a Serial cost function would be appropriate
since the rectum is a serial structure. In some cases, like this one, you may need
two serial models to meet or exceed the prescription criteria. For the first serial
model, a power law exponent of 12 with an EUD of 62.00 Gy keeps hot spots to a
minimum throughout the entire structure. Since the target and rectum volume
are so close and even overlap in some areas, we suggest that you add a second
serial cost function to this structure. Use a lower EUD and power law exponent,
such as 46.00 Gy and 5 and use a Shrink Margin of 0.4 cm. The second serial
cost function lets you further reduce the dose in the area of the rectum where the
voxel doses do not compete with the target.
Monaco® 12-5
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 5. Enter IMRT Constraints (cont.)
BLADDER - For this organ at risk, a Serial cost function would be appropriate
since the bladder is a serial structure. A power law exponent of 8 and EUD of
around 55.00 Gy would be reasonable to meet the prescription criteria. In
addition, use a Shrink Margin of 0.4 cm so as not to include the hot voxels that
surround the target. Since the bladder is filled with contrast, apply the structure
property Uniform Density, with a density of 1.0. Click on the Structures tab.
Check Force ED and verify the relative ED is 1.0. When you apply this property
to the structure, the density value you use overrides the “false” high density of
the contrast in this patient.
Patient - When you plan, you should take into consideration dose to all
unspecified tissue and apply cost function(s) to keep the dose to a minimum.
The Conformality cost function works well here. Use the Conformality cost
function with a Relative Isoconstraint of 0.7. Select Optimize over All voxels in
volume to apply the cost function up to 8 cm from the edge of the PTV.
Rt and Lt Femur - You could contour and add these structures to the
prescription. However, after dose calculation, if you look at the dose to the
unspecified tissue (patient), which includes the femurs, the % dose of 45.00 Gy is
well below 5%.
3. Layer the structures appropriately. Highlight the structure you want to move
and click the up or down arrow on the IMRT Constraints dialog box. Targets
are typically at the top and patient skin surface contour at the bottom.
12-6
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 5. Enter IMRT Constraints (cont.)
4. Once you assign all the structures, doses, and isoconstraints in the IMRT
Constraints dialog box, the system recognizes the updates and leaves the dialog
box open.
Target Structures
PTV 95% is at or above 73.80 Gy
and
Max dose < or = 81.18 Gy (110%)

BLADDER no more than 60% > 40 Gy
and
RECTUM no more than 50% > 40 Gy
and
Rt Femur no more than 5% > 45 Gy
Lt Femur no more than 5% > 45 Gy
Figure 12-1: Planning Score Criteria example
Monaco® 12-7
Prostate VMAT Case
Prostate VMAT Case

This task lets you set up the calculation parameters for the current plan.
NOTE: The values used in the training class for this exercise may not represent
actual clinical values. The Calculation Properties (Grid Spacing, Statistical
Uncertainty) are chosen to decrease the time it takes to run the plan to give
you more time to run more iterations (if needed) in the training class. Use
a smaller Grid Spacing and Statistical Uncertainty if you are calculate the
plan overnight.
1. Click the Calculation Properties button on the Planning tab

to open the Calculation Properties dialog box.
2. For this practice exercise, use a Grid Spacing of 0.4 cm.
4. Use a Statistical Uncertainty Per Calculation of 4%.
NOTE: It is possible to decrease calculation times for VMAT plans if you use
a higher Statistical Uncertainty per Calculation value for initial
planning. For the first iteration of stage 1 and stage 2, the user selects
a higher Statistical Uncertainty than what is recommend for clinical
use. When the final plan is calculated, the user can change the
Statistical Uncertainty per Calculation to a lower, more clinically
acceptable value. The segmented plan automatically begins a re-
calculation and returns the new results. The user then selects Skip
Forward when it becomes available to return the “segmentation
complete” message. The recommended values are 2-3% per plan for
initial planning followed by 1% for the final calculation.
Please note that as a consequence of using a higher statistical

uncertainty, the user must review all aspects of the plan which
includes dose distribution and DVH to make sure the plan is
acceptable. If you use a higher Statistical Uncertainty, dose to small
structures can be affected.
5. Click OK once you complete your edits.
12-8
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise

1. You can do this task at any time before Stage 2 of the optimization.
2. Click the Sequencing Parameters button.
3. Make sure that you define these sequencing parameters:
Segment Shape Optimization Checked

Pilot Beamlets Checked
Max Number of Arcs: 1 (Use 1 for only Elekta
machines. Use 2 for non-
Elekta machines. Monaco
automatically increases this
value if it needs more than
one arc for non-Elekta
machines.)
Max. # of Control Points/Arc: 120
Min. Segment Width: 1.0
Fluence Smoothing: Medium
NOTE: For more information on Sequencing Parameters definition and use,
see the Monaco Planning and Workflow or the Planning Suggestions
sections of this training guide.
4. Click OK once you complete your edits. Click Cancel if no edits were made.
Task 8. Save a VMAT Template

You can do this task at any time while in the planning process. However, it is highly
beneficial for you to create a prescription before you save the template.
2. Type the template name TrainProVMAT.

3. Type the template description TrainProVMAT.
4. (Optional) Select Pelvis from the Anatomical Site drop-down.
5. Select Save to save the template.
Monaco® 12-9
Prostate VMAT Case
Prostate VMAT Case

This task starts the optimization process. The system automatically gives feedback in
optimization on the IMRT Constraints dialog box, the console, and the progress
meter. You can manually update the dose, DVH, and fluence in the optimization
process.
1. Click the IMRT Constraints tab in the planning control.
2. Show the Console using one of these methods:
Select the Optimization Console option in the Controls drop-down menu

on the Workspace tab.
OR
3. Click the Start Optimization button on the Planning tab, to start stage
one of the optimization process.
Constraints dialog box and progress meter start to update with each
iteration.
12-10
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 9. Optimize Fluence (Stage 1) (cont.)
stage one prematurely, click the Skip Forward button. Understand that this
action does not result in fully optimized fluence.
OR
(Optional) If you would like to stop the optimization and go back to the start of
stage one, click the Skip Back button. This action removes the current
display of fluence and lets you start the optimization again at stage one.
5. Once stage one of the optimization is complete, the system shows a dialog box
with the message “Full Fluence Modulation Complete.”
6. Click OK to acknowledge.

After stage one, you have many tools available to evaluate the optimized fluence and
dose. Among these tools are Sensitivity Analysis, DVH Statistics, Fluence Toolbar, and
isodose curves on the SPV and 3D images. This task references the location in the
Monaco training guide where detailed information is located about the use or
functionality of these tools. You can use any or all for evaluation at this time.
1. You can use the Sensitivities information on the IMRT Constraints dialog box
to evaluate your plan. Refer to the Monaco Planning and Workflow section:
Plan Analysis Tools for more detailed information.
Monaco® 12-11
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 10. Evaluate Optimized Fluence and Dose (cont.)
2. You can also use the DVH tools to evaluate your plan. You can select from any
of these DVH tools on the Plan Options tab: DVH Statistics, DVH Properties,
and Structure Combination.
OR
Right-click in the DVH window to use the DVH tools.
Refer to the Plan Review Activity section of this training guide to change the
DVH Display, Properties, and Statistics.
3. Use the isodose curves on the SPV and 3D images to evaluate. Refer to these
resources:

• Plan Review Activity section, Dose Toolbar Controls

If you determine that you need to make changes to the prescription to meet prescribed
goals, you may have to re-optimize. When you apply the changes, notice if the start
button on the Planning tab changes from to . If so, the changes you made
require re-optimization. Evaluate again. Use the tools described in Task 10. You may
re-optimize and evaluate several times before calculating stage 2.
12-12
Prostate VMAT Case
Prostate VMAT Case

Once the optimized plan meets the prescription goals, you must optimize and
calculate the final dose. Both of these actions occur in stage 2 of the optimization.
1. (Optional) Verify that the Sequencing Parameters that appear are your desired
settings. Change them, if necessary. (See Task 7.)
2. (Optional) Show the IMRT Constraints dialog box and the Console. (See Task
9.)
3. Click the Start Optimization button to start stage 2 of the optimization.
stage two prematurely, click the Skip Forward button. Understand that this
action does not result in a fully optimized plan.
OR
(Optional) If you would like to pause stage 2 of the optimization, click the Skip
Back button. This action removes the current display of fluence and lets
you start the optimization again at stage one.
5. Once stage two of the optimization completes, the system shows a dialog box
with the message “Segmentation Complete”. Click OK to acknowledge.

Once the system calculates the plan, you can evaluate. Use the same tools you used to
evaluate the optimized plan (see Task 9). If you choose to make changes to the
prescription at this time, the system determines if the change necessitates that you
start again at stage 1, starting at stage 2, or continue from its current state.
Monaco® 12-13
Prostate VMAT Case
Prostate VMAT Case
Task 14. Save Plan

Save the plan once you are sure that it has met the prescribed goals.
NOTE: You can save optimized plans after stage 1, but optimized dose is not
preserved.
1. Save the plan using one of these methods:
Click the Save button on your Quicklaunch bar.
OR
Click the Monaco Application Menu and select a Save option.

There are many documents and images that offer support. You can print them for
patient files. This task references the location in the training guide where detailed
information appears about each type of print job.
Subtask 1. Print or Export IMRT Reports
For more detailed information on how to print, see the section General Operation
and Navigation.
1. Click on the Output tab to select an individual or customized report to select a

set of reports to print.
12-14
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Subtask 2. Print Single Plane View, 3D Image or DVH Graph
You can print Images from any activity. You can print the DVH graph from Planning
or Plan Review activity. Calculated dose only appears on images in Planning and Plan
Review Activity.
3. Select the necessary view to print.
4. For some reports, the system gives you the option to type a report comment.
5. Click the Print button on the preview window to print the report shown.
Subtask 3. Print DRR/BEV
You can print DRR/BEV images to paper or film and scaled appropriately when
calibrated. For more information, see the General Operation and Navigation section,
Printing Options.
1. Click the Print Views drop-down arrow located in the Reports panel on the
Output tab.
OR
Right-click on any DRR/BEV image and select the Print option to show the DRR
Print dialog box.
2. Type the applicable information for location and scaling.
3. Click OK to print the image.
Monaco® 12-15
Prostate VMAT Case
Prostate VMAT Case

Once you complete an IMRT plan, you can create a QA plan for verification.
1. In the Workspace window, right click on the plan ID you created in this exercise
and select New QA Plan from the mouse menu.
OR
Click the New Plan button on the Planning tab, and select New QA Plan from
the drop-down.
2. Select the TrainingClinic: MonacoPhantom studyset. This is the studyset where

on which the QA plan will be created.
3. For this exercise, you want to maintain the original beams angles, so do not
select Reset Beams to Nominal Angles.
4. Select Monte Carlo as the Algorithm.
5. For this practice exercise, type 0.3 cm for the Calc Vol Grid Spacing.
6. Use a Monte Carlo Statistical Uncertainty per Plan of 1%.
9. Select the isocenter Center of patient.
10. Click OK to create the QA plan.
12-16
Prostate VMAT Case
Prostate VMAT Case
Practice Exercise
Task 16. Create/Calculate a QA Plan (cont.)
12. Click the Start Dose Calculation button. Once the system completes the
calculation of the QA plan, it shows a dialog box with the message “QA
Calculation Complete.”
NOTE: You can edit the calculation properties, edit and assign electron densities,
and utilize other tools. See the IMRT QA Tools, Planning Tools, and IMRT
Tools sections for more detailed information.
Task 17. Edit QA Plan Beam Weights (Optional)

Beam weights in QA are automatically scaled to one fraction. If necessary, you can edit
the beam weights to accommodate your QA process.
1. Click the Beam tab in the Planning Control.
2. Edit the Total MU for the sequence.

The system saves the QA Plans with their associated patient plans.
1. Save the QA plan, by either using one of these methods:

Click the Save button on your Quicklaunch Bar.
OR
Click the Monaco Application Menu button and select the Save option.
Monaco® 12-17
Prostate VMAT Case
Prostate VMAT Case

If you use third party software to compare planned versus measured dose planes, you
can export those planes when you use the Dose Plane Export Tool . For
ArcCHECK, Delta4 and other 3D devices, DICOM Export the RTPLAN and RTDOSE
to third party software for measurement comparisons. Skip this step for the practice
exercise. For more information, see the IMRT QA Tools section of this training guide.

For more detailed information on how to print a QA plan information and images, see
the section General Operation and Navigation.
Subtask 1. Print QA Plan Reports
1. Right-click on the loaded QA plan in the Patient Workspace Control. Select an

Individual Report to print.
OR
Select Customized Report to select a set of reports to print.
OR
Click the Output tab. Select an Individual Report OR Customized Report to

select a set of reports to print.
Subtask 2. Print QA Plan Images
You can print images with dose on the phantom just as any single plane view image.
12-18
Head and Neck Case
Head and Neck Case
Practice Exercise
This exercise assumes you are familiar enough with the planning in Monaco that
you no longer require specific steps. You can use the steps in the Prostate Plan as
a reference if you need it. This exercise includes prescription objectives based on
the RTOG 0022 Protocol and contours already drawn for you.
This stepwise task list helps you in your planning process. You may or may not
do all of the tasks on this list to complete your plan.
• Select Patient HnNPlan and Open Studyset HnNss

• Start Plan
• Add Beams or Sequences in Planning Activity
• Enter/Update the Prescription
• Edit Calculation Parameters
• Edit Sequencing Parameters
• Save a Template
• Optimize Fluence (Stage 1)
• Evaluate Optimized Fluence and Dose
• Re-Optimize and Evaluate (Optional)
• Optimize/Calculate Dose (Stage 2)
• Evaluate Final Plan
• Save Plan
• Print the Plan
• Create/Calculate a QA Plan
• Edit QA Plan Beam Weights
• Save the QA Plan
• Export the Dose Profiles
• Print the QA plan
Monaco® 13-1
Head and Neck Case
Head and Neck Case
General Planning Instructions

1. Place the isocenter at the center of the structure PTV TOTAL.
2. Select a 6MV treatment machine that best represents a machine that you
use clinically (Varian, Siemens, or Elekta).
3. Create a plan and use seven beams spaced evenly around the patient, or
create a sequence for VMAT.
4. Use a Grid Spacing of 0.4 cm.
Target
Structures
PTV66 95% of PTV66 is at or above 66Gy 30 fx 2.2 Gy/fx
95% of PTV54 is at or above 54Gy 30 fx 1.8 Gy/fx
and
no more than 20% of any PTV receives >110% of prescribed dose
PTV54 no more than 1% of any PTV receives <93% of prescribed dose
Organs at
Risk (OAR)
Brainstem 54 Gy
Spinal Cord 45 Gy
Unspecified no more than 1% or 1 cc of the tissue
Tissue outside any PTV receives >110% of
(patient) 66Gy
Parotids Mean dose to either parotid <26 Gy
or
at least 50% of either parotid gland receives < 30 Gy
or
at least 20 cc of the combined volume of both parotid glands receives < 20 Gy.
Figure 13-1: RTOG 0022 Protocol- Plan Scoring Criteria
13-2
Head and Neck Case
Head and Neck Case
Example Prescription
Hint #1: Apply Clear all voxels below a minimum value to the targets since they
overlap or are close air voxels.
Hint #2: Apply a Surface Margin to the PTV60 and PTV54 since they are close to
the surface.
Hint #3: Apply a 0.4 cm Shrink Margin to PTV60 to shrink it away from the
higher target dose.
Hint #4: Apply Optimize over all voxels in volume to the Spinal Cord (Serial
structure) and to the Lt Parotid.
Hint #5: Apply a 1.2 cm Shrink Margin to the patient.
Monaco® 13-3
Breast Case
Breast Case
Practice Exercise
This exercise assumes you are familiar enough with planning in Monaco that you no
longer require specific steps. You can use the steps in the Prostate Plan as a reference if
you need them. This exercise includes prescription objectives and contours already
drawn for you.
This stepwise task list helps you in your planning process. You may or may not do all
of the tasks on this list to complete your plan.
• Select Patient and Open Studyset

• Start a Plan
• Save a Template
• Optimize /Calculate Dose (Stage 2)
• Save Plan
• Print the Plan
Monaco® 14-1
Breast Case
Breast Case
1. Use the patient LtBreast for planning.
2. Place the isocenter at the center of the structure PTV.
3. Select a treatment machine that best represents a machine that you use clinically
(Varian, Siemens or Elekta).
4. Create a plan. Use two tangential beams on the left breast.
5. Use the Monte Carlo algorithm for dose calculation.
6. Limit the number of segments to 40.
7. If you turn on SSO, turn on Pilot Beamlets.
Breast Plan Scoring Criteria
Target Structures
PTV (left breast tissue) 90% of PTV is at 50 Gy 25 fx 2.0 Gy/fx
And
No more than 1% of PTV to exceed 55 Gy
Organs at Risk
(OAR)
Left Lung 20% less than 20 Gy
Heart 10% less than 25 Gy
and
Maximum dose not to exceed 45 Gy
14-2
Breast Case
Breast Case
Left Breast Practice Exercise
This exercise assumes you know enough about Monaco and you do not need detailed
steps for everything. Use the patient named LTBreast1TRN for planning.
Prescriptions Target Structures

95% of PTVIIimrt is at or
above 95% of the
Prescription A PTVIIimrt prescribed dose. 27 fx 1.8 Gy/fx
Use the values that are
Organs at Risk applicable to your clinic.
Monaco® 14-3
Breast Case
Breast Case
Prescription A
1. Open and Load the patient LTBreast1TRN.
2. Select New Plan | New Monaco Plan.
a. Select Step and Shoot for Delivery Type.
b. Select All for the Anatomical Site.
c. Select the 1 field template.
d. Select TRNElekAgility as the machine.
e. Select Photon.
f. Select Monte Carlo for the algorithm.
g. Select 6MV for energy.
h. Select Center of PTVIIimrt for the Isocenter Location.
i. Select OK.
3. Go to the Prescription tab.
a. Select the Rx Site or type it in.
b. Select the Prescribe to point if necessary.
c. Type in 48.60 Gy for the prescription.
d. Type in 27 for the Number of Fractions.
a. Add eight more beams
b. Type in the Beam Description.
14-4
Breast Case
Breast Case
Prescription A (cont.)
c. Type in the Field ID.
d. Select the Geometry tab.
i. Type in the following for the gantry angles: 310, 328, 350, 13, 335,
57, 80, 102, and 120. Or use angles that are more clinically
relevant to your clinic site.
5. Then go to the IMRT Constraints on the Planning Control bar.
a. Select the IMRT Constraints so they are clinically relevant to the

prescription.
i. The PTVIIimrt needs at least 1 target cost function.
ii. Put in the OAR Constraints so they are clinically relevant to the
prescription.
iii. The contour you use as the external structure such as (Skin,
Patient, Body) needs at least 1 cost function.
6. When the optimizer completes the calculation review and evaluate the plan. Make
changes if necessary.
Monaco® 14-5
Brain Case – Two Partial Arcs
Practice Exercise
This exercise reviews the general process of planning a brain patient in Monaco
when you use Dynamic Conformal Arc or VMAT. There are many ways to
complete a plan in Monaco. This is just one suggested method of treatment
planning. This exercise does not include contouring.

Task 2. Start a Dynamic Conformal Arc or VMAT Plan
Task 4. Enter/Update the Prescription
Task 5. Edit Calculation Parameters/Global Parameters
Task 6. Enter/Edit Sequencing Parameters (VMAT Plans only)
Task 7. Optimize Fluence and Calculate Dose
Task 8. Evaluate Plan
Task 10. Save Plan
Monaco® 15-1

Workspace.
2. Select the patient ID DynamicConformal. Use one of these methods:
OR
Control.
3. Click the studyset name and select New Monaco Plan from the mouse
menu. Monaco loads the patient and shows the New Monaco Plan dialog
box.
Task 2. Start a Dynamic Conformal Arc or VMAT Plan

This task walks you through the steps to select a default template and start a new
plan.
1. Set Delivery to VMAT or Dyn. Conformal Arc depending on the delivery
type.
2. Select the appropriate template based on the delivery type.
3. Select the appropriate Treatment Unit. Select the Treatment Unit for
Elekta06xBM or ElektaAgility06x for VMAT or dynamic conformal arcs
planning. Or, if you have an add-on MLC machine, you can use it for the
exercise to create a dynamic conformal arc plan.
4. If necessary, select the Energy and set the isocenter to Center of Target.
5. Click OK to start the patient plan.
15-2

arrangements from a template. You use this task less frequently once you create
1. Click the Beams tab on the Planning Control spreadsheet. Click the New
Beam button to add two arc beams to the plan.
2. Click the Geometry button in the upper-right corner of the Beams tab. You
edit the Collimator, Couch, and Gantry information here.
Beam 1 Beam 2 Beam 3
Couch 0.0 Couch 45.0 Couch 270.0
Collimator 0.0 Collimator 0.0 Collimator 0.0
Gantry 40.0 Gantry 50.0 Gantry 50.0
Arc 140.0 Arc 130.0 Arc 130.0
Increment 20.0 Increment 20.0 Increment 20.0
Isocenter Center of Isocenter Center of Isocenter Center

Target Target of
Target
Direction CW Direction CW Direction CW
Monaco® 15-3

You use this task less frequently once you create and save your own clinical
templates.
1. Click the IMRT Constraints tab.
2. For VMAT, use the Plan Scoring Criteria below to edit existing structure
prescriptions and add structures and prescriptions (as necessary) to create
an initial prescription for this patient. You must replace any default
structures that appear in red with an actual patient structure.
Target Structures
Target 95% is at or above 46.80 Gy
Brain Stem Max 45 Gy

Chiasm Max 54 Gy
Rt Eye no more than 5% > 5 Gy
Lt Eye no more than 5% > 5 Gy
Rt Optic Nerve Max 50 Gy
Lt Optic Nerve Max 50 Gy
NOTE: For DCAT, the OARs in the prescription are only used to show
that avoidance is applied to the apertures. Therefore, you can
leave the isconstraints blank in order to avoid conflict, unless
you have Segment Shape Optimization checked. To make an
OAR an avoidance, check the Avoidance option in the
structure’s Properties dialog box.
3. Type 26 for the Number of Fractions.
4. Type 46.80 Gy for the Prescription.
15-4

This task lets you set up the calculation properties.
NOTE: The values used in the training class for this exercise may not
represent actual clinical values. The intent is to decrease the time it
takes to run the plan to give you more time to run more iterations (if
needed) in the training class.
1. Click the Calculation Properties button to open

the Calculation Properties dialog box.
3. For this practice exercise, select Monte Carlo Photon for the Secondary
Algorithm.
6. Click OK when you completer your edits.

This task lets you set up IMRT Parameters
2. For Target Margin select Narrow (3-4mm).
3. For Avoidance Margin, select Tight (2mm).
Monaco® 15-5
Click the Sequencing Parameters button to set the

sequencing parameters.
Use these sequencing parameters for this plan:
Segment Shape Optimization: Checked

Pilot Beamlets: Checked
Max Number of Arcs: 1
Max # of Control Points/Arc: 75
Min. Segment Width (cm): 0.50
Fluence Smoothing: Low
Use these sequencing parameters for a DCA plan:

Constant Dose Rate: Unchecked

This task starts the optimization process. The system automatically gives
feedback during optimization on the IMRT Constraints dialog box, the console,
and the progress meter. You can manually update the dose, DVH and fluence
during the optimization process.
1. Press the Alt and C keys on your keyboard to show the Console.
2. Click the Optimize button to start the optimization process.
Constraints dialog box and progress meter start to update with
each iteration.
15-6
Task 8. Optimize Fluence and Calculate Dose (cont.)
3. (Optional) If you want to stop the optimization and move to the end of the
optimization prematurely, click the Skip Forward button. Understand
that this action does not result in fully optimized fluence.
OR
(Optional) If you want to stop the optimization and go back to the start,
click the Skip Back button. This action removes the current display of
fluence and lets you start the optimization again.
4. Once the optimization completes, the system shows a dialog box with the
message “Final Dose Calculation Complete.”

You have many tools available to evaluate your plan. Among these tools are:
• Sensitivity Analysis
• DVH Statistics
• Fluence Display Tools
• Isodose curves on the SPV
• 3D images
This task references the location in the Monaco training guide and shows the
location of detailed information about the use or functionality of these tools. You
can use any or all for evaluation at this time.
1. Use the Sensitivity Analysis information to evaluate. The Sensitivities

button is in the upper-right corner of the IMRT Constraints tab. Refer to
the Monaco Planning and Workflow section Plan Analysis Tools for more
detailed information.
Monaco® 15-7
Task 9. Evaluate Plan (cont.)
2. Use DVH Statistics to evaluate. Refer to the Plan Review section to show a
DVH and review the DHV Statistics on the Plan Options tab.
3. Use Fluence Tools on the Planning tab to evaluate. Refer to the IMRT
Tools section Fluence Toolbar.
4. Use isodose curves on the SPV and 3D images to evaluate. Refer to these
resources:


If you determine that you need to make changes to the prescription to meet
prescribed goals, you may have to re-optimize and evaluate again. Use the tools
described in Task 8. You can re-optimize and evaluate several times before you
accept the final plan. For DCAT plans, the tools available to improve plan quality
are limited to Target and OAR avoidance margins. You can also change the beam
position to improve the plan quality.
15-8
Task 11. Save Plan

Save the plan when once you decide that it meets the prescribed goals.
1. Open the Save as Plan dialog box. Use one of these methods:
Click the Save button on your toolbar.
OR
Click the Monaco Application button and select Save Plan As from
the menu.
2. Type the plan name ArcPlan.
3. Click Save to save the plan
Monaco® 15-9
mARC Brain Case
mARC Brain Case
Practice Exercise
This exercise reviews the general process of planning a brain patient in Monaco
when you use the Siemens mARC Delivery. There are many ways to complete a
plan in Monaco. This is one suggested method of treatment planning. This
exercise does not include contouring.

Task 2. Start an mARC Plan
Task 5. Edit Calculation Parameters/Global Parameters
Task 10. Save Plan
Monaco® 16-1
mARC Brain Case
mARC Brain Case

Workspace.
2. Select the patient ID DynamicConformal. Use one of these methods:
OR
Control.
3. Click the studyset name once, and select New Monaco Plan from the
mouse menu.
The patient information loads and the New Monaco Plan dialog box
appears.
Task 2. Start an mARC Plan

This task walks you through the steps to select a default template and start a new
plan.
1. Click the Template: DEFAULT VMAT option. There is no default
template for an mARC plan. Modify the VMAT template once you are in
Planning mode.
2. In the spreadsheet, select any valid Treatment Unit. If necessary, select the
Energy.
3. Click OK.
4. Click the Beams tab on the Planning Control spreadsheet.
5. Use the drop-down menu to change the Delivery to mARC.
6. Use the drop-down menu to change the Treatment Unit to
Siemens160IMRT.
7. Use the drop-down menu to change the Isocenter Location to Center of
Target.
16-2
mARC Brain Case
mARC Brain Case

You only complete this task when you need to add beams to or modify beam
arrangements from a template. You use this task less frequently once you create
1. Add two new mARC beams to the plan. Click the New Beam button
on the Beams tab of the Planning Control spreadsheet twice to add the
beams.
2. Click the Geometry button in the upper-right corner of the Beams tab. You
edit the Collimator, Couch, and Gantry information here.
Beam 1 Beam 2 Beam 3
Couch 0.0 Couch 45.0 Couch 270.0
Collimator 0.0 Collimator 0.0 Collimator 0.0
Gantry 40.0 Gantry 50.0 Gantry Start 50.0

Start Start
Arc 140.0 Arc 130.0 Arc 130.0
Increment 20.0 Increment 20.0 Increment 20.0
Isocenter Center of Isocenter Center of Isocenter Center

Target Target of
Target
Direction CW Direction CW Direction CW
Monaco® 16-3
mARC Brain Case
mARC Brain Case

You only complete this task when you need to edit the prescription from a
template. You use this task less frequently once you create and save your own
clinical templates.
1. Click the IMRT Constraints tab on the Planning Control dialog box
spreadsheet.
2. You need to edit the existing constraints. The structures saved with this
patient are not valid. You also need to add constraints so the plan meets the
Plan Scoring Criteria. Edit the existing structure prescriptions. Add
structures and prescriptions to create an initial prescription for this patient.
Target Structures
Target 95% is at or above 46.80 Gy
Brain Stem Max 45 Gy

Chiasm Max 54 Gy
Rt Eye no more than 5% > 5 Gy
Lt Eye no more than 5% > 5 Gy
Rt Optic Nerve Max 50 Gy
Lt Optic Nerve Max 50 Gy
3. Once you assign all the structures, doses, and isoconstraints, click the
Prescription tab on the Planning Control Spreadsheet.
4. Type 26 for the Number of Fractions.
5. Type 46.80 Gy for the Rx Dose.
NOTE: If necessary, click the Plan Options tab at the top of the screen.
Change the units to Gy. Click the Planning tab to continue with the
plan.
16-4
mARC Brain Case
mARC Brain Case

This task lets you set up the calculation properties. Grid Settings are global
settings and algorithm settings are per prescription.
NOTE: The values used in the training class for this exercise may not
represent actual clinical values. Our intent is to decrease the time it
takes to run the plan to give you more time to run more iterations (if
needed) in the training class.
1. Click the Calculation Properties button to open the

Calculation Properties dialog box.
3. Use Monte Carlo Photon for the Secondary Algorithm.
5. Use a Statistical Uncertainty Per Calculation of 3%.

This task lets you set up IMRT Parameters for each prescription.
2. For Target Margin, select Narrow (3-4mm).
3. For Avoidance Margin, select Tight (2mm).
Monaco® 16-5
mARC Brain Case
mARC Brain Case

This task lets you set up the sequencing parameters for the current plan.
1. Select the Sequencing Parameters button.
2. Use these sequencing parameter for this plan:

Pilot Beamlets: Checked
Max Number of Arcs: 1
Max # of Control Points/Arc: 75
Min MU Per Dynamic CP: 2
Min. Segment Width (cm): 0.50
Fluence Smoothing: Low
3. Click OK.
NOTE: Segment Shape Optimization works the same for all delivery
modes (VMAT, SnS, dMLC, DCAT, mArc). We recommend
you use SSO in order to create better plan quality and delivery
times. When you enable SSO, the sequencer controls the target
dose rate to make sure it is optimally set for the given plan.
Therefore you do not enter a Target Dose Rate.
The Min MU per Dynamic CP is only available for mARC

plans. This variable gives you extra control over the plan
quality. For simple single arc Prostate or single lesion plans, you
can increase this value to 3 or 4 to keep the level of plan
modulation down and improve the delivery efficiency.
16-6
mARC Brain Case
mARC Brain Case

This task starts the optimization process. The system automatically gives
feedback during optimization on the prescription dialog box, the console, and the
progress meter. You can manually update the dose, DVH, and fluence during the
optimization process.
1. Click the IMRT Constraints tab on the Planning Control spreadsheet.
2. Show the Console. Use one of these methods:
Click the Workspace tab and select the Controls | Optimization Console
option.
OR
3. (If necessary) Click the Planning tab.
4. Click the Optimize button to start the optimization process.
NOTE: After you create the rays (beamlets), you can see the
prescription dialog box and progress meter start to update with
each iteration.
Monaco® 16-7
mARC Brain Case
mARC Brain Case
Practice Exercise
Task 8. Optimize Fluence and Calculate Dose (cont.)
5. (Optional) If you want to stop the optimization and move to the end of the
optimization prematurely, click the Skip Forward button. Understand
that this action does not result in fully optimized fluence.
OR
(Optional) If you want to stop the optimization and go back to the start,
click the Skip Back button. This action removes the current display of
fluence and lets you start the optimization again.
6. Once optimization completes, the system shows a dialog box with the
message “Full Fluence Modulation Complete. Press Start to Begin
Segmentation”. Click OK to acknowledge.
7. Click the Optimize button to do stage 2 of the optimization.
8. Once optimization completes, the system shows a dialog box with the
message ‘Segmentation Complete’. Click OK to acknowledge.

You have many tools available to evaluate your plan. Among these tools are:
• Sensitivity Analysis
• DVH Statistics
• Fluence Display Tools
• Isodose curves on the SPV
• 3D images
16-8
mARC Brain Case
mARC Brain Case
Practice Exercise
Task 9. Evaluate Plan (cont.)
This task references the location in the Monaco training guide and shows the
location of detailed information about the use or functionality of these tools. You
can use any or all for evaluation at this time.
1. Use the Sensitivity Analysis information to evaluate. Sensitivities tab is

located on the IMRT Constraints tab of the Planning Control spreadsheet.
Refer to the Monaco Planning and Workflow section Plan Analysis Tools
for more detailed information.
2. Use DVH Statistics to evaluate. Refer to the Plan Review

Activity section to change the DVH Display Properties and DVH Statistics.
3. Use Fluence Statistics to evaluate. Refer to the IMRT Tools section

Fluence Toolbar.
4. Use isodose curves on the SPV and 3D images to evaluate. Refer to these
resources:


Should you determine you need to make changes to the prescription to meet
prescribed goals, you may have to re-optimize and evaluate again. You can re-
optimize and evaluate several times before you accept the final plan. You can also
change the beam position to improve the plan quality.
Monaco® 16-9
mARC Brain Case
mARC Brain Case
Task 11. Save Plan

Save the plan when you are sure that it has met the prescribed goals.
1. Click the Monaco Application button and select the Save Plan As option.
2. Type the plan name ArcPlan.
3. Click Save to save the plan.
16-10
Multiple Prescription
Breast Planning Forward Planning
You can use two tangential open fields with segments to create a Forward radiation
therapy plan. The MLC segments are constructed based on BEV projections,
conforming MLCs to isodose surfaces.
This exercise shows you how to apply the Forward planning technique for breast with
Monaco. This exercise contains all necessary steps to create two tangential beams with
multiple segments. It is assumed that you are already familiar with breast planning.
Overview section of Volume 1, Section1.
Once you complete this exercise, you should understand these concepts and be able to
execute the various tasks without additional supervision.

• Contour Structures
• Manage Structure Display
• Edit beam Isocenter
• Create and edit photon and SCV ports
• Create Interest Points
• Manage Prescription Properties
• Display and Evaluate isodoses
• Create Segments
• Edit Beam Weighting
• Manage MU/Fluence Display
• Save a plan
Monaco 17-1
Breast Planning Forward Planning (cont.)
Task 1. Open the Patient
1. Click the Monaco Applications menu button.
2. Select Open Patient .
3. Select the patient BreastTRN. Use one of these methods:
OR
Click the name once and click OK.
4. The system loads the patient information into the Patient Workspace Control.
Double–click on the studyset name.
OR
Click the studyset name once, and then click the Load button. The patient data
17-2
Contour the following structures.

• Right lung
• Left lung
• Spinal cord
• Heart
• Lumpectomy_PTV
structure or create positive, negative, or variable margins on structures. Refer to the
Contouring Tools section of this training guide for more information on creating 3D
auto margins.
1. Click the Auto Margins button on the Contouring ribbon.
2. Type the structure name: Lumpectomy_PTV in the Structure field.
4. Select Tumor (GTV) in the Structure Selection List.
6. Make sure Uniform Margin is checked.
7. Type the value 1.0 cm next to Superior.
Monaco 17-3
Task 4. New Plan from Template
1. Click the drop-down arrow next to New Plan .
• This opens the New Monaco Plan dialog box (Figure 17–1).
3. Type a plan name and description: ForwardBreast.
17-4
Task 4. New Plan from Template (cont.)
6. Select the Template: DEFAULT3D1beam (Rx Site , Rx Dose: 2.000 Gy, Total
Beams: 1).
7. The Treatment Orientation for this plan is Head First. The Scan Orientation is
indicated as Head First Supine.
8. Select the Treatment Unit labeled Demo Synergy – 6MV.
NOTE: The Treatment Units in the training data are associated to specific
energies.
10. Select 6.0 MV for the beam energy.
11. Select any option in the Isocenter Location column. This exercise guides you to
change the location of the isocenter in Task 5.
The Patient orientation icon shows the head pointing toward the top of the
screen.
Figure 17-2: Head First Patient Orientation Icon
Monaco 17-5
Task 5. Edit Beam Isocenter
2. Click Edit Beam .
3. Position the mouse cursor over the central crossmark on the isocentric plan. The
Figure 17-3: Mouse Cursor to Move Isocenter
17-6
Task 5. Edit Beam Isocenter (cont.)
4. Click and drag the crossmark to a new isocenter location close to the chest wall
(Figure 17-4).
Figure 17-4: Isocenter Location
NOTE: You can also change the isocenter when you type the X, Y, and Z
coordinates for the new isocenter location on the beam tab in the
Planning Control. Select Beams on the Planning Control Bar |
General.
Monaco 17-7
Task 6. Edit Gantry Angle
1. Your Edit Beam button should still be selected.
2. Position the mouse cursor over the active beam’s central ray. The mouse pointer
looks like this: (Figure 17-5).
3. Left-click and move the mouse in a circular motion until you achieve your
desired medial tangent gantry angle.
Figure 17-5: Mouse Cursor to Rotate Gantry
NOTE: You can also change the Gantry, Collimator, and Couch angles by
navigating to the Planning Control. Select Beams on the Planning
Control Bar| Geometry.
17-8
Task 7. Manage Structure Display
1. Open the Structure Visibility Control. In the default location, the control
appears on the right side of your screen.
2. (Optional) If you cannot find the Structures Control, reset your controls.
3. Click the Column Header: Structure to turn all structures off. When all
structures are off, the Structure Visibility window is gray.
4. Click Breast_PTV_EVAL to show your target volume.
NOTE: You can also manage structure’s visibility on the Structures tab on
the Planning Control Bar. Select and unselect the Visible box.
Monaco 17-9
Task 8. Edit Field Size
1. Left-click in the Beam’s Eye View (BEV) to activate window.
2. Right-click and select Maximize.
3. Toggle the MLC display off. Right-click in the BEV, unselect Show MLC. Your
Edit Beam button should still be selected.
4. Position your mouse pointer over the collimator jaw position lines so that the
5. Increase the field length so that the field covers the whole target. Move the
mouse while you hold down the left-mouse button to adjust the collimator jaw
position line to the desired position.
Figure 17-6: Mouse Cursor to Edit Field Size
NOTE: You can also change the Field Size in the Planning Control when you
select Beams on the Planning Control Bar | Geometry.
17-10
1. Turn on your MLC display. Right-click in the BEV window and select Show
MLC. Monaco places a checkmark in the menu when the MLCs
appear.
2. Select Create and Edit Ports .
4. Use the mouse cursor to draw a Medial Tangent port.
5. (Optional) Edit individual MLC leafs. When you hover your mouse over the
MLCs, the selected MLC for editing appears in red. The mouse cursor for editing
a MLC is a . Click and drag a MLC leaf to the new location.
OR
Select Show Leaf Table in the Create and Edit Ports dialog box.
a. A MLC leaf table is seen which is editable (Figure 7-17).
Monaco 17-11
Figure 17-7: Show Leaf Table
7. Close the Create and Edit Ports dialog box when the previous step is complete.
17-12
Task 10. Duplicate and Oppose Beam to Create Lateral Tangent
1. Click the New Beam drop-down.
2. Select Duplicate and Oppose .
Task 11. Edit Beam Descriptions in the Beam Control
1. Open the Beams tab on the Planning Control, located on the bottom of your
screen above Slice Mode.
NOTE: You can Reset the location of the Planning Control by selecting
Workspace | Reset Controls. If the Beams tab is not visible select
Workspace| Controls | Beams. The Beams tab should then become
visible on the Planning Control Bar.
2. On the General tab of the Beam Control, edit the Beam Descriptions and Field
IDs (Figure 17-8).
Figure 17-8: Field ID and Description
Monaco 17-13
Task 12. Line up Superior Edge of the Fields
There are different techniques on how to line up the Superior field edge to get rid of
divergence. This is just one way to demonstrate this.
1. While looking at the 3D View change the Couch angle on the Beams tab|
Geometry to line up the superior edge of the field. The couch angle moves the
superior edge of the field superior to inferior.
2. While looking at the 3D View change the collimator angle on the Beams tab|
Geometry. The collimator angle tilts the beam edge left to right.
NOTE: You may line up the superior edge if you are going to treat a half beam
block supra clavicular field.
Zero Couch Rotation Zero Collimator Rotation
Figure 17-9: Zero Rotation
17-14
Task 12. Line up Superior Edge of the Fields (cont)
Figure 17-10: Couch and Collimator Rotations
Figure 17-11: Bean data for couch and collimator rotations
Couch and Collimator rotations to get rid of superior edge divergence.
Task 13. Re-evaluate the Ports
1. Since the Couch and Collimator have moved you want to re-evaluate your ports
to make sure they are covering everything.
2. If changes need to be made select Create and Edit Ports and make the edits.
Monaco 17-15
In the Tools ribbon, you can place interest points or markers. This task explains how
to create interest points in Monaco. For more information on how to place interest
points or markers, refer to the Planning Tools section in this training guide.
1. Click the Interest Points/Markers button on the Tools tab. Monaco shows
the Interest Points& Markers dialog box (Figure 17-12).
2. To place an Interest Point, select New Interest Point .
• An interest point appears on the studyset (Figure 17-13).
Figure 17-13: Interest Point
17-16
Task 14. Add an Interest Point (cont.)
3. Type a Description for the Interest Point next to its coordinates.
4. Move the point on a transverse, sagittal, or coronal image. To do this, place the
mouse pointer over the point or marker. (The mouse pointer visually
changes to look like this .) Hold down your left mouse button and drag
the point to a new location.
OR
NOTE: Try to keep the interest point 2cm away from the field edge if you are
using it as a weight point. This will keep it out of the penumbra
region. You can use the Measure tool on the Tools tab if you need to
measure the distance (Figure 17-14).
Figure 17-14: Measure Distance for Interest Points
Monaco 17-17
1. Click the Prescription tab on the Planning Control.
2. Type LtBREAST as the Rx Site. Monaco asks if you want to add the LtBREAST
site to the list of Rx Sites.
Figure 17-15: Add to the List of Rx Sites dialog box
3. Click Yes.
4. Select the Prescribe To point. This could be the Interest Point you just created.
5. Type an Rx Dose (Gy) of 48.6.
6. Type 27 Number of Fractions. The Fractional Dose updates to 1.8 Gy.
7. Equally Weight the Prescription dose between the Medial Tangent and Lateral
Tangent, Beam 1 and 2 in the example below (Figure 17-16).
Figure 17-16: Beam Weights
17-18
Task 17. Evaluate Dose/Isodose Templates
1. Open Isodoses Control. The default location for this control is on the left side of
your screen (Figure 17-17).
Figure 17-17: Isodoses Control
2. (Optional) To Locate your Isodoses Control:
3. Click Workspace | Reset Controls.
OR
Click Workspace | Controls| Isodoses.
4. Adjust Isodose levels as needed.
Monaco 17-19
Task 17. Evaluate Dose/Isodose Templates (cont.)
5. You can also select an isodose template from the drop-down.
Figure 17-18: Isodoses Template drop-down
6. If you want to create an Isodose template:
a. Type in the isodose line values.
b. Select if you want the isodose line value on or off for 2D and 3D.
c. Select Save As.
d. Type in the Template Name or select a template from the drop-down you
want to re save it as.
e. Select Save.
7. Review the 100% isodose line to make sure it adequately covers the breast and
does not intrude into the lung. If it does not adequately cover the breast, return
to Task 2 and increase the field sizes and/or rotate the gantry until you are
satisfied with the coverage. You may also need to scale your Prescription.
17-20
Task 18. Edit Beam Weighting
1. Click the Prescription tab in the Planning Control.
2. (Optional) Adjust the beam weighting for the Tangent fields 1and 2 to achieve
the best isodose display.
Figure 17-19: Beam Weighting Dose
Task 19. Display 3D Isodose for Forward Planning
1. Open the Isodoses Control (see task 17).
2. Pin the Isodose Control. To do this, click the thumb tack button.
3. In the first Isodose value box, type the first overdose value you want to remove.
4. Click the 3D drop- down arrow for the first isodose value box (Figure 17-20).
5. Select an option.
Figure 17-20: Isodoses Control
Monaco 17-21
Task 20. Manage MU/Fluence Display
1. Right-click in the BEV. Select Maximize from the submenu.
2. Right-click in the BEV. Select Show MU / Fluence from the submenu. You
should now only see the 3D dose display and MLCs on the BEV (Figure 17-21).
Figure 17-21: BEV 3D Dose Display
The above window shows the 118% hotspot in the BEV of your medial tangent.
You use this to create the first segment.
17-22
Task 21. Create Second Medial Segment
1. Open and pin the Prescription tab.
2. Select the Segments tab.
3. You then want to copy segment 1. Click Copy Segment.
NOTE: If you select Add Segment the jaw settings default to the parent
beam’s open field size.
Figure 17-22: Copy Segment 1
5. Click Create and Edit Ports.
Monaco 17-23
Task 21. Create Second Medial Segment (cont.)
modulation.
• As you add segments the system freezes the dose from the previous
calculation so the isodose is still visible when you add segments.
Figure 17-23: BEV Blocking Hotspot
7. Click Close on the Create and Edit Ports dialog box when the previous step is
complete.
17-24
Task 22. Calculate Dose and Adjust Beam Weighting for Second Medial
Segment
2. On the Segments tab you can adjust the weight of the new segment
(Figure 17-24).
Figure 17-24: Beam Weight Second Segment
3. Increase segment 2 weight using the slider bar or by typing a value in the weight
field, until the overdose 3D isodose disappears (Figure 17-22).
4. You must recalculate each time after you adjust the weight.
Figure 17-25: Isodose not seen in BEV
Monaco 17-25
Task 23. Create Second Lateral Segment
1. Edit the 3D isodose display to a value approximately 2-5% less than its current
value (Figure 17-26).
Figure 17-26: 2-5% Less Hot Spot Isodose
2. Click the Beam drop-down and select Beam 2 (Figure 17-27).
Figure 17-27: Beam drop-down on Segments tab
3. Click Copy Segment (Figure 17-28).
Figure 17-28: New Segment
17-26
Task 23. Create Second Lateral Segment (cont.)
5. Click Create and Edit Ports.
6. Edit the MLC’s to block the overdose region displayed as a 3D isodose (Figure
17-29).
Figure 17-29: New Segment Blocks Hot Spot area
5. Click Close on the Create and Edit Ports dialog box when you are finished
editing the block.
Monaco 17-27
Task 24. Calculate Dose and Adjust Beam Weighting for Second Lateral
Segments
2. On the Segments tab you can adjust the weight of the new segment
(Figure 17-30).
Figure 17-30: Beam Weight Second Lateral Segment
3. Increase segment two’s weight using the slider bar or by typing a value in the
weight field, until the overdose 3D isodose disappears (Figure 17-31).
Figure 17-31: Segment covers Hot Spot Isodose
17-28
Task 25. Calculate Dose and Adjust Beam Weighting for Remaining
Segments
1. Alternating between the Medial and Lateral Tangent fields, repeat the same
procedure as previously described above to eliminate other hotspots until you
reach your desired isodose distribution. Be aware of the location of your
calculation point that it is not being covered by the block.
Task 26. Rescale a Plan
1. (Optional) You may need to rescale the plan. To do this click the Prescription
tab in the Planning Control.
2. Rescale the Dose: 48.6Gy to Cover 97% of Breast_PTV_EVAL

(Figure 17-32).
NOTE: Review the plan after you rescale to make sure the plan has adequate
coverage.
Figure 17-32: Rescale Dose
Monaco 17-29
Task 27. Add Setup Beams
2. Click the Setup Beams tab.
4. Edit the beam Description, ID, and Geometry an Anterior Posterior (AP)
setup field.
6. Edit the beam Description, ID, and Geometry to create a Left Lateral setup field.
17-30
Breast Planning – Multiple Prescriptions – Electron Boost Plan
Task 1. Add another Prescription
1. Select Add RX on the Prescription tab (Figure 17-33).
Figure 17-33: Add Rx
2. The Import Template into Existing Plan opens (Figure 17-34).
Figure 17-34: Import Template into Existing Plan dialog box
Monaco 17-31
Breast Planning – Multiple Prescriptions –- Electron Boost Plan (cont.)
Task 1. Add another Prescription (cont.)
5. Select the Template: DEFAULT3D1beam (3D Number of Beams: 1).
6. The Treatment Orientation is the same as the Initial RX. This option is grayed
out and not editable.
7. Select the Treatment Unit labeled DemoSynergyElec.
8. Select Electron as the Modality.
9. Monte Carlo populates in the Algorithm column.
10. Select 12MeV for the beam energy.
11. Select Center of Lumpectomy PTV in the Isocenter Location column.
13. The Plan now shows the multiple prescriptions in the Workspace.
a. The electron boost is Rx B (Figure 17-35).
Figure 17-35: Multiple Rx in the Workspace
17-32
Breast Planning – Multiple Prescriptions – Electron Boost Plan (cont.)
Task 2. Fill in the New Prescription Information
1. Select the Prescription tab on the Planning Control Bar opens.
2. Fill in the Prescription information:
a. Rx Dose-1200cGy
b. Number of Fractions-6 fractions
c. Select the Prescribe to Point drop-down
i. Select Depth of Beam 3 (Figure 17-36).
Figure 17-36: Depth of Beam 3
ii. Next type in the depth in cm that is clinically relevant for the
energy you chose to calculate to. (Figure 17-37)
NOTE: If bolus is assigned to the electron beam the bolus

thickness must be taken into account when you choose
a depth.
Figure 17-37: Depth in centimeters (cm)
Monaco 17-33
3. Scale the beam to the absolute line of 1080cGy, which is 90%. (Figure 17-38)
Figure 17-38: Rescale the Prescription
4. (Optional) Fill in Beam Information (Figure 17-39).
a. Description
b. Field ID
Figure 17-39: Beam Information
Task 3. Edit Electron Beam
1. Click the Beams tab on the Planning Control.
2. Type the Beam Description: eBoost.
3. Type 3A for the Field ID.
17-34
Task 4. Edit Isocenter Location
2. Click the Edit Beam button.
3. Position the mouse cursor over the beam entrance point on the plan. The mouse
pointer looks like this: (Figure 17-40).
Figure 17-40: Edit the Beam
4. Rotate the gantry so the beam is en face to the e- boost/PTV target.
5. You can fine tune the gantry rotation on the Beams tab| Geometry.
a. Example-Gantry 54.
Monaco 17-35
6. On the Geometry tab you can also make couch rotations if necessary.
a. Example-Couch 15 degrees
b. On the Sagittal and Coronal view the beam appears more en face to the
patient surface. (Figure 17-41)
Figure 17-41: En face beam in sagittal view and coronal view
7. Then go to Beams|General tab and select SSD as the Setup.
8. Type 105 for the Source to Skin Distance, SSD (CM).
Task 5. Add Applicator
1. Click the Treatment Aids tab on the Beam Control.
2. Click the Applicator ID drop-down arrow.
3. Choose an Applicator size to cover your target.
a. Example: A 10 x 10
17-36
Task 6. Create Electron Aperture
1. Click the Create and Edit Ports button on the Planning ribbon. The
Create\Edit Ports dialog box appears on your screen (Figure 17-42).
Figure 17-42: Create/Edit Ports dialog box – electron
2. (Optional) check the box Cut Aperture at Applicator Limits to toggle the option
on and off. The aperture cannot extend beyond the electron applicator limits. You
can use the Cut Aperture at Applicator Limits option to automatically cut the
aperture at the edge of the applicator. If you do not use this option, Monaco will
not calculate dose if the aperture does not fit within the applicator.
NOTE: Electron beams can have only one aperture per beam. You cannot
change the material and thickness values defined in beam modeling for
the Electron Monte Carlo algorithm.
Monaco 17-37
Task 6. Create Electron Aperture (cont.)
3. Draw your aperture on the BEV.
OR
4. You can create a uniform margin around a structure if you select a structure from
the Structure drop-down.
a. Example - Lumpectomy PTV
5. Then, type in the margin in the Margin text entry box.
6. Select Apply to Visible Beams.
7. Then, select Close to close the Create/Edit Ports dialog box.
17-38
2. Click Calculate.
a. With multiple prescriptions from the calculate drop-down you can select
Calculate Active Rx or Calculate All Rx (Figure 17-43).
Figure 17-43: Calculate Rx Options
1. Open the Beam Visibility Control.
a. Select the Dose check box next to the prescription(s) you want to review.
i. This effect the dose seen in the T/S/C views, DVH, and DVH
statistics
Figure 17-44: Dose Column Option on Beam Visibility
b. Review the isodose display and adjust Isodose levels as needed.
Monaco 17-39
Breast Planning – Breast Bolus
Here are steps on how to generate a bolus structure if a bolus is needed for planning.
Task 1. Generate and Assign Bolus to Beams
1. Click the Structures tab in the Planning Control.
2. Click <click to add a new row>.
3. Rename the “NewStructure”: 0.5 cm Bolus.
4. Select Bolus as the “0.5 cm Bolus” structure type.
NOTE: You must create a bolus structure type in order to activate the Bolus
button on the Contouring ribbon.
5. Click the Contouring Ribbon.
6. Click the Bolus button. The Generate Bolus dialog box opens.
7. Type 0.5 cm as the bolus description.
8. Select Patient as the base structure.
9. Type 0.5 as the Thickness (cm).
10. The Relative ED for the exercise stays as 1.0.
11. In the transverse view, Define Start Point and Define End Point. Click on the
base (patient) structure to define the bolus start and end points. For this exercise,
the start point is the medial border and the end point is the lateral border.
NOTE: The System creates bolus clockwise from the start to the end point on
plans in the Head First orientation. The System creates bolus
counterclockwise from the start to the end point on plans in the Feet
First orientation.
17-40
Breast Planning – Breast Bolus (cont.)
Task 1. Generate and Assign Bolus to Beams (cont.)
12. Click the image where you want to define the top (superior) and bottom
(inferior) points of the bolus. You can Define Top Point and Define Bottom
Point in any of the T/S/C or BEV views.
13. (Optional): You can move the mouse over the points and press the Delete key on
the keyboard to remove it.
14. Click the Generate button in the Generate Bolus dialog box.
17. Click the Treatment Aids tab.
18. Click the drop down arrow in the Bolus column and select the 0.5 cm bolus that
you generated. This assigns the bolus to the beam for calculation.
NOTE: The calculation engine does not take into account any bolus outside
the patient structure for dose calculation (that is, unless you assign
the bolus on the Treatment Aids tab of the Beams Control). For
IMRT plans the bolus has to be on all or none of the beams. For 3D
plans you can select which beams have bolus assigned to them.
Monaco 17-41
Multiple Prescriptions – Prostate Exercise
Prostate with Nodes Exercise
This exercise assumes you know enough about Monaco you do not need detailed steps
for everything. Use the patient named ProstateNodes for planning.

PTV1 4500 -right and
left pelvic nodes, 1.0 95% of PTV1 4500 is at or
Prescription A cm margin above 45.0 Gy 25 fx 1.8 Gy/fx
PTV2 5580- prostate +
sv, 1 cm margin with
0.5 cm margin 95% of PTV2 5580 is at or
Prescription B posterior above 55.80 Gy 6 fx, total 31 fx 1.8 Gy/fx
PTV3 7740 - prostate, 95% of PTV3 7740 is at or
1 cm with 0.5 cm above 77.40 Gy
Prescription C margin posterior 12 fx, total 43 fx 1.8 Gy/fx

Rectum Limit 17% to 65 Gy
Limit 35% to 40 Gy
90% isodose line should not cover more than ½ the rectal
volume
50% isodose line should not cover the entire rectal volume
Avoid hotspots near the anterior rectal wall
Bladder Limit 25% to 65 Gy
Limit 50% to 40 Gy
Bowel No more than 150cc should exceed 40 Gy
Femoral Heads Limit 10% to 50 Gy
Figure 17-45: Prostate with Nodes - Plan Scoring Criteria
17-42
Prostate with Nodes Exercise (cont.)
Prescription A
1. Open and Load the patient ProstateNodes.
b. Select All for Anatomical Site.
d. Select TRNElekta80 as the machine.
e. Select Photon.
h. Select Center of PTV1 4500 for the Isocenter Location.
i. Select OK.
4. Go to the Beams tab on the Planning Control bar
a. Type in the Beam Description.
b. Type in the Field IMultiple Prescriptions
Monaco 17-43
c. Select the Geometry tab.
i. You can use the gantry angles that are listed or use angles that are
more clinically relevant to you such as – 180, 231, 282, 333, 24, 75,
and 126.

prescription.
i. The PTV1 4500 needs at least 1 target cost function.
prescription.
NOTE: For faster calculation times, use a higher statistical uncertainty per
calculation value for initial planning. When the final plan is calculated,
change the statistical uncertainty per calculation to a lower value. For
optimized plans a re-calculation automatically begins and returns the
updated results. Click skip forward when it becomes available to
return segmentation complete message. Recommended values are 3%
per calculation for initial planning followed by 1% for the final
calculation.
Prescription B
1. Once you complete the plan for prescription A, go to Prescription on the Planning
Control bar.
2. Select the Add Rx button.
17-44
Prescription B (cont.)
3. The Import Rx into Existing Plan window opens. Select your options.
e. Select Photon.
i. Select the isocenter location you chose for the initial unless you
are going to do a shift to a new isocenter.
i. Select OK.
b. Type in the Field ID.
Monaco 17-45
more clinically relevant to you such as – 230, 295, 0, 65, and130.
ii. Delete the last 2 beams.

prescription.
prescription.
a. When you evaluate a plan with multiple prescriptions you can choose
which prescription doses you evaluate.
i. Select Beam Visibility.
ii. Check the check box in the Dose column next to the prescription
and/or beams you dose to appear in the T/S/C and DVH views.
17-46
Prostate with Nodes Exercise (cont.)
Prescription C
1. Once you complete the plan for prescription B, go to Prescription on the Planning
Control bar.
e. Select Photon.
i. Select OK.
Monaco 17-47
Prescription C (cont.)
b. Type in the Field ID
i. You can use the gantry angles that are listed or use angles that
are more clinically relevant to you such as – 230, 295, 0, 65,
and130.

prescription.
prescription.
17-48
and/or beams you dose to appear in the T/S/C and DVH views.
Monaco 17-49
Multiple Prescriptions – Bias Dose Plan
Bias Dose Plan
This exercise assumes you know enough about Monaco you do not need detailed steps
for everything. Use the patient named ProstateNodes for planning.

PTV1 4500 -right and
left pelvic nodes, 1.0 95% of PTV1 4500 is at or
Prescription A cm margin above 45.0 Gy 25 fx 1.8 Gy/fx
PTV2 5580- prostate +
sv, 1 cm margin with
0.5 cm margin 95% of PTV2 5580 is at or
Prescription B posterior above 55.80 Gy 6 fx, total 31 fx 1.8 Gy/fx
PTV3 7740 - prostate, 95% of PTV3 7740 is at or
1 cm with 0.5 cm above 77.40 Gy
Prescription C margin posterior 12 fx, total 43 fx 1.8 Gy/fx

Rectum Limit 17% to 65 Gy
Limit 35% to 40 Gy
90% isodose line should not cover more than ½ the rectal
volume
50% isodose line should not cover the entire rectal volume
Avoid hotspots near the anterior rectal wall
Bladder Limit 25% to 65 Gy
Limit 50% to 40 Gy
Bowel No more than 150cc should exceed 40 Gy
Femoral Heads Limit 10% to 50 Gy
Figure 17-46: Prostate with Nodes - Plan Scoring Criteria
17-50
Bias Dose Plan (cont.)
Prescription A
1. Open and Load the patient ProstateNodes.
e. Select Photon.
i. Select OK.
b. Type in the Field Multiple Prescriptions.
Monaco 17-51
Prostate with Nodes Case – Bias Dose Plan
more clinically relevant to you such as – 180, 231, 282, 333, 24, 75,
and 126.

prescription.
prescription.
Prescription B
1. Once you complete the plan for prescription A, go to Prescription on the Planning
Control bar.
17-52
e. Select Photon.
i. Select OK.
b. Type in the Field ID.
Monaco 17-53
i. You can use the gantry angles that are listed or use angles that
are more clinically relevant to you such as – 230, 295, 0, 65,
and130.
a. Select the IMRT parameters button.
b. The IMRT Parameters dialog box opens.
i. Select Rx A to contribute the dose from the plan to create a bias

dose plan.
Figure 17-47: IMRT Prescription Parameters dialog box
ii. Then select OK.
17-54
c. Select the IMRT Constraints so they are clinically relevant to the

prescription.
1. For a more homogeneous result plan to the prescription

dose for the PTV. For this example that would 10.80Gy.
Make sure the Bias Dose column is not checked.
prescription.
2. For a Bias dose plan you want to put in constraints for the
OARs that includes the dose from all bias dose
contributors. Make sure the Bias Dose column is checked
on the IMRT Constraints tab. For this example you would
plan for 55.80Gy.
Figure 17-48: IMRT Constraints panel
Monaco 17-55
and/or beams for the dose you want to appear in the T/S/C and
DVH views.
8. Now save prescription B as template to use for prescription C.
a. Select Monaco Application button | Save Template As.
Figure 17-49: Save Template As option
17-56
b. Then, type in the Template Name, Template Description and select an

Anatomical Site.
Figure 17-50: Save Template As dialog box
c. Select Save.
Monaco 17-57
Prescription C
1. Once you complete the plan for prescription B, go to Prescription on the Planning
Control bar.
b. Select the anatomical site you saved the Prescription B template as.
i. In this example it is under Pelvis.
Figure 17-51: Import Templates into Existing Plan dialog box
c. Select the 5FieldIMRT template.
i. This populates all the other fields. Check to make sure these are
correct.
d. Select OK.
17-58
6. Check the beams are labeled and positioned correctly.
a. Select the IMRT parameters button.
Monaco 17-59
b. The IMRT Parameters dialog box opens.
i. Select Rx A and Rx B to contribute the dose from the plans to

create a bias dose plan.
Figure 17-52: IMRT Prescription Parameters dialog box
ii. Then select OK.
c. Select the IMRT Constraints so they are clinically relevant to the

prescription.
1. For a more homogeneous result plan to the prescription

dose for the PTV. For this example that would 21.60Gy.
Make sure the Bias Dose column is not checked.
17-60
prescription.
1. For a Bias dose plan you want to put in constraints for the
OARs that includes the dose from all bias dose
contributors. Make sure the Bias Dose column is checked
on the IMRT Constraints tab. For this example you would
plan for 77.40Gy
ii. Check the check box in the Dose column next to the
prescription and/or beams you dose to appear in the T/S/C and
DVH views
Monaco 17-61
Bias Dose – Head and Neck
Bias Dose – Head and Neck Exercise
This exercise shows you how to create a bias dose plan on an existing base plan. In this
case, the patient lost weight during treatment. Create the bias dose plan on the new CT
taken after the patient lost weight.
Task 1. Fuse Base Plan CT with Bias Dose Plan CT

Task 2. Review the Base Plan
Task 3. Create a Bias Dose plan from a Base Plan
Task 4. Enter the Bias Dose Prescription
Task 5. Start the Optimization and Dose Calculation
Prescription Goals
Target Structures
GTV Base Dose Plan 95% to 54 Gy
Bias Dose Plan 95% to 18 Gy
Total Dose Plan 95% to 72 Gy
Spinal Cord Limit Total Dose to 45 Gy for the composite plan

Rt Parotid
Lt Parotid Limit Mean Dose to 30 Gy for the composite plan
NOTE: Due to the proximity of the Rt Parotid to the GTV,

the Rt Parotid dose limit will be exceeded.
Oral Cavity Limit Mean Dose to 45 Gy for the composite plan
Keep Hot spots inside GTV and limit them in unspecified

Unspecified Tissue tissue
Monaco® 18-1
Bias Dose – Head and Neck Exercise (cont.)
Task 1. Fuse Base Plan CT with Bias Dose Plan CT
There are two studysets for the Bias Dose patient. Phase 1 is the studyset on which you
planned the base dose. Phase 2 was taken later and is the studyset you use to plan the
Bias Dose plan. The first step, if you are to create a bias dose plan on a different
studyset, is to fuse the studysets.
1. On the Patient Selection dialog box, select the patient Bias Dose and click OK.
2. Select the Image Fusion Workspace.
3. Click the Fusion Ribbon.
4. Load / Activate the plan BaseHnN.
5. Right-click on Phase2 and select Load/Set As Secondary to load the studysets

into Fusion activity.
6. Click Start Auto Registration to register the studysets.

You can make manual adjustments to the fusion if necessary.
7. Once the registration completes, close the Image Fusion Progress dialog box and
click the Save button.
Task 2. Review the Base Plan
For this exercise, a base plan is available to use as the start point for you to create a
Bias Dose plan. The Base plan dose prescription is GTV to 54 Gy.
1. Select Activities | Planning.
2. Review the prescription, IMRT Constraints, dose distribution, DVH statistics,

Calculation Properties, and Sequencing Parameters to become familiar with the
Base plan.
18-2
Bias Dose – Head and Neck Exercise (cont.)
Task 3. Create a Bias Dose Plan from a Base Plan
This task demonstrates how to create the Bias Dose plan from an existing Base plan.
1. Right-click on BaseHnN and select New Bias Dose Plan| Phase 2.
NOTE: The system adds a yellow B next to the BaseHnN plan in the
Workspace control to designate it as a Base plan.
2. On the New Plan Template dialog box, use the default template BASE:
BaseHnN.
3. Select Center of GTV for the Isocenter.
4. For this exercise, use the default values for the Machine and Delivery Mode, then
click OK.
5. Click Workspace | Controls |Beams to open the Planning Control – Beams

tab. Review the Delivery Mode, Machine ID, and Isocenter Location, and then
click OK.
Task 4. Enter the Bias Dose Prescription
Type the prescribed dose to the Bias Dose plan only on the Prescription tab of the
Planning Control.
1. Click the Prescription tab and type the Rx Site.
2. Type 9 for the number of fractions and 18 Gy for the Prescription dose.
Monaco® 18-3
Bias Dose –Head and Neck
3. Click IMRT Constraints tab on the Planning Control. Make these changes to
the prescription. (An example prescription is at the end of this exercise.)
• Uncheck the box under Bias Dose for all cost functions on the GTV and the
patient. You only take bias dose into account on the OARs you want to
spare.
• Scale the Quadratic Overdose for the GTV to reflect only the Bias Dose
prescription (18Gy).
• Scale the Quadratic Overdoses on the patient structure to what you would
use for only the Bias Dose plan.
• All other structures reflect values for the composite plan. We suggest you
leave these values first, then optimize and see where you need to make
adjustments.
Task 5. Start the Optimization and Dose Calculation
Optimize and review the DVH and isodoses until you have an acceptable plan. Then
generate segments and calculate dose. Adjust the prescription as needed to meet the
prescription goals.
1. Click Workspace | Controls | Optimization Console to show the console

window.
2. Click the Start Optimization button.
NOTE: Should you receive an optimization failure soon after ray creation,
you may have a prescription parameter that needs a slight
adjustment. On the prescription panel, look for a cost function that
has a relative impact with four plus (+) signs. Loosen the
isoconstraint for that cost function slightly and re-optimize.
18-4
Task 5. Start the Optimization and Dose Calculation (cont.)
3. After stage 1 optimization completes, review your DVH statistics, change your
prescription, and re-optimize as needed.
4. When you are satisfied with your optimized plan, click the Start Optimization
button to begin stage 2. Change your prescription and re-optimize, as

needed.
5. To save your final plan, select the Monaco Applications Menu | Save Plan As
and type the plan name: CompositePlan. Checkmark the option to Include Base
Doses so that the saved plan represents a composite plan.
Figure 18-1: Example IMRT Constraints
6. Change the Power Law Exponent to 14.0 on the Spinal Cord structure to help
lower the Max Dose.
Monaco® 18-5
MR Planning
MR Planning
Oblique MR Planning
You can use oblique and transverse MR Images to create treatment plans. If you use
oblique images you can contour on the oblique images, and copy the contours to a
transverse studyset for planning purposes. If you use a transverse studyset you can
both contour and plan on the studyset. This section contains two exercises. In the first
exercise you contour on an oblique MR studyset and plan on a transverse CT studyset.
In the second exercise you both contour and plan on a transverse MR studyset.
Monaco® 19-1
MR Planning
MR Planning
Oblique MR Planning (cont.)
In this exercise, you import an oblique MR studyset and a transverse CT studyset. You
then contour on the MR studyset, copy the contours to the CT studyset and plan on
the CT studyset.
Import the New Patient
1. Navigate to the location where the DICOM files for the TiltedMRwithCT patient
is stored.
2. Import both the CT and the MR studysets.
Figure 19-1: Importing CT and MR studysets for a new patient
19-2
MR Planning
MR Planning
Oblique MR Planning
Import the New Patient (cont.)
3. Load both the MR and CT studysets in Fusion and fuse them together. You can
use either the automatic or manual fusion tools.
Figure 19-2: Image fusion with the CT and MR studysets
4. Click the Planning button to switch to Planning mode. Save your changes before
you load the MR studyset as the primary studyset and the CT studyset as the
secondary studyset.
5. Use the tools on the Contouring tab to create the CTV and PTV on the MR
studyset. Copy the CTV and PTV to the CT studyset.
6. Load the CT studyset as the primary studyset. Contour the Patient (Skin), Brain
Stem, Right and Left Optic Chiasm, Right and Left Optic Nerve, Right and Left
Retina, Right and Left Lens and the Brain. Add a 2mm margin to the each Optic
Nerve and Optic Chiasm to create the Optic Nerve PRV and Optic Chiasm PRV.
Monaco® 19-3
MR Planning
MR Planning
Oblique MR Planning
Import the New Patient (cont.)
7. Create an IMRT plan.
Target Structures
PTV 95% to 46.0 Gy 23 fx 2.0 Gy/fx
No more than 50.6 Gy hot spot
Sequential Boost for an additional 7 fractions to
PTV 60 Gy 7 fx 2.0 Gy/fx

Brain Stem Max Dose 55 Gy
Spinal Cord Max Dose 45 Gy
OpticChiasm_PRV Max Dose 55 Gy
Optic Nerve L PRV or

Optic Nerve R PRV Max Dose 55 Gy
Retina L or Regina R Max Dose 45 Gy

Lens L or Lens R
Brain Limit 5% to 78.7 Gy
Figure 19-3: NRG-BN001 – Plan Scoring Criteria
19-4
MR Planning
MR Planning
Transverse MR Planning
In this exercise you start with an existing transverse MR studyset. You contour and
plan on the MR studyset.
RTOG 1115 – Plan Scoring Criteria
1. Use patient Fusion Prostate for planning.
2. Load/Activate the MR1 studyset.
3. Contour the Patient (Skin), GTV, CTV, PTV, Bladder, Rectum, Left Femoral
Head, Right Femoral Head, and Penile Bulb. The GTV includes the prostate. The
CTV is an expansion of the GTV of <0.3 cm to include the seminal vesicles. The
PTV is the CTV plus a 0.5 cm – 1.0 cm 3D margin.
4. On the Planning Tab, select to create a New Monaco Plan. Acknowledge the
message that All Structures are set to Force ED for Planning.
5. Create an IMRT Treatment Plan (5 or 7 beams) using a template. Use a

treatment machine that best represents a machine that you use clinically (Elekta,
Varian or Siemens).
6. On the Structures tab of the Planning Control, change the Relative ED of the Left
Femoral Head, Right Femoral Head and Bladder to what you would use in your
clinic.
Monaco® 19-5
MR Planning
MR Planning
Transverse MR Planning
RTOG 1115 – Plan Scoring Criteria (cont.)
7. The planning criteria are shown in Figure 19-4 below:
Target Structure
PTV 98% of the PTV receives 79.2 Gy 44 fx 1.8 Gy/fx
Maximum dose of 84.74 Gy

Bladder No more than 15% receives >80 Gy
No more than 25% receives >75 Gy
Rectum No more than 15% receives >75 Gy

Penile Bulb Less than 50% receives >52.5 Gy
Femoral Heads Less than 10% receives >52.0 Gy
Figure 19-4: RTOG 0831 Target Structures and Organs at Risk
19-6
Additional Cases
Additional Cases
These exercises assume you are familiar enough with planning in Monaco that you no
longer require specific steps. You can use the steps in the Prostate Plan as a reference if
you need it. This exercise includes prescription objectives and the contours are already
drawn for you.
The exercises in this section and the information provided are subject to the disclaimer
included in the Overview section of Volume 1, Section 1. This stepwise task list helps
you in your planning process. You may or may not do all of the tasks on this list to
complete your plan.
• Select Patient and Open Studyset

• Start a Plan

• Save a Template
• Optimize /Calculate Dose (Stage 2)
• Save Plan
• Print the Plan

Monaco® 20-1
Additional Cases
Additional Cases
Esophageal Case
1. Use patient ESOPHAGUS for planning.
2. Place the isocenter at the center of the structure PTV.
3. Select a 6MV treatment machine that best represents a machine that you use
clinically (Elekta, Varian or Siemens).
4. Create a plan. Use seven (7) beams spaced evenly around the patient, or create a
sequence for VMAT planning.
Target Structures
PTV 95% to 50.4 Gy 28 fx 1.8 Gy/fx
No more than 55.45 Gy hot spot
Organs at Risk
(OAR)
Less than 25% of both lungs should
Lungs receive greater than or equal to 20 Gy
Spinal Cord Max Dose 45 Gy
Heart 33% less than 50 Gy
66% less than 45Gy
Figure 20-1: Plan Scoring Criteria
20-2
Additional Cases
Additional Cases
Rectal Case
RTOG 0822 – Plan Scoring Criteria
1. Use patient Rectum for planning.
2. Place the isocenter at the center of the structure CTV_5400.
3. Select a 6MV treatment machine that best represents a machine that you use
clinically (Elekta, Varian or Siemens)
4. Create a plan. Use seven (7) beams spaced evenly around the patient, or create a
sequence for VMAT planning.
Target Structures
CTV_5400 95% to 54 Gy 30 fx 1.8 Gy/fx
No more than 5% to receive greater than
56.7 Gy (105% hot spot)
PTV_4500 95% to 45 Gy 30 fx 1.5 Gy/fx
Limit 25% to 49.5 Gy
Limit 10% to 54 Gy

Bladder 40% to 40 Gy
15% to 45 Gy
Max Dose 50 Gy
Small Bowel 10% (180cc) to 35 Gy
6% (100cc) to 40 Gy
4% (65 cc) to 45Gy
Max Dose 50 Gy
Femoral Heads 40% to 40 Gy
25% to 45Gy
Max Dose 50 Gy
Figure 20-2: Target Structures and Organs at Risk
Monaco® 20-3
Additional Cases
Additional Cases
Head and Neck Case II
Use the patient named AdvHnN for planning.
Target Structures

Trachea 40 Gy
Brainstem 54 Gy
Spinal Cord 40 Gy
Optic Chiasm 35 Gy to 50%
Left and Right Lens 9 Gy each
Left and Right Optic Nerve 54 Gy each (add a 3 mm margin)
Left and Right Parotids 30 Gy to 50% each parotid
Figure 20-3: HnN Case – II-Plan Scoring Criteria
20-4
Additional Cases
Additional Cases
Practice Exercise 1. IMRT and QA
This exercise helps you understand the IMRT and QA planning workflow.
It is assumed that you have reviewed the sections IMRT Tools and QA Tools. You can
use them as a reference as you walk through the software.
Create an IMRT Plan
• Open Monaco and select the Patient Fusion Prostate
• Load the Studyset CTClean (If you have not completed the exercise in Section
5 of this training guide, use the Studyset CT1, it already has contours.)
• Apply the IMRT Template DEFAULTSNS
• Place the Isocenter at the center of the PTV
• Select any Machine from the drop-down list
• Click on the IMRT Constraints tab on the Planning Control and resolve any
Structure Mismatches (Apply)
• Open Console
• Set the Grid Spacing to 0.2 cm
• Start Optimization (Stage1)
• Watch Progress Meter during optimization
• Review Sensitivity
• Use the Dose Cursor Tool
• Enter and Review DVH Statistics
Monaco® 20-5
Additional Cases
Additional Cases
Practice Exercise 1. IMRT and QA
Create an IMRT Plan (cont.)
• Change the Normalization (Absolute/Percent, Gy/cGy)
• Start Optimization (Stage 2)
• Use the Fluence Toolbar (Review beams, segments and MU values in BEV)
• Save the plan
• Print Plan Reports
Create a QA Plan
• Start a New QA Plan with the IMRT Plan you created
• Change the Grid Spacing to 0.2 cm
• Select Isocenter Center of Skin
• Start QA dose calculation
• Edit the Beam Weights
• Export the QA dose profiles (using any option)
• Close the Patient and Reopen to see the updated icons in the Workspace
Control
20-6
Additional Cases
Additional Cases
Practice Exercise 2. Plan Review
This exercise lets you practice using the plan review tools available in Monaco.
It is assumed that you have reviewed the section Plan Review Activity. You can use it
as a reference as you practice with these tools.
• Open Monaco and Select the Patient HeadandNeck
• Select and Load the three plans MonPlan1, MonPlan2 and tonsil
Monaco® 20-7
Additional Cases
Additional Cases
Practice Exercise 3. Editing IMRT Prescription Elements
This exercise lets you practice editing elements of the IMRT Constraints dialog box in
the Planning Activity.
It is assumed that you have reviewed the section Monaco Planning and Workflow.
You can use it as a reference as you practice using these tools.
• Open a Saved Plan in Planning activity (If the saved plan has dose, you have
to change from Plan Review activity to Planning Activity once the patient is
loaded.)
• Remove an cost function from a structure on the IMRT Constraints Planning

Control
• Remove a structure
• Add a structure
• Add a cost function to the structure
• Edit the Structure’s Cost Function Properties
• Edit an existing Structure’s cost function properties
• Change the layering order
• Edit the References Doses, Multicriterial, Isoconstraint, and Enabled

directly on the IMRT Constraints Planning Control
• Print the IMRT Constraints
20-8
Additional Cases
Additional Cases
Practice Exercise 4. Optimization and Plan Evaluation
This exercise lets you practice using the optimization, sequencing, and plan evaluation
tools available in Monaco.
• Open a Saved Plan in IMRT activity (If the saved plan has dose, you have to
change from Plan Review activity to Planning Activity once the patient is
loaded.)
• Click on IMRT Constraints tab in Planning Control
• Open the Console
• Edit the Calculation Parameters
• Start the Optimization (Stage 1)
• Edit the Isoconstraint, Multicriterial, or Enabled options during

optimization
• Evaluate Optimized Plan using available plan evaluation tools
• Edit various IMRT Constraints and Re-optimize as needed (Try changing

any of the elements previously discussed. Examples, Structure Optimization
Properties and Cost Function Properties.)
• Start the Optimization (Stage 2)
• Review the Final Plan using the Plan Evaluation Tools
Monaco® 20-9
Additional Cases
Additional Cases
Practice Exercise 5. Serial Power Law (k)
This exercise demonstrates how the OAR DVH curve is affected when you adjust the
Serial Power Law (k). It includes these tasks:
• Task 1. Select Patient and Open Studyset
• Task 2. Adjust Power Law and Run IMRT Plans
• Task 3. Plan Review
Adjust the Power Law (k) value to show the effects to the Serial Cost Function.
1. Open the Monaco software to show the Patient Selection dialog box.
2. Click to select the patient Fusion Prostate.
3. Click OK. The system loads the patient information into the Patient Workspace
Control.
4. Click to select the Exercise plan under CT1; then click Load. The patient loads in
the Planning activity.
Task 2. Enter/Adjust Power Law and Optimize IMRT Plans
1. Select the IMRT Constraints tab on the Planning Control to show the
prescription dialog box. The PTV and patient have cost functions applied to
them.
2. <Click to add new structure> to add a new structure to the list.
3. Select RECTUM in the drop-down menu of the new structure line.
4. Right-click in the Rectum field and select Add Cost Function | Serial.
20-10
Additional Cases
Additional Cases
Task 2. Enter/Adjust Power Law and Optimize IMRT Plans (cont.)
5. Use a Power Law Exponent of 10 with an EUD of 6000 cGy. Check Optimize
Over All Voxels in Volume to keep hot spots to a minimum throughout the
entire structure.
6. Put the structures in this layering order: PTV, Rectum, and Patient. Highlight
the structure you want to move, Click the up or down arrow on the left side of
the IMRT Constraints dialog box to layer the structures.
7. Click OK.
8. Click the Start Optimization button to start stage one of the optimization
process.
with the message “Full Fluence Modulation Complete. Press Start to Begin
Segmentation.” Click OK to acknowledge.
10. Click the Start Optimization button to start stage two of the optimization
process.
11. Once Phase 2 is complete, the system shows a dialog box with the message
“Segmentation Complete”. Click OK to acknowledge.
12. Click on the Monaco Application Menu button followed by Save Plan As….
13. In the Save As Plan dialog box, type k10 for the Plan Name.
14. Click on the IMRT Constraints tab on the Planning Control. Right-click over
the Rectum Serial cost function and select Properties to change the Power Law
Exponent to 2.
15. Change the Power Law Exponent of Rectum to 2 and restart the optimization
process.
Monaco® 20-11
Additional Cases
Additional Cases
Task 2. Enter/Adjust Power Law and Optimize IMRT Plans (cont.)
16. Once Phase 2 is complete, click the Monaco Application Menu button then
Save Plan As….
17. Type in k2 for the Plan Name.
18. After you save the plan, go to the IMRT Constraints dialog box and change the
Power Law Exponent of Rectum to 18. Restart the optimization process.
19. Click the Monaco Application Menu button then click Save Plan As…
20. In the Save As Plan dialog box, type k18 for the Plan Name.
20-12
Additional Cases
Additional Cases
Practice Exercise 5. Serial Power Law (k) (cont.)
Task 3. Plan Review
1. In the Patient Workspace Control, hold down the shift key and highlight the
three plans (k10, k2, and k18) to select all three of them for Plan Review.
2. Once you highlight the plans, right-click and select Load Into Plan Review.
3. Right-click in the DVH window and select Multiple Plans. The system shows
All three plans.
4. Review the DVH curve of the Rectum for each plan to see the variation based on
the changed Serial Power Law (k).
The Serial Power Law Exponent (k) controls the high dose when you use a high
(k) value (18). When the (k) value is medium-high (10), the oar DVH curve
shows a steep dose gradient. While a low (k) value (2) controls the mean dose, it
does not put a primary focus on one point and works on the overall curve of the
oar DVH.
Figure 20-4: Serial Power Law Exponent
Monaco® 20-13
Additional Cases
Additional Cases
Practice Exercise 6. Parallel Power Law (k)
1. Adjust the Power Law (k) value to show the effects to the Parallel Cost Function.
2. Open the Monaco software to automatically show the Open Patient Selection
dialog box.
3. Click to select the patient HnN Plan, then click OK. The system loads the
patient information into the Patient Workspace Control.
4. Select the CT studyset HnNss
Task 2. Load IMRT Template
1. Select New Plan on the Planning tab to select a plan type.
2. Select New Monaco Plan in the drop-down list. This opens the New Monaco
Plan dialog box (Figure 13- ).
4. Select Step and Shoot IMRT for the Delivery
5. Place a checkmark by the Template: DEFAULTSNS (Rx Site: , Rx Dose: , Total

Beams: 7)
7. Select TRNElekta80 for the treatment unit.
20-14
Additional Cases
Additional Cases
Task 2. Load IMRT Template (cont.)
8. Select the isocenter location: Center of PTV TOTAL.
9. Click OK to load the template and open the patient in Planning activity.
Monaco® 20-15
Additional Cases
Additional Cases
Practice Exercise 6. Parallel Power Law (k) (cont.)
2. Select Plan Isocenter in the Prescribe To column.
3. Type 33 in the Number of Fractions column.
4. Type 2.00 in the Fractional Dose (Gy) column. The Rx Dose (Gy) column
updates with 66.00 as the value.
5. Click on the IMRT Constraints tab to enter the necessary values.
1. Click on the IMRT Constraints tab on the Planning Control.
2. Replace PTV and SKIN with valid structure names to use in the prescription.
3. <Click to add new structure> to add a new structure to the list.
20-16
Additional Cases
Additional Cases
4. Use the data in the table below for the prescription (Figure 20-6).
Prescription (Gy): 60.00 Max Dose (Gy): 62.00

PTV60 Target Penalty: Quadratic
Minimum Volume: 96.00 Overdose: RMS(Gy): 1.00
LT PAROTID Reference Dose (Gy): 35.00

(optimize over all Mean Organ Damage (%):45.00
voxels) PARALLEL:
Power Law (k): 1.5
patient Max Dose (Gy): 66.00

Quadratic
Overdose: RMS(Gy): 0.3
Shrink Margin: 0.4
Figure 20-6: IMRT Constraints Table
5. Once you type the constraints data, layer the structures in this order (Figure 20-
7).
Figure 20-7: IMRT Constraints: Layering
Monaco® 20-17
Additional Cases
Additional Cases
Task 5. Enter Calculation Properties
1. Click on Calculation Properties on the Planning tab.
2. In this dialog box, update this information:
• Grid Spacing: 0.40

• Statistical Uncertainty (%): 2
3. Click OK.
Task 6. Enter IMRT Parameters
2. In the dialog box, update this information:
• Target Margin: Narrow (3-4 mm)
3. Click OK.
20-18
Additional Cases
Additional Cases
Task 7. Adjust Power Law (k) and Optimize IMRT Plans
1. Click the Start Optimization button to start stage one of the optimization
process.
with the message “Full Fluence Modulation Complete, Press Start to Begin
Segmentation”.
4. Click the Start Optimization button to start stage two of the optimization
process.
5. Once Phase 2 is complete, the system shows a dialog box with the message
“Segmentation Complete”. Click OK to acknowledge.
6. Click on the Monaco Application Menu button followed by Save Plan As….
7. In the Save As Plan dialog box, type in klow for the Plan Name.
8. Type K Power Law Plan for the Description.
9. Right-click over the Lt Parotid Parallel cost function on the IMRT Constraints
tab on the Planning Control and select Properties to change the Power Law
Exponent to 3.5 and restart the optimization process.
10. Once Phase 2 is complete, click on the Monaco Application Menu button
followed by Save Plan As… and type in khigh for the Plan Name.
Monaco® 20-19
Additional Cases
Additional Cases
Task 8. Plan Review
1. In the Patient Workspace Control, hold down the shift key and highlight both
plans (klow and khigh) to select the two plans for Plan Review.
2. Once you highlight the plans, right-click and select Load Into Plan Review.
3. Turn all structures off in the DVH window. Click each structure name in the
structure list. Leave the Lt Parotid structure turned on (Figure 20-8).
Figure 20-8: Structure List
4. Review the DVH curve of the Lt Parotid for each plan to see the variation based
on the changed Parallel Power Law (k).
20-20
Additional Cases
Additional Cases
Task 8. Plan Review (cont.)
5. The Parallel Power Law Exponent (k) places emphasis on the volume of dose to a
given point of the DVH curve assigned in the prescription, but also works on the
other points of the curve. The oar DVH curve has a steep slope when you use a
higher Power Law Exponent (k). A lower Power Law Exponent (k) creates a
wider slope in the oar DVH curve (Figure 20-9).
Figure 20-9: K value comparison in DVH
Monaco® 20-21
Additional Cases
Additional Cases
Practice Exercise 7. Multiple Prescriptions
This exercise lets you practice using multiple prescriptions to make a plan with a
boost.
• Open Monaco and select the Patient GlioLeftTRN.
• Select New Monaco Plan for Studyset SS_CT1.
• Start a new IMRT plan for Phase I of the treatment using a saved template and
a treatment machine similar to what you would use in your clinic. Phase 1
treats PTV46 to 46 Gy in 23 fractions.
• Edit the Beams and IMRT Constraints.
• Optimize your plan.
• Review the isodose lines and DVH for the PTV46 and Organs at Risk to
determine if the planning criteria are met. If necessary, edit the IMRT
Constraints to better meet the planning criteria.
• Save your Plan.
• On the Prescription tab, click Add Rx to add a new Prescription. Phase II

treats PTV60 to 60 Gy in an additional 7 fractions.
• Select New Plan | New Monaco Plan to add additional beams to the plan.
• Review the Composite DVH and 66 Gy, 57 Gy, 48 Gy, 44 Gy and 40 Gy

isodose lines to determine if the planning criteria are met.
20-22
Additional Cases
Additional Cases
Practice Exercise 7. Multiple Prescriptions
• The planning criteria are shown in Figure 20-10:
Target Structure
PTV46 95% of PTV46 is covered by 46 Gy 23 fx 2.0 Gy/fx
PTV60 95% of PTV60 is covered by 60 Gy Add’l 7 fx 2.0 Gy/fx
99% of PTV60 is covered by 54 Gy
Maximum dose of 66 Gy
Lenses Maximum Dose of 7 Gy

Retinae Maximum Dose of 50 Gy
Optic Nerves Maximum Dose of 55 Gy
Optic Chiasm Maximum Dose of 56 Gy
Brainstem Maximum dose of 60 Gy
Figure 20-10: RTOG 0825 Target Structures and Organs at Risk
Monaco® 20-23
Additional Cases
Additional Cases
Practice Exercise 8. Head and Neck III
This exercise lets you practice making an IMRT Plan.
• Open Monaco and select the Patient ClivusTRN.
• Select New Monaco Plan for Studyset SS_CT1.
• Start a new IMRT plan for the treatment using a saved template and a
treatment machine similar to what you would use in your clinic.
• Edit the Beams and IMRT Constraints.
• Optimize your plan.
• Review the isodose lines and DVH for the Targets and Organs at Risk to
determine if the planning criteria are met. If necessary, edit the IMRT
Constraints to better meet the planning criteria.
• Save your Plan.
20-24
Additional Cases
Additional Cases
Practice Exercise 8. Head and Neck III (cont.)
• The planning criteria are shown in Figure 20-11:
Target Structure
ptv 95% of ptv is covered by 54 Gy 33 fx 1.6
PTV LT node 95% of PTV is covered by 60 Gy 33 fx 1.8 Gy/fx
PTV RT node 95% of PTV is covered by 60 Gy
ptv boost 95% of ptv boost is covered by 66 Gy 33 fx 2.0 Gy/fx
Patient Maximum dose of 69 Gy

Maximum Dose of 54 Gy, 1cc cannot exceed 60 Gy
Brain Stem
Cord+5 45 Gy, 1cc cannot exceed 50 Gy
Mandible No more than 5% of the volume ≥ 66 Gy
Parotid Mean dose < 23 Gy (at least one parotid)

Minimum of 20 cc of combined volume < 20 Gy
Oral Cavity Low as possible, mean dose < 35 Gy
Figure 20-11: Planning Criterial for Target Structures and Organs at Risk
Monaco® 20-25
QA Tools
QA Tools
Overview
This activity defines the options you have available when you create a QA Plan. It
describes a workflow you can use to create, calculate, export dose profiles of, and print
QA plans. These tools discussed in this section are available for QA Plans. You can use
the same tools on a QA plan that you can use in treatment planning. You can open
and review a QA Plan in both the Planning and Plan Review activities.
When you complete this section, go to the Additional Exercises section in Vol II, of
this guide.
Dose Calculation Tools
Calculate the QA plan from the Dose Calculation toolbar (Figure 21-1). All imported
prescriptions from a multiple Rx treatment plan are combined into one Rx called ‘QA’.
Figure 21-1: Dose Calculation Toolbar
This is the Start Dose Calculation

button.
This is the Reset Calculation
Engine button. When you select
Reset Calculation Engine, the
system abandons the dose
calculation.
Monaco® 21-1
QA Tools
QA Tools
Beam Tools
You click the Planning tab to edit the plan. The New Beam button lets
you add a new beam to the plan. You can add a duplicate beam of the active beam to
the plan. You have the option of opposing the duplicate beam. You can use the <click
to add a new beam> option on the Planning Control to add beams to an existing QA
plan for the purpose of acceptance testing and commissioning, while preserving the
integrity of the original plan. You can add Static, Arc, and Dynamic QA beams to the
QA plan.
You can only add Dynamic QA beams to a QA Plan. A Dynamic QA beam delivers a
uniform rectangular field to the phantom. Click the <click to add a new beam> option
on the Planning Control to add a new beam. You must change the Delivery of the new
beam to Dynamic QA. You can define the Window Width of the Dynamic QA beam.
You cannot edit the Jaw Trailing field. The Field Type field can be ‘MLC Only’ or
‘Jaws and MLC’ if the selected Machine has dynamic jaws.
Type in Monitor Units to reweight the beam. In the BEV, Monaco shows a window of
the length of the field and the specified width that starts at the left edge of the field,
and ends at the right edge of the field.
Figure 21-2: Beam tab of the Planning Control
The Delete Beam button lets you delete the currently active beam
(appears in red in the SPV). This could be a beam from the original plan, or a new
beam you added to the QA Plan.
21-2
QA Tools
QA Tools
Fluence Toolbar
Fluence analysis and visualization tools are available on the Planning tab (Figure 21-3)
and have the same functionality as described in the IMRT Tools section.
Figure 21-3: Fluence Toolbar-IMRT, dMLC and Conformal RT Plans
Figure 21-4: Fluence Toolbar-VMAT and Dynamic Conformal Arc Plans
To show the fluence image view, right-click in the BEV and select Show MU/Fluence.
Other right-click fluence options are available as described in the IMRT Tools section.
Monaco® 21-3
QA Tools
QA Tools
Fluence Toolbar (cont.)
Beam and Dose Visibility Control
You can toggle individual beams or sequences and/or dose display on or off from the
Beam Tab of the Planning Control. Monaco highlights the active beam/sequence in
red. Monaco highlights all other beams/sequences in blue.
1. Left-click on any beam/sequence name to toggle the beam visibility on or off.
2. Left-click on the heading Beam to toggle all beams/sequences on or off.
3. Left-click in any checkbox under the Dose heading to toggle the dose display on
or off.
4. Left-click on the heading Dose to toggle all doses on or off.
21-4
QA Tools
QA Tools
Dose Plane Output
Click the Output tab to access the reports and dose information. The Dose Export
Tool button launches the Dose Plane Output dialog box (Figure 21-6). Here you
can export QA Dose planes. This tool is only available once dose is calculated. You can
export Dose Planes for all beams which contain dose, including frozen dose and all
beams in a multiple Rx plan. Turn of a beam’s Dose visibility and select As Viewed on
the Beam Visibility dialog box if you do not want to export an individual dose plane
for that beam. Select All Beams if you want to export a dose plane which contains dose
from all beams in the plan which contain dose. If you want to export a single dose
plane which contains dose for one Rx in a multiple Rx plan, you must:
1. Save the plan.
2. Delete the unwanted beams.
3. Export the dose plane using the All Beams option.
4. You select the Combine Split Fields option to export one file for beams which
split. Click OK to close the dialog box and export the selected QA plans to file.
You can find the files under the Focal Data folder in a folder labeled
“DosePlanes.”
Figure 21-6: Dose Plane Output dialog box
Monaco® 21-5
QA Tools
QA Tools
Show Dose Extents
transverse, sagittal and coronal views, select the Show Dose Extents button on the
Plan Options tab. This option is available in Planning and Plan Review.
Measure and Interest Point Tools
Figure 21-7: Tools Toolbar

The Measure, Interest Point and Anatomical Groups Tools are available in all
activities. See the Planning Tools and IMRT Tools sections for more detailed
information on the use of these tools. See the Contouring section for more
information on Anatomical Groups.
You can review the dose to dose reference points on the QA phantom on the Dose
Reference Points tab of the Planning Control dialog box.
Figure 21-8: Dose Reference Points tab
21-6
QA Tools
QA Tools
Create a QA Plan
After you create and save a treatment plan, follow these instructions to create a QA
plan.
1. When you have a treatment plan which was calculated in Monaco open and are
in the Planning Activity, click the New Plan button then the New QA Plan
option.
OR
In the Workspace, right-click on any plan with dose which was calculated in
Monaco and select New QA Plan to open the New QA Plan dialog box (Figure
21-9).
Figure 21-9: New QA Plan dialog box for multiple prescriptions and a single prescription
2. Select a Studyset for which you want to create the QA plan. This could be a
phantom or any other studyset associated with this patient. You cannot use an
MR studyset for a QA plan.
Monaco® 21-7
QA Tools
QA Tools
Create a QA Plan (cont.)
3. Select the Studyset Orientation for QA Plan. If you change the QA Plan
Orientation so that it differs from the Treatment Plan, Monaco shows a message
for you to verify this information (Figure 21-10).
Figure 21-10: QA Studyset Orientation Message
4. To create a QA plan, use the plan beam angles or set the Gantry, Collimator
and/or the Couch to nominal, check the associated boxes under Reset Beams to
Nominal Angles. You can click Reset All to quickly check all the boxes at once.
5. Select the Algorithm you want to use when you calculate the QA plan.
6. Select the Calculation Volume Grid Spacing that you want to use for the QA
plan.
7. For plans calculated using the Monte Carlo algorithm, type the Statistical
Uncertainty Per Control Point or Per Calculation you want to use.
8. Select Calculate Dose Deposition to Medium or Water.
9. Select the Rx you want the QA plan to include.
• If there is only one prescription Rx A is the only option.
• If there are multiple prescriptions, select the check box next to the
prescriptions you want to include.
21-8
QA Tools
QA Tools
Create a QA Plan (cont.)
10. Click OK to open the Set Up QA Plan dialog box (Figure 21-11).
Figure 21-11: Set Up QA Plan dialog box
11. Select the Isocenter for the QA plan. If you have multiple isocenters, you can set
them all to a common isocenter. Place a checkmark next to the option Use
Common Isocenter.
12. Click OK to create the QA plan.
NOTE: Couchtop structures do not automatically import into QA from the

IMRT plan. You must add couchtop structures to your phantoms for
use in QA.
13. (Optional) Open the console window from the Workspace tab. Select Controls
| Optimization Console. This window gives feedback as to the status of the QA
dose calculation.
14. (Optional) Before or after dose calculation, you can add new beams of type
Static, Arc or Dynamic QA to the plan. If you add them after dose calculation,
re-calculate to include the new beam.
15. Start the Dose Calculation from the Planning tab. Click the Calculate button.
16. (Optional) Click the Beams tab of the Planning Control to edit the MU
weighting and number of fractions.
NOTE: Beam monitor units are automatically scaled to one fraction’s

monitor units per beam. When you change the number of fractions,
the graphical representation of the multiplied dose appears.
Monaco® 21-9
QA Tools
QA Tools
Edit Dose Calculation Properties
Once you open your QA plan, you can edit your dose calculation properties.
1. Click the Calculation Properties button on the

Planning tab to show the Dose Calculation Properties dialog box (Figure 21-12).
2. Edit the Grid Spacing (cm).
3. Edit the Calculate Dose Deposition to option.
4. Edit the Force entire volume to be treated as water option.
5. Edit the Statistical Uncertainty per Control Point or Per Calculation. This
option is only available when Monte Carlo is the selected algorithm.
6. Click OK to close the dialog box.
21-10
QA Tools
QA Tools
Edit Assigned Electron Densities
Once you open your QA plan, you can edit your assigned electron densities.
1. Click the Structures tab of the Planning Control to assign structure densities.
Figure 21-13: Assign Densities dialog box
2. You can use the Electron Densities calculated from the CT image. You can Force
the Electron Density or Fill the Electron Density.
3. If you Force ED or Fill ED, type the Electron Density in the Relative ED field.
Save the QA Plan
1. Once the QA plan completes, save it.
2. Click the Monaco Application button then the Save Plan As option to save the
QA plan. Monaco saves the QA plan with the patient and uses the name and
description given by you.
Monaco® 21-11
QA Tools
QA Tools
Export the QA Plan
1. Once dose is calculated, click the Output tab then the DICOM Export button
.
2. You can DICOM export images, structure sets, plans, and dose from within a
QA Plan. Monaco updates the DICOM fields for exported QA plan images.
The Study and Demographic modules are updated.
Figure 21-14: DICOM Export dialog box
21-12
QA Tools
QA Tools
Tips When Creating a QA Phantom
1. Import your phantom into the Installation/QA clinic. This lets you keep your
phantoms separate from your clinical patients.
2. Create a CT-to-ED file and save that file in the Installation/QA clinic. It is
recommended that you save an existing CT-to-ED file to the QA clinic and use
the Save As… option located on the CT-to-ED Conversion Files dialog box. See
the Planning Tools section of this training guide for more information on how
to create, edit, and save a CT-to-ED file in Monaco.
Exercise
Go to the Additional Cases section in Volume II, Sec 22 of this guide to complete the
“IMRT QA” exercise.
Monaco® 21-13
QA Exercise
QA Exercise
This section walks you through the steps for each of these processes.
• Create an IMRT QA Phantom
• Use a couchtop with a QA plan
• Create an IMRT QA plan
• Create QA verification beams
Creating an IMRT QA Phantom
Import your phantom into the Installation/QA clinic. This lets you keep your
phantoms separate from your clinical patients.
1. Start Monaco.
2. Select Import New Data from the Patient Selection dialog box.
3. On the DICOM Import – 3D dialog box in the DICOM Patient field, browse to:
C: Users/All Users/Public/Public Documents/CMS/FocalData/DICOM/Import.
4. Click Calib_5mm to highlight it.
5. Click OK. Monaco loads the data.
6. Select Calib_5mm from the DICOM Patient drop-down list.
7. Click CT1 to highlight it.
8. Select Installation for the Local Installation field.
9. Select QA Clinic for the Local Clinic field.
10. Type QAExample in the Patient ID field.
Monaco® 22-1
QA Exercise
QA Exercise
Creating an IMRT QA Phantom (cont.)
11. Type phantom in the Patient Name field.
12. Click Add. Monaco shows the studyset information and images.
NOTE: You can use any studyset in the QA clinic for the QA plan, except for
a studyset that has the same modified date as the studyset that
belongs to the patient. If you select a QA studyset that has the same
name as a studyset that belong to the patient, the system prompts
you to rename the studyset.
13. Right-click on the name of the studyset (currently CT1) and rename it.
14. Select a CT- to-EE file from the CT-to-ED Assignment field.
NOTE: CT-to-ED files are only available if you saved them in the clinic
where the patient/phantom resides. You must copy the CT-to-ED file
used with the phantom to the clinic that contains the Monaco
patients. We recommend that you save a previously created CT-to-
ED file to the QA clinic. Use the Save As… option located on the CT-
to-ED Conversion Files dialog box. See the Planning Tools section of
this training guide for more information.
15. Click Import.
16. Click Close to close the DICOM Import dialog box.
17. Select the Open Patient button to open the Patient Select dialog box.
18. Select the QA Clinic folder. The new phantom appears in the list.
19. Select the new phantom.
20. Click OK.
22-2
QA Exercise
QA Exercise
Creating an IMRT QA Phantom (cont.)
21. Name the exterior contour of the phantom the same name that you use for the
external contour of a patient.
22. Click the Phantom Studyset, and select Load/Activate from the mouse menu.
23. Contour the phantom. See the Contouring Tools section of the Monaco Training
Guide for instructions on the contour tools available in Monaco.
24. Select the Monaco Application button and Exit to save the change and exit
Monaco.
Add a Couchtop to an Existing Studyset
1. Open Monaco and select the Patient Fusion Prostate.
2. Load the studyset MonacoPhantom.
3. Select the Plan Options tab.
4. Select the Import Positioning Device button.
5. Select sampleElekta from the list of available couchtops.
6. Click OK to close the dialog box and add the couch to the phantom.
NOTE: The action adds the couchtop to all QA plans for Patient
FustionProstate which uses the MonacoPhantom studyset. This does
not invalidate doses for existing plans.
7. Click Done to accept the default couch location.
Monaco® 22-3
QA Exercise
QA Exercise
Add a Couchtop to an Existing Studyset (cont.)
8. You must assign a couch to the beams in order for the dose calculation to take it
into account. This option is on the Treatment Aids section of the Beams tab on
the Planning control.
Figure 22-1: Beams tab
22-4
QA Exercise
QA Exercise
Create an IMRT QA Plan
1. Load the Plan MonProstate.
2. Click the Planning button on the Workspace control

to switch to the Planning Activity.
3. Click on the Plan MonProstate and select New QA Plan from the mouse menu.
If prompted, click No to saving the changes.
4. Select TrainingClinic: PROSTATE: MonacoPhantom from the drop-down list

as the Studyset for QA Plan.
5. Check the option(s) to Reset Beams to Nominal Angles. You can reset the
Gantry, Collimator, Couch or Reset All.
6. Select the Algorithm you want to use when you calculate the QA plan.
NOTE: The suggested algorithm for patient QA is Monte Carlo.
7. Select the Calculation Volume Grid Spacing that you want to use for the QA
plan. Suggested grid spacing for this practice exercise is 0.4 cm.
NOTE: The recommended grid spacing for clinical patient QA is 0.3 cm.
8. For plans calculated that use the Monte Carlo algorithm, type the Monte Carlo
Standard Deviation per Control Point or per Calculation you want to use. The
suggested Standard Deviation for this practice exercise is 4.00 %.
NOTE: The recommended Standard Deviation for clinical patient QA is 1.0 %.
Monaco® 22-5
QA Exercise
QA Exercise
Create an IMRT QA Plan (cont.)
10. Change the isocenter coordinates to X (cm): 0.37 Y(cm): 0.25 Z (cm): 1.90 and
click OK. This places the isocenter of all the beams at a depth of 10 cm in the
phantom.
NOTE: If you have a plan with multiple isocenters, you have the option to set
the same isocenter for all the beams when you check the box Use
Common Isocenter.
11. Verify the isocenter is at a depth of 10 cm in the phantom. Use the Measure
Tool .
12. Create an Interest Point at the isocenter and at any other required positions in
the phantom. Click the Interest Points/Markers button and add points.
13. On the Interest point and Marker dialog box, type 0.5 cm as the radius for the
volume sphere you want around the interest points.
NOTE: When you use an ion chamber to compare measurements, the Radius
value is approximately the radius of the chamber.
14. Click DONE to close the Interest Point and Marker dialog box.
16. Review status of QA dose calculation. Open the console window, click the
Workspace tab, then select Optimization Console from the Controls
button.
17. Once dose calculation completes, click on the Prescription tab on the Planning
Control dialog box.
18. Edit the MU weighting of each beam to 100 MU and number of fractions of each
beam to 1.
22-6
QA Exercise
QA Exercise
Create an IMRT QA Plan (cont.)
19. Review the total weight (cGy) of each beam. Click the Reports, Individual
Reports drop-down menu and select the Plan option.
20. Review the mean dose to the interest point radius. Click the Interest
Points/Markers button.
21. Save the QA plan. Click the Save button.
22. Verify on the navigation toolbar that the coronal slice shown is at C (z): 1.90.
This is the coronal plane at 10 cm depth in the phantom.
23. Click the Output tab. Click the Dose Plane button to open the Dose Plane
Output dialog box.
24. Export the Coronal absolute dose plane. Place a checkmark next to Coronal.
25. Create individual dose plane files for each beam. Select Individual Beams.
26. Click OK to export the dose profile to a file.
27. Create a composite dose plane file. Re-open the Dose Profiles dialog box and
select All Beams. Click OK to export them to file.
28. Exported dose plane files are located in the …\CMS\FocalData\ DosePlanes
folder.
29. You can review the available reports from the Output tab as well.
Monaco® 22-7
QA Exercise
QA Exercise
Create QA Verification Beams
1. In the Workspace, click on a saved plan and select New QA Plan from the mouse
menu.
2. Use TrainingClinic: PROSTATE:MonacoPhantom as your QA phantom.
3. Force the density of the phantom to a uniform density of 1.00. Place All
Beams/Sequences at Nominal Angle.
4. Select the Monte Carlo dose calculation algorithm.
5. Type a Calculation Volume Grid Spacing of 0.4 cm.
6. Type a Monte Carlo Standard Deviation per Calculation of 4.00 %.
7. Click OK to open the Setup QA Plan dialog box.
8. Set the isocenter of beams to X (cm): 0.37 Y(cm): 0.25 Z (cm): 1.90.
9. Click OK. Monaco positions the beams.
11. Delete all existing beams except Beam 1 (you delete this one in a future step).
Delete individual beams. Select the beam number to delete on the click the
Delete Beam button.
22-8
QA Exercise
QA Exercise
Create QA Verification Beams (cont.)
12. Create four new beams. To do this, click the New Beam button. Use these
parameters for each beam:
a. Width 10 cm, Length 10 cm
b. Width 5 cm, Length 15 cm
c. LW 0 cm, RW 10 cm , UL 0 cm, LL 5 cm
d. LW -2 cm, RW 5 cm , UL -3 cm, LL 5 cm
e. Set Gantry, Collimator and Couch angles to nominal
f. Select Jaws Only to use the width and length jaws to form the fields
g. Set MU/fx to 100 MU
13. Delete Beam 1. You do not need it for the task.
14. Place interest points at appropriate locations.
16. Once the dose calculation completes, review the dose to the interest points.
Monaco® 22-9
Stereotactic Planning with Monaco
Outline for Stereotactic Planning with Monaco Section

Learning Objectives
Introduction: Stereotactic Planning with Monaco
Workflow Diagrams
Stereotactic Cone Configuration and Graphical Preferences
Monaco Planning with Stereotactic Cones

• Delineate additional structures if needed
• New Plan & Stereotactic Cone Templates
• Dose Prescription
• Stereotactic Cone Selection
• Stereotactic Cone Visualization
• Beam Spreadsheet
• Dose Calculation
• Plan Evaluation
• Practice Exercise: Brain Mets with 3D Static Arc/Stereo Cones
MLC Stereotactic Planning: Training Guide Practice Exercises

• Lung with VMAT
• Lung with DCA
• Spine with VMAT
Training Data
Six practice cases for stereotactic planning
• Brain5TargetsTRN
• LeftLungSBRTTRN
• SpineSingleTRN
• BrainAVMTRN
• BrainTrigemTRN
• Spine2TargetsTRN
NOTE: Use your clinic’s procedures for Quality Assurance to every part
of the stereotactic process, beginning with patient positioning
and immobilization all the way through to image-guided
verification at treatment.
Monaco® 23-1
Learning Objectives
• Describe the use of Stereo Cone Parameters in the Settings dialog
box for stereo cone configuration
• Explain how the Visibility Increment for 3D Static Arc delivery is

created and applied
• Discuss one way to use a stereotactic cones dose prescription in the

Physician’s Intent and Beam Weights section
• Identify where to select the Applicator ID for the relevant stereo cone
size after you determine the target size
• Recognize how stereotactic cones look in the 2D, 3D, DRR view types,
and how to change their visualization
• Examine the beam spreadsheet to verify accurate information in all

fields
• Use Isodose Tools and DVH statistics to analyze target dose

conformity, gradient, heterogeneity; and dose to normal tissue
• Use Dynamic Conformal Arc and VMAT delivery types to create, optimize,
calculate and evaluate Lung and Spine SBRT treatment plans.
Introduction: Stereotactic Planning

In the Monaco Stereotactic Planning section of the training guide, you first
review a general workflow of the stereotactic process, and how Monaco
treatment planning fits into the stereotactic workflow.
Next, you go into greater detail of Monaco stereotactic planning as you learn
how to use stereotactic cones with 3D Static Arcs throughout the treatment
planning process.
Then, work through exercises that give you the opportunity to practice
planning not only with 3D Static Arc & Stereo Cones for a brain metastases
example, but also, as you use Dynamic Conformal Arc and VMAT with MLC
for spine and lung targets.
Disclaimer
The examples and exercises used throughout this section are for
illustrative purposes only, and are in no way to be construed as Elekta
acting in any way to give medical direction or advice.
23-2
Workflow Diagrams
Monaco Stereotactic Planning General Stereotactic

Workflow Workflow
Positioning, Imaging, Fusion, QA

Delineate Target
and Normal Positioning, QA
Structures Frame/Frameless Positioning and
Immobilization Fixation
Start New Monaco

Plan
Select and
Import Imaging (may QA
Template occur prior to the Imaging
Enter Dose
day of treatment)
Prescription
(Physician’s Intent,
Beam Weights)
Import
Images
MLC
Measure Target
and Select Cone
(3D Static Arc QA
Delivery) Image Fusion
Use visualization Image Fusion
tools to evaluate
beam geometry and
shaping devices Verify and
Determine Beam
Geometry
Monaco
Treatment Planning
Set IMRT
Set Calculation
Constraints if
Parameters Localization, QA, Image Verification, Treatment
DCA/VMAT
Localize
Stereotactic
Frame
Calculate Plan Send
information
Export Plan to MOSAIQ
to Localizer
Verify Plan
Analyze Plan Quality: Information in
Isodoses; Target MOSAIQ
Conformity, Gradient QA: Linear
&, Heterogeneity Accelerator
QA: Treatment
Plan, Isocenter at
Linear
Export Plan Accelerator
Approve Plan
to MOSAIQ
Image Calculate/Verify
Verification MU
Treat Patient
Figure 23-1: Monaco Stereo Planning Workflow and General Stereotactic

Workflow
Monaco® 23-3
Stereotactic Cone Configuration

Configure your clinic’s stereotactic cones from the Stereo Cone Parameters
section of the Settings window.
Figure 23-2: Stereo Cone Parameters in Settings Window
Refer to the Settings section of Appendix C for more information.
23-4
Visualization Increment in Graphical Preferences

In the Settings window (Figure 23-3) under Graphical Preferences, type the
desired Visualization Increment you want to use while you view each beam
arc. Remember, this increment does not affect the dose calculation.
Figure 23-3: Visualization Increment in Settings Window

While you are in Planning Mode, from the Fluence ribbon, select or scroll
through the 10° visualization increments with the up/down arrows to the
right of the Gantry angle. The Beam’s Eye View (BEV) updates as you select
the respective arc increment.
In the next two figures, notice the BEV as you view the stereotactic cone field
relative to the target and adjacent normal structures throughout the arc. In a
Single Planar View (SPV), you see the stereotactic cone start/stop positions
and beam path of the corresponding increment angle.
Monaco® 23-5
Visualization Increment in Graphical Preferences (cont.)
Figure 23-4: Transverse SPV and the BEV at the Stop angle of 340°
Figure 23- 5: Next visualization increment at 330°, which is 10° off the
Stop Angle of this arc
23-6
Monaco Planning with Stereotactic Cones

1. Additional Structures
Add more structures for planning, if needed.
2. New Monaco Plan
Begin a treatment plan that uses stereotactic cones the same way you start any
new Monaco plan. Select a delivery type, template, and desired beam
information.
3. Stereotactic Cone Templates with 3D Static Arc
Use the beam information from your template for planning and treatment, or
use it as a starting point from which you may adjust parameters. Notice that
Monte Carlo is the algorithm for 3D Static Arc with Stereotactic Cones. Here is
an example of a template for 3D Static Arc with Stereo Cones (Figure 23-6).
Figure 23-6: Example of a template for 3D Static Arc with Stereo Cones
Monaco® 23-7
Monaco Planning with Stereotactic Cones (cont.)
4. Dose Prescription
The method in which the Dose Prescription is described for stereotactic

treatments can vary from non-stereotactic treatments. Throughout the exercises,
you can use different Physician’s Intent entries and Beam Weights based on the
delivery mode. Start with equal weights, and then adjust later as you evaluate the
plan (Figure 23-7).
Figure 23-7: Example of one type of prescription used with Stereo Cones and
3D Static Arc
5. Stereotactic Cone Selection
To determine the stereotactic cone applicator size, use the Measure Tool to
measure the target on the transverse, sagittal, and coronal single planar views.
Then, select the relevant cone size in Applicator ID of Treatment Aids section of
the Beams tab.
Figure 23-8: Stereo Cone Applicator ID selection in the Beams window
23-8
6. Stereotactic Cone Visualization
Use the various Monaco Views to assist in visualization of stereotactic cone

beams.
Figure 23-9: BEV and SPV of beam arc with Stereo Cones
Monaco® 23-9
Figure 23-10: 3D representation of arc beam with stereo cones
23-10
For an example of how you use block transparency for stereotactic cones, look at
a non-arc beam with a beam modulator treatment machine in the figures below.
Set block transparency while inside the Single Planar View. Right-click and
select Options Menu | Block Transparency. This turns on and off transparency
that covers the image.
Figure 23-11: Block Transparency for Stereotactic Cone
Notice the two sets of collimators: 1) stereotactic cone, 2) default field size.
Monaco® 23-11
In this example, the inner set represents the stereo cone applicator. The outer
set represents the 2x2 cm. default field size of the leaf bank, set during cone
configuration and data collection. For other treatment machines, this outer
set represents the default jaw settings.
Figure 23-12: Field Edge Representation of Stereo Cone Applicator and

Default Collimator
You can set the stereo cone display graphics in the 2D Treatment Aid Display
from the Options menu.
Figure 23-13: 2D Stereo Cone Display
23-12
7. Visualization while you plan the arc angles
You can use several methods to visualize and adjust the arcs to avoid normal
structures in the beam’s path. One method is that described earlier when you use
visualization increments in the BEV and SPV.
Another way is to keep a 3D view and Single Planar View together on the screen,
and watch the arc path in the 3D view as you drag the start/stop arc in the 2D
view (SPV).
8. Beam Spreadsheet
In the Beam Spreadsheet, you can modify information previously set in the New
Monaco Plan template.
In the figure of the General section, notice that for 3D Static Arc, you use Monte
Carlo algorithm. You cannot use Collapsed Cone algorithm.
Figure 23-14: General Tab
Monaco® 23-13
In the Geometry section, as you evaluate the target volume relative to the
normal tissue, you may decide to change the number of beams, gantry, couch,
and collimator parameters. Remember, you cannot set an arc increment for the
calculation.
Figure 23-15: Geometry Tab
In the Treatment Aids section, you can select the desired stereotactic cone
applicator for each beam.
Figure 23-16: Treatment Aids Tab
23-14
9. Dose Calculation
Use Monte Carlo algorithm for the dose calculation.
Initially, use coarse (high) values for the calculation parameters to minimize the
calculation time. Then, tighten the values as you refine beam and dose planning
parameters. The Calculation Properties dialog box below shows an example of
values to use after you have refined your beam parameters.
NOTE: Remember not to lower the grid spacing below that specified in
your beam modeling parameters.
Monaco® 23-15
10. Plan Evaluation
You begin stereotactic cone plan evaluation early in the planning process, as
described previously. Use isodose curves to determine if your dose prescription
is adequate to meet your physician’s prescribed percent tumor coverage. Also,
use the isodose curves to check general conformity to the target.
Use Isodose Tools (Isodose to Structure, etc.) and Dose Volume Histogram
statistics to evaluate Organ at Risk sparing and plan quality. Specifically:
• Dose Conformity to the target
• Dose Gradient outside the target
• Dose Heterogeneity within the target
Several models exist in the literature and protocols to determine these values.
Use the model your clinic has adapted in its procedures. In the exercises, you
review a couple of examples.
NOTE: Use your clinic’s procedures for Quality Assurance for every part
of the stereotactic process, beginning with patient positioning and
immobilization all the way through to image-guided verification
at treatment.
23-16
Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones

Disclaimer: This Practice Exercise uses example values from legitimate, authoritative third
parties for training purposes only. In no way is Elekta providing medical
direction or advice.
Table 23-1: Overview of Tasks for Stereotactic Brain Metastasis Exercise.

Task Task
#
1 Pre-Exercise Work and Select Patient
2 Add planning margin
3 Start a New Monaco Plan and Import Template
4 Enter Dose Prescription
5 Determine Stereotactic Cone Size
6 Determine arc-beam number and geometry
7 Set Calculation Properties and calculate dose
8 Evaluate plan with isodose tools and DVH statistics
References
The references listed at the end of the Stereotactic Planning Section of the training
guide were used for the Tasks in this exercise.
Monaco® 23-17
Practice Exercise 1. Brain Mets with 3D Static Arc/Stereo Cones (cont.)
Task 1. Pre-Exercise Work and Select Patient
In preparation of this exercise, you must make a few edits to the Structure Set
of the example patient. If you want to save the original Image/Structure Set,
follow the steps below to copy the file.
Otherwise, skip to step number 2.
1. Find the Image & Structure Set folders to make copies.
a) Access your Training Clinic Folder in Microsoft Windows.
b) The file path may vary depending upon your training clinic’s file
structure, but an example is: |Focal Data | Installation | Training Clinic.
c) Open the folder of the example case: Brain5TargetsTRN.
d) Copy the Image & Structure Set folder labeled CT1_Clean and place the
newly copied folder CT1_Clean_Copy in the same Brain5TargetsTRN
folder.
e) Inside the CT1_Clean_Copy folder, rename the CT1_Clean folder that

contains the index.DAT file to CT1_Clean_Copy. This is the file name
you see in the Monaco application Workspace.
f) Use this new copy to edit the structures.
2. After you open the example patient Brain5TargetsTRN in Monaco, select the
desired Structure Set from the Monaco Workspace.
3. Set patient contour type to External.
23-18
Task 1. Pre-Exercise Work and Select Patient (cont.)
4. Optional: Delineate the right cochlea and left cochlea.
5. Despite the patient name, plan for only one target, called tumor-cerebel in this
exercise.
6. Turn off the visibility of the other four tumor structures.
Figure 23-18: Tumor Structure
Task 2. Add Planning Margin
1. Use Auto Margin to add a 2 mm uniform margin around tumor-cerebel.
2. Name the new structure PTV_cerebel.
Monaco® 23-19
Task 3. Start a New Monaco Plan & Import Template
1. Click the Planning tab and select New Monaco Plan from the New Plan menu.
Figure 23-19: New Plan Menu
2. Create a New Plan Name and Description.
3. Verify the Scan Orientation and the Treatment Orientation.
4. In the New Monaco Plan window, select the values shown in the table below for
the respective information type.
Table 23-2: Value Entry for New Monaco Plan Window
Information Value
Type
Delivery Type 3D Static Arc
Template to Template: StereoCones > 3D Static Arc
Import
Treatment Unit StConesBM06x
Algorithm Monte Carlo
Isocenter Center of tumor-cerebel
Location
Port Options Import Beams Only
5. If your clinic uses standard beam information, set your standard parameters and
save as a New Monaco Plan template for future use.
See the Template section in the training guide for more information to save
templates.
23-20
Task 4. Enter Dose Prescription
In stereotactic planning, you can describe the dose prescription several ways.
For this exercise, normalize the plan to the Max Dose and prescribe to a
Prescription Isodose, which is the isodose line that encompasses the target.
• Plan normalized to: Max Dose
• Prescribed Target Dose: 20 Gy
• Prescription Isodose: 80%
1. Type a prescription in the Physician’s Intent section.
2. Type Brain in the Rx Site field if it is not already listed in the drop down menu.
3. Click the Prescribe to drop-down menu and select Center of tumor-cerebel.
4. Type an Rx Dose of 25 Gy to the PTV isocenter.
In this example, you begin with 25 Gy as maximum dose, where the prescription
is 20 Gy at the 80% isodose surface.
5. Type the number of fractions: 1fx.
Monaco® 23-21
Task 5. Determine Stereotactic Cone Size
1. Set up a transverse, sagittal, and coronal view (SPV) on the screen. Scroll to the
largest extent of the PTV on each slice.
2. Use the Measure Tool to measure the target on all three SPV images. From
these values, determine which stereotactic cone to use.
Figure 23-20: Measurement Value in SPV views, with BEV to Show Cone Size
and Target
3. Inside Beams spreadsheet, select a stereotactic cone from the Applicator ID

drop down menu for each beam. For this exercise, you can start with a 14 mm or
18 mm cone.
NOTE: Once you select the Stereo Cone Applicator, the collimator angle
automatically sets to the default value set during Data Collection.
(See Stereo Cone Parameters under the Settings section of the
Training Guide.)
23-22
Task 6. Determine Beam Geometry, Information, and Number of Beams
With a BEV on the screen, scroll through all beam arcs to view target
coverage and normal structure blocking.
1. Use the visualization tools to evaluate if you want to adjust the number of beams
and/or the beam geometry relative to the target and normal structures.
Remember to toggle through the gantry visualization arc increments in the

Fluence ribbon as you watch the beam and cone geometry move relative to the
structures in a BEV.
NOTE: Refer to the visualization information in the earlier part of this

training guide section for more information.
2. The table below shows the beam geometry from the template you selected
earlier in the exercise. You can keep these parameters and calculate the plan, or
you can adjust the parameters based on your evaluation in the previous step.
Table 23-3: Beam Geometry Set in New Monaco Plan Template
Beam Direction Gantry Start Arc Couch
1: RtArc CW 200 140 10

2: Rt45Arc CCW 340 140 45
3: VertexArc CW 200 140 90
4:Lt45Arc CCW 160 140 315
5:LtArc CW 20 140 350
3. Then, while you plan, adjust the parameters as needed.
4. If needed, change the Stereotactic Cone Applicator in the Treatment Aids sheet.
Monaco® 23-23
Task 7. Set Calculation Properties and Calculation
1. Verify in the Beams Spreadsheet that you have set the algorithm to Monte
Carlo.
2. From the Calculation ribbon in the Planning tab, select the Calculation
Properties for the plan.
Figure 23-21: Calculation Properties
3. Initially, set a high value, such as 3.0 mm, for the grid spacing to minimize the
calculation time. Then, lower the grid value within a range of 1.0 mm - 2.0 mm
as you refine the beam and prescription parameters during planning.
NOTE: Remember not to lower the grid spacing below that specified in
your beam modeling parameters.
23-24
Task 7. Set Calculation Properties and Calculation (cont.)
The figures below show an example of grid spacing early and late in the
planning process.
Figure 23-22: Early in Planning Process Figure 23-23: Late in Planning Process
4. For this example, set Calculate dose to: Medium, and set 1% Statistical
Uncertainty per Calculation.
5. Click OK to apply the new properties.
6. To start the calculation, click the Calculate icon .
7. Once the calculation completes, proceed to plan evaluation.
Monaco® 23-25
Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics
You can use a variety of tools to evaluate, and strategies to re-optimize your
stereotactic cones plan. In this exercise, you apply Monaco’s isodose tools
and DVH information to analyze dose quality relative to the target, and dose
volume information to the normal structures.
Terminology used in this Plan Evaluation Task:
PIV: Prescription isodose volume
PIV 0.5 : Volume receiving half of the PIV
PCI: Paddick Conformity Index
GI: Gradient Index
HI: Heterogeneity Index
1. In the Isodoses tab, set these initial isodose values:
Table 23-4: Isodose values for Plan Evaluation

Isodose Description of Dose
Value (Gy)
25* 125% (or max dose)*
20 Prescription Dose
10 50% Prescription Dose
4 20%
2 10%
*The max dose may change as you evaluate and modify the plan to achieve
target coverage by the 20Gy isodose line and improve CI, GI, HI.
23-26
Task 8. Evaluate the Plan with Isodose Tools and DVH Statistics (cont.)
2. Use the Normal Tissue tolerances below as you evaluate the plan.
Table 23-5: Normal Tissue Tolerances

Structure Maximum Volume
Dose (Gy)
Brainstem - 10 < 0.5 cc
Avoid if
possible
Optic Chiasm 10 < 0.2 cc
Right Optic 10 < 0.2 cc
Nerve
Left Optic 10 < 0.2 cc
Nerve
Right Eye 10 < 0.2 cc
Left Eye 10 < 0.2 cc
Right 9 Point
Cochlea*
Left Cochlea* 9 Point
Brain 12
*Optional delineated structure for this exercise.
3. You can use many strategies to evaluate and optimize your plan.
a) Do a visual check of the overall shape or conformity of the prescribed

isodose distribution.
b) If the dose is not conformal to the target, repeat the beam geometry
optimization by gantry angles, arc start/stop angles, couch rotation, and
number of beams, cone size, isocenter location.
c) Look at dose to the normal structures and determine if you need to

adjust beam geometry.
d) Change the isocenter, if necessary.
e) Change the cone size, if necessary.
Monaco® 23-27
f) In general, find the proper combination of modifications to the

variables below to achieve the best conformity (CI), dose gradient (GI):
• Number of beams
• Gantry angle
• Arc increment per beam
• Couch angle
• Collimator angle
• Cone size
• Isocenter or Cone placement
• Prescription Dose - renormalize
4. Apply the parameters your clinic uses to evaluate measures for target
conformity, gradient, and heterogeneity.
NOTE: Several models exist in the literature and protocols to determine

these values. Use the model your clinic adapted in its procedures.
In the exercises, you view the examples below.
Abbreviations you use in this exercise are:
TV: Target Volume
PIV: Prescription Isodose Volume
PCI: Paddick Conformity Index
GI: Gradient Index (Paddick and Lippitz)
HI: Heterogeneity Index
23-28
For 3D Static Arc plans, use Monaco isodose tools and DVH statistics to
calculate these factors.
Table 23-6: Example of the heterogeneity, conformity, and gradient
indices
Index/ What it measures Formula Value to
Measurement Achieve
*PCI Conformity of the dose (TV covered by 1.0 is perfect
prescription to the size & PIV)2 / TV x PIV
shape of the target
GI Description of the steep PIV 0.5 / PIV < 3.0
dose gradient outside the
target
HI Dose heterogeneity within (D max – D min ) /
the target Mean Dose
*PCI - Conformity
The Paddick Conformity Index analyzes the quality of target volume (TV)
coverage:
And the volume of healthy tissue receiving a dose larger than or equal to the
prescription isodose volume (PIV):
Which gives the final formula:

= (TV covered by PIV)2 / TV x PIV
Monaco Evaluation Tools: To access variables needed to measure GI, use

isodose and DVH tools described in earlier sections of the Monaco Training
Guide. For example, create an isodose to structure to find the volume of
PIV 0.5 .
Monaco® 23-29
MLC Stereotactic Planning: Training Guide Exercises

Practice Exercise 2: SBRT Lung with Volumetric Modulated Arc Therapy
Practice Exercise 3: SBRT Lung with Dynamic Conformal Arc
Practice Exercise 4: SBRT Spine with Volumetric Modulated Arc Therapy
Practice Exercise 2. SBRT Lung with VMAT

Table 23-7: Tasks for SBRT Lung Exercise with VMAT

Task # Task
1 Pre-Exercise Work & Select Patient
2 Add planning structures
3 Start a New Monaco Plan, Import Template, Set Isocenter
5 Set Beam Geometry
6 Set Structure Optimization Parameters
7 Set Calculation Properties and Sequencing Parameters
8 Set Cost Functions and Dose Constraints
9 Calculate Fluence – Optimization Phase 1
10 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-evaluate
11 Calculate Segments – Optimization Phase 2
Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-
12
optimize Phase 2, Re-evaluate
References
23-30
Practice Exercise 2. SBRT Lung with VMAT (cont.)
In preparation of this exercise, you reset a structure and target parameters.

1. Open the Patient in Monaco and select the LeftLungSBRTTRN patient from
the Training Clinic.
2. Open Structure Set: SS_CT1_Clean2.
3. Delete two (2) unwanted trachea contours on the image slices described below.
- At the left lung on Image Slice: 17.35.
- Outside of patient’s left side on Image Slice: -4.90.
4. Uncheck the structures R_Hilar_CTV45 and R_HilarPTV45. You do not use

these structures for this exercise.
5. Rename the LL_CTV to LL_ITV.
6. In this exercise, use LL_PTV as the target.
7. Create a new structure for the Left Chest Wall, which is 2cm expansion from
ipsilateral lung, and extends 1.2 cm superior and inferior to the PTV.
Monaco® 23-31
Task 2. Add Planning Structures
1. Optional: Use auto margin to create a uniform structure around PTV to use as a
guide to evaluate dose gradient. For an example, create PTV + 2cm.
2. In this example, you have not delineated brachial plexus, stomach, liver, or
kidneys, however, with different beam geometry and in the clinical setting, you
may need to define these structures. Follow your clinic’s procedures for normal
structure delineation.
3. Save your changes.
Task 3. Start a New Monaco Plan, Import Template, Set Isocenter
4. In the New Monaco Plan window, type a Name and Description.
23-32
Task 3. Start a New Monaco Plan, Import Template, Set Isocenter (cont.)
5. Select the training template and type the values that appear in the table below for
the respective plan information.
Table 23-8: Values for Plan Information
Plan Information Value

Delivery Type VMAT
Template to Import Template: VMATTraining
Treatment Unit TRNElekAgility
Energy 6.0 FFF
Isocenter Location* Center of LL_PTV *
* Optional: As an alternative to the Isocenter Location that appears in the table

above, continue the exercise with the Isocenter Location set to the center of the
Patient. Or, create an Isocenter Location that you use in your clinic for ease of
patient setup.
6. If your clinic uses standard beam information, set your clinic’s parameters and
NOTE: See the Template section in guide for more information on saving
templates.
Monaco® 23-33
The literature shows various dose prescription criteria for lung SBRT. For an
example in this exercise, you use a prescription of 54 Gy in 3 fractions.
Example Dose Prescription Criteria for this Exercise.
• Prescription Dose
54 Gy in 3 fractions
• Prescription Isodose Surface must be ≥ 60% and < 90% of the
maximum dose.
Often it is 80%.
• PTV Coverage (example)
99% of PTV must receive minimum of 90% of prescription dose
(54Gy x 0.9 = 48.6Gy)
95% of PTV is conformally covered by the prescription isodose
surface
1. In the Prescription tab, type the values from the table below for the Physician’s
Intent.
Table 23-9: Values for Physician’s Intent

Information Type Value
Prescribe To Center of LL_PTV
Rx Dose (Gy) 54.00
Number of 3
Fractions
Fractional Dose 18.00
(Gy)
23-34
Task 4. Enter Dose Prescription (cont.)
2. Type a prescription in the Physician’s Intent section.
a) Type Lung in the Rx Site field if it is not already listed in the drop down
menu.
b) Click the drop-down menu in the Prescribe to: field and select Center of
LL_ITV.
c) Type an Rx Dose of 54 Gy to begin with. The actual dose changes after

you set cost function constraints and optimize.
d) Type the number of fractions: 3 fx.
Task 5. Set Beam Geometry
1. Use the visualization tools to evaluate the appropriate beam geometry.
2. Set a gantry angle and Arc length to best avoid organs at risk.
3. For this exercise, set the arc beam geometry values as they appear below:
Table 23-10: Beam Geometry Values
Beam Direction Gantry Start Arc Inc Collimator Couch

1: Left Arc CW 340 200 10 0 0
Monaco® 23-35
Task 6. Set Structure Optimization Properties
Some clinics override the PTV density. Follow the guidelines set by your clinic to
determine if you want to force the PTV electron density (ED). For this exercise, use
a relative electron density of 0.50.
Task 7. Set Calculation Properties, IMRT Parameters and Sequencing

Parameters
Carlo.
NOTE: For this exercise, you use Grid Spacing and Statistical Uncertainty
values that reduce calculation time so you can complete the
exercise during class.
In your clinic, type tighter parameters for a more accurate

calculation.
2. From the Calculation ribbon in the Planning tab, select Calculation Properties
.
3. Type the Calculation Properties values that appear in the figure below.
23-36

Parameters (cont.)
4. Type the IMRT Parameters that appear in the figure below.
Figure 23-25: IMRT Parameters
Monaco® 23-37
Task 7. Set Calculation Properties and Sequencing Parameters (cont.)
5. Select the Sequencing Parameters icon , then, start with the parameter
values that appear in the Figure 23-26.
Figure 23-26: Sequencing Parameters: VMAT
Task 8. Set Initial Cost Function Constraints

1. Select the IMRT Constraints Tab, or access it by Workspace | Controls | IMRT
Constraints.
23-38
Task 8. Set Initial Cost Function Constraints (cont.)
2. You can use a variety of approaches to set cost function constraints. The settings
below are only one of many possible uses and combinations. Begin with the
example constraints in the table below, and as you evaluate the plan, you can
adjust the cost functions as needed during and after fluence optimization.
Table 23-11: Example Dose Constraints

Optional
Structure Cost Function Required Parameters Physical
Parameters
LL_ITV** Quadratic Overdose 64.0Gy Max Dose; 0.50 Gy
RMS
Target EUD 60.0Gy; 0.50 Cell Sensitivity
LL_PTV** Target Penalty 54.0Gy; 98% Min. Vol.
Quadratic Overdose 60.0 Gy Max Dose; 2.0Gy
RMS
Left Lung Serial* 16.0Gy EUD; 8.0 Exponent 1.0cm Shrink
(ipsilateral) Margin
Conformality 0.70 Isoconstraint
Chest Wall Serial 25.0Gy EUD; 8.0 Exponent
Patient Quadratic Overdose 25.0Gy Max Dose; .100Gy
RMS
** With stereotactic planning, you want a steep dose gradient outside the
target. To achieve this gradient, you have a more heterogeneous dose
distribution inside the target volume, with hot spots of 120 – 130%. Carefully
evaluate the hot spot location within the target, and make sure it is in the
center of the target and not close to its periphery.
*In this example, although the lung is considered parallel tissue, we use the
serial cost function because we deliver a high dose to a small target and a
small volume of overall lung tissue. As an optional exercise, you can use
parallel cost function for the lung.
3. At this point, select Save Template As to keep this template in case you make
changes during and after optimization, and want to return to it.
4. After you complete Cost Function & Dose Constraint entry, go to the
calculation phase of planning.
Monaco® 23-39
Task 9. Calculate Fluence – Optimization Phase 1
1. To start the fluence stage of dose optimization, select the Optimize icon from
the Calculation ribbon in the Planning Control.
2. Begin with loose parameters, then tighten isoconstraints during optimization.
3. Once stage 1 is complete, evaluate the plan’s fluence.
Task 10. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1,

Re-evaluate
Several models exist in the literature to determine the values associated with target
dose conformity, gradient and heterogeneity. For this exercise, use the model your
clinic has adapted in its procedures to evaluate the plan quality, or use several
parameters from RTOG 0915 and 0236.
1. Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze the
measures that determine dose quality relative to the target and organ at risk
sparing. We use example criteria below to evaluate plan quality that includes:
• Dose Heterogeneity within Target

- As an example, monitor the location of the hot spot – keep in
center of PTV and away from OARs, Maintain hot spot of about
125%.
• Dose Conformity to Target (High Dose Spillage)
- As an example, any dose > 105% of prescription dose (56.7 Gy in
this exercise) should occur primarily within the PTV itself and not
within the normal tissues outside the PTV.
• Dose Gradient outside of Target (Low Dose Spillage)
- As an example, the maximum dose 2cm from PTV cannot be
greater than 50% of the prescribed dose (27 Gy). Use Monaco
auto margin tools and Isodose to Structure tool to assist in
evaluation.
• Target Dose Prescription (one example)
- As in our example, 95% of PTV is covered by 99% of the
prescription dose of 54 Gy.
23-40
Task 10. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1,

Re-evaluate (cont.)
• Organ at Risk Sparing, for example:

- Use the table below as an example of SBRT threshold values
when you evaluate how well your plan met normal tissue
dose/volume constraints.
Table 23-12: Example of Normal Tissue Dose/Volume Tolerances
Structure Maximum Dose (Gy) Volume

Rib 30Gy < 30 cc
Chest Wall 2cm 30Gy ≤ 70cc
*Total Lung - 12Gy 1000cc
ITV
Heart 24 Gy < 15cc
Spinal Cord 12.3 Gy < 1.2 cc
Esophagus 17 Gy < 5cc
Select Structure Combination from the options menu in the DVH to create
Total Lung.
2. As you evaluate the plan and see it is not meeting your goals, among strategies to
improve the plan are:
• adjust cost functions

• renormalize or rescale the dose prescription
• apply a Shrink Margin on normal structures adjacent to the PTV
• refer to the Isoeffect values and adjust the Isoconstraints if needed
3. Re-optimize the Fluence calculation, re-evaluate, and continue on to Stage 2

optimization of Segment calculation.
Monaco® 23-41
Task 11. Calculate Segments – Optimization Phase 2
1. Select the Optimize 2 icon from the Calculation ribbon to start.
2. If you notice that target conformality degrades between stage 1 and stage 2
calculation, you may try to increase the number of Control Points.
Task 12. Evaluate Plan, Adjust Calc Properties & Sequence Parameters,
Re-optimize Phase 2, Re-evaluate
1. As in plan evaluation after Fluence Optimization, use the Isodose Tools, DVH
Statistics & Display, and your clinic’s procedures to analyze the plan for
quality of:
• MLC Segments
• MU Summary
• Dose Conformity around the Target
• Dose Gradient outside Target
• Dose Heterogeneity inside the Target – Pay close attention to location

and value of hot spot
• Target Dose Prescription Constraints
2. Once the plan is acceptable, continue to plan approval and export.
23-42
Practice Exercise 3. SBRT Lung with DCA

Table 23-13: Overview of Tasks for SBRT Lung with DCA Exercise
Task # Task
5 Set Beam Geometry
6 Set Structure Optimization Parameters
10 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-
evaluate
Evaluate Plan, Adjust Calc Properties & Sequence Parameters,
12
References
Tasks 1 and 2. Pre-Exercise Work, Select Patient, Add Planning

Structures
Continue to Task 3 since the steps in Tasks 1 and 2 are identical to the previous
SBRT Lung VMAT exercise.
Monaco® 23-43
Practice Exercise 3. SBRT Lung with DCA (cont.)
4. In the New Monaco Plan window, type a Name and Description.
5. Select Dynamic Conformal Arc (DCA) delivery type.
The default Dynamic Conformal Arc template in Monaco has four (4) beams
arcs. In this exercise, you modify the number of beams later on the Beam
spreadsheet in the Planning activity.
6. Refer to the figure below and select the listed beam information and isocenter.
Figure 23-26: New Monaco Plan
23-44
*Optional: As an alternative to the Isocenter Location that appears in the figure

above, continue the exercise with the Isocenter Location set to the center of the
Patient, or, create an Isocenter Location that you use in your clinic for ease of
patient setup.
7. Use an Agility treatment unit.
NOTE: If you select the Apex unit, later in this exercise, We advise you
not to use Segment Shaped Optimization. See the note in the
Sequencing Parameters task.
8. If your clinic uses standard beam information, set your standard parameters and
NOTE: See the Template section in the guide for more information to
save templates.
Monaco® 23-45
1. In the Prescription tab, type the values in the table below for the Physician’s
Intent.
Table 23-14: Example entry for Physician’s Intent

Prescribe To Center of LL_PTV
Rx Dose (Gy) 54.00
Number of Fractions 3
Fractional Dose (Gy) 18.00
2. Use the Dose Prescription criteria from the previous Lung SBRT (VMAT)
practice exercise.
23-46
Task 5. Determine Arc Beam Number and Geometry
1. Use the visualization tools to evaluate the appropriate beam geometry. Keep in
mind, the MLC leaves appear after the optimization completes.
2. Set a Gantry angle and Arc length to best avoid organs at risk.
Table 23-15: Example Beam Geometry Values
Beam Direction Gantry Arc Inc Collimator Couch

Start
1: Left Arc CW 340 200 10 0 0
Task 6. Set Structure Optimization Properties
Some clinics override the PTV density. Follow the guidelines set by your
clinic to determine if you want to force the PTV electron density. For this
exercise, use a relative electron density of 0.50.
Task 7. Set Calculation Properties and Sequencing Parameters
Carlo.
exercise in the training class.

calculation.
.
Monaco® 23-47
3. Type the values for Calculation Properties that appear in the table below.
23-48
4. Type the IMRT Parameters that appear in the figure below.
Figure 23-28: IMRT Parameters
5. Segment Shaped Optimization (SSO) is available with DCA.
Figure 23-29: Sequencing Parameters: Dyn. Conformal Arc with and without
Segment Shape Optimization turned on
Monaco® 23-49
6. Optional: You can go through this exercise twice.
Run the first plan with SSO unchecked and save the plan. Then, run the second plan
with SSO checked. If you check SSO, we recommend you check Pilot Beamlets.
*Keep in mind, the calculation with SSO checked takes more time.
NOTE: When you use an Apex treatment unit, if you check SSO for a
Dynamic Conformal Arc delivery plan, the resulting plan may be
undeliverable because the minimum dose rate is violated.

Constraints.
2. Begin with the dose constraints in the table below. Then, while you evaluate the plan,
you can adjust the cost functions as needed during and after fluence optimization.
Table 23-16: Example Dose Constraint Values

Optional Physical
Structure Cost Function Required Parameters
Parameters
LL_PTV Target Penalty 54 Gy; 98%
Quadratic 66 Gy; 2 Gy RMS Dose
Overdose Excess
Target Penalty 60 Gy; 95%
Patient Conformality 0.70 Isoconstraint
** With stereotactic planning, you want a steep dose gradient outside the target.
To achieve this gradient, you have a more heterogeneous dose distribution
inside the target volume. Carefully evaluate the hot spot location within the
target, and ensure it is in the center of the target and not close to its periphery.
3. At this point select Save Template As to keep this template in case you make
23-50
Task 9. Calculate Full Fluence Modulation – Optimization
1. To start the fluence stage of dose optimization, select the Optimize icon
from the Calculation ribbon in the Planning Control.
2. Once stage 1 completes, evaluate the plan’s fluence.
Task 10. Evaluate Plan, Adjust Cost Functions, Re-evaluate
Several models exist in the literature to determine the values associated with target
dose conformity, gradient, and heterogeneity. For this practice exercise, use the
model your clinic has adapted in its procedures to evaluate the plan quality, or use
the examples below.
1. Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze plan
quality measures relative to the target and organ at risk sparing. Use the example
criteria for the qualities listed below:
- As an example, monitor location of hot spot –keep in the center of

PTV and away from OARs, maintain hot spot of about 125%.
• Dose Conformity to Target (High Dose Spillage)
- As an example, any dose >105% of the prescription dose (56.7 Gy

in this exercise) should occur primarily within the PTV itself and
not within the normal tissues outside the PTV.
• Dose Gradient outside of Target
- As an example, the maximum dose 2 cm from PTV cannot be

greater than 50% of the prescribed dose (27 Gy). Use Monaco
auto margin tools and Isodose to Structure tool to assist in
evaluation.
• Target Dose Prescription (one example)
- As in our example, 95% of PTV is covered by 99% of prescription

dose of 54 Gy
Monaco® 23-51
Task 10. Evaluate Plan, Adjust Cost Functions, Re-evaluate (cont.)
• Organ at Risk Sparing
- Use the table below as an example of SBRT threshold values when

you evaluate how well your plan met the critical structure
dose/volume constraints.

e
Maximum
Structure Volume
Dose (Gy)
Rib 30Gy < 30 cc
Chest Wall 2cm 30Gy ≤ 70cc
*Total Lung - 12Gy 1000cc
ITV
Heart 24 Gy < 15cc
Spinal Cord 12.3 Gy < 1.2 cc
Esophagus 17 Gy < 5cc
*Select Structure Combination from the options menu in the DVH to create Total Lung.

3. Re-optimize the Fluence calculation, re-evaluate, then continue to Stage 2

23-52
Task 11. Final Calculation
1. The final calculation automatically occurs.
a) If you have SSO unchecked, notice a message at the bottom of the screen
that indicates the Final dose calculation is complete.
b) If you have SSO checked, notice a message at the bottom of the screen
that indicates the segments are calculating for the second phase of
optimization.
Statistics & Display and your clinic’s procedures to analyze the plan for quality
of:
• MLC Segments
• MU Summary

2. Once the plan is acceptable, continue on to plan approval and export.
3. Optional Task: Repeat this Exercise, but use the Flattening Filter Free 6X
Modality (6.0 FFF)
Monaco® 23-53
Practice Exercise 4. SBRT Spine with VMAT

Table 23-18: Overview of Tasks for Stereotactic Spine Exercise

Task # Task
5 Set Beam Geometry
9 Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-
evaluate
11 Evaluate Plan, Adjust Calc Properties & Sequence Parameters, Re-
optimize Phase 2, Re-evaluate
References

In preparation of this exercise, delineate several additional organs at risk
if you want to look at dose to these structures.
1. Open the Patient in Monaco and select the SpineSingleTRN patient from the
Training Clinic.
2. Open Structure Set: SS_CT_Clean2.
3. Optional: delineate these structures: stomach, liver, right kidney, and left kidney
in the Contouring tab.
4. Continue to the Contouring tab.
23-54
Practice Exercise 4. SBRT Spine with VMAT (cont.)
Task 2. Add Planning Structures
1. Create a structure called Spinal Cord + 1.0 mm to serve as a planning organ at

risk volume (PRV)
2. Optional: Create PTV + 1cm. Use this structure to identify hot spots outside the
PTV.
3. Save your changes.
4. Select the training template and type the values that appear in the table below for
the respective plan information:
Table 23-19: Values for New Plan Information
Plan Information Value

Delivery Type VMAT
Template to Import Template: VMATTraining
Treatment Unit TRNElekAgility
Energy 6.0 FFF
Isocenter Location* Center of PTV
Monaco® 23-55
5. If your clinic uses standard beam information, set your clinic’s parameters and
NOTE: See the Template section in guide for more information on saving
templates.
Task 4. Enter Target Dose Prescription
The literature shows several dose/fractionation schemes when you treat Spine
Metastases with stereotactic body radiotherapy. However, common PTV
coverage is D90, where 90% of the PTV is covered by the prescription dose.
In this exercise, you use 16 Gy in one fraction.
1. Select the Prescription tab, and type the values in the table below for the
Physician’s Intent.
Table 23-20: Example of Physician’s Intent

Prescribe To Center of PTV
Rx Dose (Gy) 16.00
Number of Fractions 1
Fractional Dose (Gy) 16.00
2. In this exercise, you use the prescription and planning criteria.
• PTV coverage
- Prescription isodose line is usually the 80% - 90% line
- At least 90% of PTV must receive prescription dose
• High dose spillage (conformity)
- Dose outside of the target is limited to 105% to an area ≤ 2cc
- Dose ≥ 105% of prescription dose must be within a 1cm region from

the PTV edge
23-56
Task 5. Set Beam Geometry
1. Set the arc beam geometry values that appear in the table below.
Table 23-21: Example values for beam geometry
Beam Direction Gantry Arc Inc Collimator Couch

Arc Rotation Start
1: Spine CW 360 360 30 90 0

Parameters
Carlo.
exercise during class.

calculation.
.
Monaco® 23-57

Parameters (cont.)
3. For this exercise, type the Calculation Properties values that appear in Figure
23-29 below. Use 0.30 cm Grid Spacing.
23-58
Task 6. Set Calculation Properties, IMRT Prescripton Parameters and

Sequencing Parameters (cont.)
4. Type the IMRT Prescription Parameters that appear in the figure below.
Figure 23-30: IMRT Prescription Parameters
5. Next, select the Sequencing Parameters icon . Then, set the parameters with
the values that appear in the Figure 23-31.
6. Start with 150 Control Points per Arc and increase this value, especially if
during plan evaluation, you notice a conformality degrade between stage 1 and
stage 2 optimization.
Figure 23-31: Sequencing Parameters: VMAT
Monaco® 23-59

Constraints.
2. You can use a variety of approaches to set cost function constraints. The settings
below are only one of many possible uses and combinations. Begin with the
example constraints in the table below, and as you evaluate the plan, you can
adjust the cost functions as needed during and after fluence optimization. After
you evaluate the plan, determine if you want to add a constraint on the
esophagus.
Table 23-22: Example Values for Dose Constraints

Optional Physical
Structure Cost Function Required Parameters
Parameters
Target EUD 18 Gy;
0.50 Cell Sensitivity
PTV Quadratic 17 Gy;
Overdose 0.5 Gy RMS Dose Excess
Target Penalty 16 Gy; 90%
Spinal Cord + Serial Exponent: 12.0 Multicriterial; Optimize
1mm EUD: 9.0 Gy over all voxels
Patient Conformality 0.70 Isoconstraint Multicriterial
** With stereotactic planning, you want a steep dose gradient outside the target.
To achieve this gradient, you have a more heterogeneous dose distribution
inside the target volume, with hot spots of 120 – 130%. Carefully evaluate the
hot spot location within the target, and make sure it is in the center of the target
and not close to its periphery.
3. At this point, select Save Template As to keep this template in case you make
23-60
Task 8. Calculate Fluence – Optimization Phase 1
1. To start the fluence stage of dose optimization, select the Optimize icon from
the Calculation ribbon in the Planning tab.
2. Begin with loose parameters. Then, tighten isoconstraints during optimization.
3. Once stage 1 completes, evaluate the plan’s fluence.
Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-

evaluate
1. You can use a variety of methods to evaluate, and strategies to re-optimize your
plan. Apply Monaco’s Isodose tools and DVH Statistics and Details to analyze
the measures to determine dose quality relative to the target and organ at risk
sparing.
Use the example criteria below to evaluate your plan quality.
2. These qualities include:
• Dose Conformity to Target and Gradient outside the Target
- Several models exist in the literature to determine the values

associated with target dose conformity, gradient, and heterogeneity.
- For this exercise, use the model your clinic has adapted in its
procedures to evaluate the plan quality. Or, use the example RTOG
criteria discussed in the prescription task.
• Organ at Risk Sparing
Monaco® 23-61
Task 9. Evaluate Plan, Adjust Cost Functions, Re-optimize Phase 1, Re-

evaluate (cont.)
Use the table below as a guide when you evaluate how well your plan met the
normal tissue dose/volume constraints.
Structure Volume Volume Max (Gy)

Spinal Cord ≤ 0.35 cc 10Gy
Spinal Cord ≤ 0.03 cc 14 Gy
Heart <15 cc 16 Gy
Heart < 0.03cc 22 Gy
Total Lung - ITV 1000cc 7.4 Gy
Esophagus < 0.03cc 16 Gy
Esophagus < 5cc 11.9 Gy
NOTE: In this exercise, some organs at risk constraints are difficult to

meet due to target shape and proximity of normal structures to
the target.

4. Re-optimize the Fluence calculation, re-evaluate, then continue to Stage 2

23-62
Task 10. Calculate Segments – Optimization Phase 2
1. Select the Optimize 2 icon from the Calculation ribbon to start.
2. If you notice that target conformality degrades between stage 1 and stage 2
calculations, you may try to increase the number of Control Points.
Statistics & Display, and your clinic’s procedures to analyze the plan for
quality of:
• MLC Segments
• MU Summary

2. Once the plan is acceptable, continue on to plan approval and export.
Monaco® 23-63
References
References below were used for information and exercises throughout this
stereotactic section.
1. Al-Omair A, Smith R, Kiehl T-R, et al. Radiation-induced vertebral compression
fracture following spine stereotactic radiosurgery: clinicopathological
correlation. J Neuosurg Spine 18:430-435, 2013.
2. Benedict et al. Stereotactic body radiation therapy: The report of TG101.

Medical Physics, 37(8), August 2010.
3. Diot Q, Timmerman R, Miften M. Biological-based optimization and

volumetric modulated arc therapy delivery for stereotactic body radiation
therapy. Med. Phys. 39(1), January 2012.
4. Diot, Q. Webinar presentation: Advances in lung SBRT planning utilizing

radiobiological planning with Elekta’s Monaco®. Sponsored by Medical Physics
Web, June 4, 2013.
5. Foote M, Letourneau D, Hyde D et al. Technique for stereotactic body

radiotherapy for spinal metastases. Journal of Clinical Neuroscience 18 (2011)
276-279.
6. Gerszten P C, Sahgal A, Sheehan J P, et al. A multi-national report on methods

for institutional credentialing for spine radiosurgery. Radiation Oncology 2013,
8:158; http://www.ro-journal.com/content/8/1/158.
7. Guckenberger M, Sweeney R A, Flickinger R A, et al. Clinical practice of image-

guided spine radiosurgery – results from an international research consortium.
Radiation Oncology 2011, 6:172; http://www.ro-journal.com/content/6/1/172.
8. Mutter. RW et al. Dose-volume parameters predict for the development of chest

wall pain after stereotactic body radiation for lung cancer. Int J Radiat Oncol
Biol Phys. 82(5), 1783-1790, 2012.
9. Pellegrini R and Somell B. A dose comparison between Perfexion and Linac

based radiosurgery for metastases (Whitepaper). Elekta, Feb 13, 2013.
23-64
References (cont.)
10. Gevaert T, Levivier M, Lacornerie T, et al. Dosimetric comparison of different

treatment modalities for stereotactic radiosurgery of arteriovenous
malformations and acoustic neuromas. Radiother Oncol 2013; 106: 192-197.
11. Paddick I and Lippitz B. A simple dose gradient measurement tool to

complement the conformity index. J Neurosurg (Suppl) 105; 194-201, 2006.
12. Ryu S, Pugh S L, Gerszten, P C, et al. RTOG 0631 phase 2/3 study of image-
guided stereotactic radiosurgery for localized (1-3) Spine Metastases: Phase II
Results. Practical Radiation Oncology. Published online 06 June 2013. Article in
press.
13. Stanley J et al. Evaluation of stereotactic radiosurgery conformity indices for 170
target volumes in patients with brain metastases. Journal of Applied Clinical
Medical Physics, Vol 12, No 2 (2011).
14. Timmerman R, Paulus R, Galvin J, et al. Stereotactic Body Radiation Therapy

for Inoperable Early Stage Lung Cancer. JAMA. 2010; 303(11): 1070-1076.
15. Xiao Y, Papiez L, Paulus R, et al. Dosimetric evaluation of heterogeneity

corrections for RTOG 0136: stereotactic body radiotherapy of inoperable stage
I-II mon-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2009;73(4): 1235-
1242.
Monaco® 23-65
Monaco Patient Model
Volume III of IV Monaco Training Guide
1-1
You can notice the poor resolution in the uninterpolated CT image can be
noticed at the interface between high contrast media and at the external
interface.
Reference : LRMMON0001 – Monaco Dose Calculation Technical Reference
1-2
The defining points of the surface contour are noted in red. The line segment
connects the individual points for visualization
1-3
1-4
1-5
1-6
1-7
1-8
1-9
In versions prior to Monaco 3.3, the last dose voxel had the uniform density
assigned to the entire voxel.
1-10
1-11
1-12
1-13
1-14
1-15
1-16
Dose to Medium/Dose to Water
2-1
2- 2
2- 3
2- 4
2- 5
2- 6
2- 7
2- 8
2- 9
2- 10
2- 11
MU Workflow in Monaco
3-1
3-2
3-3
There are two phases of optimization in Monaco:
• Phase I: beamlet weights are optimized using the fsPB Algorithm.

• Phase II: segment weights are optimized using MC Algorithm.
These weights relate the number of MU to be delivered and the final dose
distribution.
3-4
Voxelization process  PTV projected into the BEV  Beamlets

generation
3-5
3-6
The fsPB are calculated during the modeling process. Since they are
commissioned against MC calculation, the computation is done in absolute
dose terms.
3-7
The output in the PB fitting process is:

Beamlet dose distributions are stored in terms of fitting parameters. These
distributions account for the dose contribution of each beamlet and add up
to a broad beam dose of 100 MU. Therefore, the relationship between MU
and absolute dose is obtained at this point.
3-8
3-9
To obtained a modulated dose distribution, the contribution of each

beamlet needs to be varied. This means that the beamlet MU will vary as
well. Therefore, the dose contribution of each beamlet is weighted by Φj .
3-10
3-11
Objective: Translate the continuous profiles into discrete profiles and

extract segments.
The static Sequencer performs a number of operations on the fluence

profiles in order to extract a number of field shapes. These field shapes are
then turned into proper MLC Segments.
The operations are:

• Fill&Skim: removal of small-scale irregularities
• Truncate: removal of low weight contributions
• Decomposition: decompose profile into separate peaks which
need to be delivered one after the other
• Clustering: transform the smooth profile into a piecewise constant
one with few discrete values
• Extraction: extract field shape on clustering.
3-12
First, you need to prepare the continuous profile:

1. It fills fluence dips and/or removes fluence peaks narrower than a specified
segment with Truncate fluence weights lower than the specified min MU per
segment.
Next, you need to discretize the profile:
2. Identify fluence peaks that have to be delivered in separate shots. The split
lines are put along the fluence valleys, where leaves have to be placed to
produce the gradients. The continuous fluence values are translated in discrete
steps. Only the superposition if static MLC segments can deliver these
discrete values. This result in a stair-stepped fluence weight profile. The
minimum MU per segment is the minimum discrete increment between 2
fluence levels.
Finally, extract the segments and the MU from the discrete profile:
3 The stair-stepped profiles are processed. The algorithm decomposes theses
profiles into a set of field shapes which are basically constant profiles. The
superposition of these field shapes with their appropriate MU weights equals
the stair-stepped input profile.
The MLC shape is extracted and takes into account the minimum MU per
segment. For different minimum MU values, the fluence levels and shapes
will be different as well.
At this point, the MU per segment is calculated.
3-13
3-14
3-15
3-16
3-17
3-18
The register monitor units can be physically separated into a signal due to
forward flowing particles and a signal for particles backscattered into the
monitor chamber from the upper part of the adjustable collimators.
(Therefore, it is dependent on the beam aperture A). The B factor is the
quotient between both signals.
The calibration factor should be measured separately for open beam and
the available mechanical wedges.
3-19
3-20
For motorized wedges, prior to dose calculations, the effective wedge

angle of the motorized wedged is converted into MU weights for the
wedge and open beam components.
3-21
3-22
3-23
Monaco Optimization Dose Calculation Algorithms
4-1
In this presentation, you learn about the algorithms used during the optimization
and dose calculation of segmented and arc plans.
4-2
4-3
The pencil beam model needs to include Penumbra parameters of the primary and
secondary contributions and Central axis depth dose curve information. The
truncation of beamlet tails in large field output factors is included in the depth
dose curve base data
4-4
4-5
The pencil beams include a density correction. This density correction was
verified through Monte Carlo simulations for a stereotactic lung IMRT case.
4-6
The parameters u1x , u2x , u1y , u2y ,w1 are dependent on depth in the phantom, field
size, and SSD. During the commissioning of PB, the system generates the
parameters u1, u2, w1, w2 from fitting to MC calculated profiles at 90cmSSD.
They are stored in lookup tables for depths from 0 to 30cm in 2-10 mm increment,
and for fields like 4x4, 10x10, and 20x20cm2. (Our implementation of PB uses all
measured fields and a large number of depths.)
4-7
This formula was arrived at by Monte Carlo simulations. The dose changes
introduced by the presence of heterogeneities cannot be described only by the
equivalent path length. The shape of the pencil beam changes according to the
density. A correction for the change in weight behind the heterogeneities is
applied.
Four step process:

1. Find the rescaling functions to adjust the shape of the pencil beam in order
to account for changes in ranges and lateral spread of scatter electrons and
photons . This functions are called penumbra widening factors: fu1(ρ), fu2(ρ),
fw1(ρ), fw2(ρ) for u1, u2, w1, and w2, respectively.
2. Find the u1(t), u2(t), w1(t), w2(t) in the lookup tables obtained during the
commissioning of the pencil beam in water.
3. Correct w1, w2 with: Apply factors fu1(p), fu2(p), to correct steepness
parameters.
4. Calculate dose.
4-8
Therefore, if you have a multiple beamlets incident on a point inside the patient,
the total dose is the weighted sum of all beamlets doses.
4-9
4-10
The Monte Carlo Method
For the system to be useful in radiotherapy, it must meet several criteria of which
the energy deposition is a part.
It must also accurately characterize the linac’s radiation production, its beam
modulation, and account for patient contours and inhomogeneities.
Treatment aids are accurately modeled. The algorithm uses transmission filters
through which Monte Carlo tracking does not occur when the jaws/MLCs are
modeled. The algorithm tracks particles from source to end. This is not the case
for XVMC where MC tracking starts at the patient surface.
The system tracks particles from source to end. This is not the case for XVMC
where MC tracking starts at the patient surface.
4-11
The fluence ends above the modifiers (leaves and jaws). Modifiers are a separate
part of the whole stack of models ,and you could (in theory ), replace them
independently. The algorithm uses transmission filters to model MLC/jaws.
4-12
Modules: The Fluence Engine
In a true Monte Carlo simulation, you can handle the simulation of the fluence
engine in a variety of methods.
You can simulate the entire photon production from the wave-guide, and the
electron spectrum through the bend magnet and target. You usually use the
BEAM package to do detailed head modeling and simulation. It provides the gold
standard for benchmarking codes. Or, you can begin at a specific point
downstream of the produced particles, such as the primary source or target. The
assumption is that the particle production (beyond a certain point in the linac) is
reproducible within a level of uncertainty.
4-13
The Fluence Engine: Source Model
An accurate source model requires the input of incident beam data to perform
accurate dose calculations. You can obtain the beam information directly from the
phase-space data which describes the position, energy, and direction of each
particle from a Monte Carlo simulation of the machine head. This requires large
storage space and detailed knowledge of the head geometry. This can be time
consuming and the complete information is often not available. Or, you can
extract the required information from distribution functions, such as energy
spectrum, primary and scattering fluence distributions, etc. This approach is often
referred to as Virtual Energy Fluence (VEF).
Virtual-source models are based on the fact that particles from different
components of an accelerator have significantly different energy, angular and
spatial distributions, while the particles from the same component have very
similar characteristics in terms of energies and incident directions.
Particles coming from different parts of an accelerator may be treated as if they

are coming from different sub-sources. Each sub-source represents one or more
components in the linear accelerator geometry. The system determines its
intensity, type, and geometrical dimensions by the component.
4-14
VSM 1.6 is based on three virtual sources:
• Primary Photon Source (located at the target position)

• Secondary Photon Source (located at the base of primary collimator)
• Electron Contamination Source (located in the base of flattening filter)
Note: The secondary photon source and the electron source are energy-
dependent multi-Gaussians.
The Secondary photon source is not a true Gaussian. It is a Gaussian core

with non-Gaussian rims.
Virtual Sources are described by:

• Geometrical Parameters
• Energy Spectrum Parameters
4-15
• Primary photons spectrum describes the energy distribution of the primary

photons above flattening filter.
• The modeler uses the primary parameters ENERGY-MAX, ENERGY-MIN,

B-VALUE and effective thickness of flattening filter t (calculated from A-
VALUE and Z-VALUE) to describe the spectrum. There are also other
parameters that are not controlled by the modeler ( BIN1-START, BIN1-
WEIGHT). ENERGY-MAX and ENERGY-MIN are for both primary and
secondary.
• The secondary source energy spectrum parameters are: ENERGY-MAX,

ENERGY-MIN, SEC-B-VALUE, BIN1-START, BIN-SEC-WEIGHT.
• The energy distribution changes off-axis. The phenomena is modeled by

DELTA-B-OAS and SEC-DELTA-B parameters which determine the relative
change of exponents with respect to the tangent of angle between CAX and
direction of the particle at the MC starting plane.
• Electron contamination energy spectrum parameters are : CHARGED-E-

MEAN is electron spectrum fitting parameter, NOMINAL ENERGY and
CHARGED-E-MAX, as max-min energy for electrons –ln(0.95).
• Fluence correction is either h0, h1, … or OAS table.
4-16
NOTES (continued from previous page)
• Primary photons fluence distribution is located at the target position is a

Gaussian distribution with a standard deviation PRIMARY-SIGMA (Σpri) .
• Secondary photons fluence distribution is a Gaussian distribution situated at
the base of primary collimator with a standard deviation BDT parameter
SCATTER-SIGMA (Σscat).
• Electron fluence distribution is also a Gaussian distribution with standard
deviation dependent on energy σecon(E), which is a function of a parameter
CHARGED-RADIUS(Σecon ).
• Primary fluence correction parameters are multipliers on primary photon
weight relative to central axis or Padé function coefficients' PRIMARY-H0,
H1, H2, H3, H4.
• The dose is calculated separately for each source. The total dose is the sum of
the weighted doses for subsources. Weights(or relative contributions) are
PRIMARY-PHOTONS and CHARGED-PARTICLES.
4-17
Workflow:
1. When you use measured data, the fitting (modeling) tool derives the free
parameters of the VSM.
2. Source type, energy, position, direction of particules are sampled from the
VSM. You can generate the required number of particles on the fly.
3. Particles are projected to the arbitrary plane above the collimators in which all
Monte Carlo particle histories are started. We do not construct phase –space
files from real MC simulation. It is done from the VSM parameters as
described:
• Determine if it is a photon or an electron.
• Determine if it is a primary or a secondary particle.
• Follow one particle all the way through its end, before moving to the next
particle.
• Take the next particle and do the same.
Note that in the MC implementation, there is not a complete phase that is
created and then start the patient interaction.
4. The particles are transported through beam modifiers using two "cookie cutters"
in the collimator planes and transmission probability filter in the MLC plane.
5. The system uses XVMC to calculate the dose deposited in the patient.
4-18
Beam modifiers are modeled simply and have a minimal impact on computation
time. The algorithm does not produce secondary particles during transport
through MLC.
• Transmission filters in multiple layers

• Simulate all passive effects: rounded leaf tips, stepped leaf sides
• Do not produce scattered particles: the fraction of photons scattered on the
MLC on the central axis of a 10x10 field is approximately 0.5%
• Speed increase approx. a factor 100
See the Machine Configuration section of the Appendix for more information on
how to edit the MLC Geometry Parameters and the MLC Dynamic Parameters.
4-19
4-20
Beam modifiers are modeled simple and have a minimal impact on computation
time.
4-21
4-22
The algorithm simulates particle history one particle at a time.
4-23
The Dose Engine:

Mean Free Path and Survival Probability:
In this slide, we show how to get from URNG (uniform random number
generated) to path. Exponential distribution to path gives us log function to
sample it.
• If r==0, then particle path is also 0.

• If r==1, particle path will be infinity, and it will go outside the
volume/patient.
Where:  is the probability per unit path length of a particle interaction.
4-24
Dominant Interactions in Teletherapy

In the therapeutic range of photon energies and human tissues, the prevailing types
of photon interactions resulting in energy deposition are the Compton Interaction,
Pair Production, and Photoelectric Effect respectively.
Photoelectric Effect:
Dominant in low energy photon process, the photon gets absorbed by an electron
in an atom, and lets the energetic electron escape from its orbit about the nucleus.
Low energy photons are released as the electron cloud settles into ground state.
Compton Interaction:
The Compton interaction is an inelastic interaction of a photon with an electron in
an atomic shell of a nucleus (also known as incoherent scattering, as the photon
looses energy in the recoil).
Pair Production:
Photons of sufficiently high energies can interact with the Coulomb field of an
atomic nucleus to be transformed into an electron positron pair.
4-25
Cross section is a measure of the effective surface area seen by the impinging
particles (express in units of area(1barn=10E-28m2).
Differential scatter cross sections

σ(Ω)/dΩ=number of particles scattered into solid angle per unit time divided by
incident intensity
4-26
4-27
History Repetition:
A photon reference track is simulated in an infinite homogeneous medium such as

water.
This track is then applied to the patient geometry at different interaction sites.
The application of the reference track to the heterogeneous patient geometry

requires the appropriate scaling of the step lengths and the multiple elastic
scattering angles to account for differing densities. This technique has the
potential to double the efficiency of the time taken for MC calculations.
4-28
VRT: Photon Splitting
The idea of photon splitting is to save calculation time by taking a photon entering
a region, and splitting it into several versions of itself. This lets you get more
information about the dose deposition in a given area without generating new
photons from the source.
Here, the region is not related to changes in medium or areas, but simply imply
the space before and after splitting occurs.
To keep this process statistically valid, the photon weight or its cross-section
(prior to splitting) must be equal to the total weight of the newly created photons
post-splitting.
This is a valid approach as you could achieve a similar result by simply increasing
the total number of histories at the start of the calculation, but that would be very
CPU intensive.
Photons of initial weight W0 entering a region of interest are immediately split
nsplit times.
Post-split, each split photon is assigned a statistical weight of WF . This ensures
that the photon weight pre-splitting is equal to the total weight of all post-split
photons . The interaction sites for the nsplit photons are distributed evenly along
the original photon path.
4-29
VRT: Russian Roulette

The weight of a particle is proportional to its score and what it contributes to the
final dose. If the weight is too small, the contribution from this particle is very
limited. To track it can be very expensive. Because of statistical bias, particles
with weights below a certain threshold cannot just be killed off. Instead, you play
Russian roulette with it.
To kill a particle, yet not bias the statistics, you must preserve the total weight of
the tracked particles. To achieve this, the algorithm redistributes the weight of
the killed particle amongst the remaining particles. But, rather than simply kill all
particles below a threshold, you can use a kill/survival probability to govern this
process.
1. Compare current particle weight, W, to some threshold weight, WL.

2. If W < WL, the particle is killed off according to a fixed probability Pk.
3. If a random number, n is such that n < Pk the particle is killed off.
4. If n > Pk , then the particle survives and its new weight is W´ = W/ Pk.
4-30
VRT: Truncation
Ecut:
The electron cut-off-energy or Ecut refers to both the secondary electron
production threshold energy and the transport cut-off energy.
Pcut:
Pcut is the photon energy cut-off parameter. If a scattered photon has energy less
than Pcut , it is not transported. The energy is deposited locally. The smaller the
Pcut, the more accurate the results.
There are two possible criteria to select Pcut: (1) the MFP of photons with energy
equal or less than Pcut is small compared with the voxel sizes, or (2) the energy
fraction carried by photons with energy less than Pcut is negligible compared with
the energy fraction deposited. In the latter case, you can deposit the energy of cut-
off photons locally or ignore them altogether. In Monaco, the voxel size is
employed as the criteria.
4-31
Refer to the Monaco Dose Calculation Technical Reference for more information
on Monaco’s Dose Calculation Algorithms. Appendix B of the Monaco Dose
Calculation Technical Reference shows the results of measurements done to test
the accuracy of the algorithms.
4-32
Monaco assigns interaction probabilities and stopping powers to each voxel based
on its mass density. Monaco’s XVMC algorithm calculates dose based upon mass
density (in g/cc). It converts CT numbers to ED numbers using the user-defined
CT-to-ED file.
4-33
Material composition: Cross-sections are stored for soft-tissue like and bone-like
materials and corrected depending on mass density (from CT scans).
4-34
You do not need to discriminate between tissue types with different material
compositions. The dose calculation requires only a properly calibrated CT.
4-35
In this presentation you learned about the algorithms used during the optimization
and dose calculation of segmented and arc plans.
4-36
Electron Monte Carlo Algorithm
5-1
In the energy range typically used for radiotherapy, electrons go through

approximately one (1) million interactions before they are absorbed. When
you look at the dose calculation for electron beams ,you have to look into the
scatter interactions. Scatter interactions are mainly due to Möller Scattering,
Bremsstrahlung, ionization energy loss, and multiple scattering.
5-2
The depth dose curve shown at the top right is typical for electron beams in
contrast to photon beams. There is a relatively quick buildup, and then a
plateau area in depth dose curve followed by a steep, almost exponential,
decrease. There will be a long exponential Bremsstrahlung tail caused by
contaminant photons. The cross profiles you see are typical for electrons with
the drop shaped isodoses and, depending on linac model, some horns at the
edge of the profile.
5-3
Typical calculation times for Electron Monte Carlo beams with the BEAM
algorithm (the benchmark) are on the order of 10 hours to several days. This is
not a clinically usable timeframe. In these calculations, scatter particles make
up 10-20% of the total beam fluence and you have to account for them. The
graph above shows a depth dose curve for an 18 MeV beam along with the
different components which make up the total dose. Those components
include Direct electrons, scatter from the applicator, scatter from the jaws,
photon (Bremsstrahlung) background radiation, and secondary scatter
electrons.
5-4
The advantages of using eMC over other algorithms such as the pencil beam
algorithm include accuracy, efficiency (at least with modern algorithms and
hardware). It is relatively easy to implement new treatment techniques such as
electron MLCs. Also, the Monte Carlo algorithm, like the collapsed cone
algorithm for photons is volume oriented. So, dose to the full volume is
obtained in a single calculation.
5-5
You have two challenges when you calculate dose. First, you have to create
the beam which is formed by complicated geometry in the linac treatment
head (high z materials such as copper, aluminum and lead). After the beam
enters the patient you have to consider low z materials such as hydrogen,
nitrogen and carbon. The patient is represented in a regular electron density
grid based on the CT image. At interface (beam/phase space is used). The
phase space is represented as a stream of particles with certain properties.
This is discussed in detail later in the presentation.
5-6
Monaco uses a coupled multisource phase space engine. This is a model

developed in the Upsalla office in Sweden. One advantage is you have full
control over the beam characterization. The beam characterization is done by
software called TUC. The dose is calculated in the patient using the VMC++
code. This code was developed by Iwan Kawrakow and is the current state-of-
the-art Monte Carlo code. You can use it for both electrons and photons. The
code is licensed from the National Research Council in Ottawa, Canada.
5-7
When you look at electron components calculated by the algorithm, as

mentioned earlier, approximately 5%-15% of the dose comes from indirect
electrons and 1-7% from Bremsstrahlung photons. In the graph above, you
can see a comparison of dose calculated by the eMC algorithm compared to
measured dose. The blue line is direct electron dose, and the purple line is
Bremsstrahlung photons. The noisy black curve shows Gamma. You can also
see dose from the scattered (indirect) electrons. This same information is
shown in the depth dose curve on the right of the slide. You can see the lowest
part of depth dose curve is magnified so you can see the bremsstrahlung
photons. This portion resembles a photon depth dose curve.
5-8
Now, you will look in detail at the coupled multi-source electron beam model.
5-9
A typical electron treatment looks approximately like this. Typically, a dual

foil technique is used to shape the beam at the isocenter plane. The secondary
scatter foil can have different thicknesses and vary by energy. The jaws and
possible the MLC come after the scattering foils. With exception of Siemens,
the MLC will be retracted in electron mode. The applicator contains 2-4
layers. A patient specific insert can be placed at the lowers layer. This model
should work for a single foil technique, although that situation has not been
tested.
5-10
The electron beam is modeled by three components, direct electrons, indirect

electrons and Bremsstrahlung photons. In the patient, both electron
components are transported using the VMC++ code.
5-11
The exit phase space has six (6) degrees of freedom (see the red plane on
previous slide). Other parameters such as charge and mass can be ignored
because they are identical for electrons.
5-12
You split the treatment head model into two phase spaces. You start with a
source phase space which is independent of the applicator. The source phase
space only depends on energy setting. Then, you transport (propagate)
particles from source phase space using Monte Carlo code through the jaws
and the applicator down to the exit phase space.
5-13
Although you have only one source phase space for each energy, and the
source phase space is the same for all applicators (but specific for each
applicator energy), you have different exit phase spaces.
5-14
Exit phase space components are the electrons (direct fluence) which have not
interacted with any collimating elements but gone straight through to the
patient, indirect fluence (electrons emitted from collimating elements) and the
bremsstrahlung photons are generated from the treatment head.
5-15
5-16
For the energy distribution, the energy spectrum of the electron beam model is
based on measured, open field (no applicator) depth dose curves. This energy
spectrum is then modeled by fitting a calculated depth dose to a measured
depth dose. This is different from photons, because there, you model the
spectrum directly. Here, you model a depth dose curve. The applicator is not
present, so there are no indirect electrons. You only consider direct electrons
and bremsstrahlung photons. You exclude the surface region because
measurements are not accurate enough and you do not have electronic
equilibrium.
5-17
The Spectrum function is a two-sided Woods-Saxon function with a linear

low energy tail. You can see the top equation describes the tail function. The
function is set to zero above and below the cut-off energies.
5-18
The Woods-Saxon parameters are stored in a ‘spectrum file’. This is different

from Monaco. The files are only used to transport the beam data from the
processing system to the user’s system. The information is then implemented
into an SQL database.
5-19
Because of what was mentioned, the energy spectrum for direct electrons is
derived from open field depth dose curves measured without applicators. That
means all applicators use a common direct electron spectrum. So, all
differences between open and non-open fields are due to indirect electrons,
and also for small fields there is a loss of lateral charge activity. You also
assume that the spectrum is independent of the lateral position, so you use the
same energy spectrum over the whole applicator exit plane. That means that if
there is a depth offset between the open field and applicator depth dose scans
a corresponding depth, an offset will occur in the verification calculations.
Therefore, it is important to make sure there is no depth offset between the
two sets of measurements.
5-20
5-21
When you look at the spatial/angular distribution of the source phase space,
you start with the scatter foils. An older technique was to use only a single
scatter foil, which if you want a broad enough beam, required relatively thick
foils resulting in significant energy loss. All modern linacs use the dual foil
technique. A thin primary foil and varying thickness secondary foil are used.
The total material thickness can be significantly reduced by this technique.
5-22
The primary foil is usually a high z material. The secondary foil is usually a
lower z material such as aluminum. The primary foil can be found 0-10 cm
downstream from geometrical focal point.
5-23
These are typical secondary scattering foils.
5-24
When you look at treatment head designs, you see differences depending on
linac manufacturer.
5-25
As building blocks for source phase space, you need:
1. Plane near secondary scattering foil

2. Beam atoms with average direction and gaussian angular spread
3. Virtual source point
4. A lateral fluence distribution which is equivalent to the beam atom weight
5-26
The source phase space is specified by an energy spectrum and five

parameters. The parameters a and b describe the linear radial dependence of
the beam atom gaussian angular spread. The source phase space fluence is
proportional to the energy spectrum, lateral fluence, and angular distribution
for an area inside the source phase space disk. Outside, you set the source
phase space to zero.
5-27
When you process beam data, you have to find source phase space parameters
that match the measurement as close as possible. This is done by optimizing
simulated (calculated) in air fluence profiles with measured fluence profiles.
You typically look at the above field sizes/energies and two different SSDs
(detector distances). Source detector distances are measured in air. These
different field sizes are not shaped by applicators, but by the existing jaws.
You also require X and Y profiles using as small as detector as possible for
the same field sizes. The simulation does not use the VMC++ code. Instead, it
uses the QMC code.
5-28
Here are some typical results comparing the measured data to the simulated
data.
5-29
data.
5-30
data.
5-31
Next, you look at Exit Phase Space.
5-32
Exit Phase Space is found by propagating the source phase space to the exit
phase space plane using the QMC Monte Carlo code. In this code, you use
one in air step with multiple scattering per collimating layer. So, from each
layer to the next is one step with multiple scattering.
5-33
The direct part of exit phase space is parameterized by the fluence distribution
obtained by scoring the position of direct electrons when they reach the exit
phase space plane. Direct electrons do not interact with the applicator or jaws
so they travel directly to the exit phase space plane. You assume an effective
source of a Gaussian distribution with an angular spread with radially varying
width and source distance. This is obtained by scoring exit fluence angles on
annular rings.
5-34
Here, you see some typical exit phase space angular distributions.
5-35
Next, you look at the indirect fluence. Indirect fluence is caused by electrons
being scattered at the applicator or collimator rims. While you propagate the
fluence for direct electrons, you can also score those electrons which hit one
of the applicators. At run time of the dose calculation, this pre-calculated
result is used for sampling indirect electrons from pre-calculated scatter
kernels and transporting them to the exit phase space plane. Therefore, this
part of the simulation is done during beam data processing. The kernels are
generated at that time. During dose calculation, these kernel results are
propagated down to the exit phase space plane.
5-36
These collimator scatter kernels were calculated with the EGSnrc code on an
edge geometry. The algorithm distinguishes between the two different kernels,
an inner edge kernel and a front face kernel. The kernels are scored in
direction and energy.
5-37
Here, you have a typical example of 12 MeV inner edge and front face kernel.
5-38
Here, you have the final results for a Siemens 9 MeV 10x10 applicator.
5-39
When you look at the dose calculation, there is a problem with MC. Typical
electrons under go ~1million interactions. Even on today’s computers, a
complete event-by-event is impossible in clinically acceptable calculation
times. You need to find shortcuts which cut the calculation time. The next
slides show two examples of shortcuts used in VMC++ code.
5-40
The Condensed History Technique (also called Class II Monte Carlo) was
introduced in roughly 1963. It is based on the observation that you can group
many of these individual scatter and transport groups into one group.
5-41
The other short cut is called STOPS, Simultaneous Transport of Particle Sets.
5-42
The idea is you have several particles with the same energy, but which may
vary in other parameters such as position, direction, and weight. This allows
you to calculate all material independent quantities (interpolation indices,
azimuthal angles, maximum acceptable step-lengths) once for the whole set,
because if they have the same energy, these parameters are identical.
5-43
Material dependent quantities must be sampled separately. The advantage of

this technique is that it involves no approximations. The algorithm can be
applied to arbitrary materials.
5-44
5-45
Here is a graph showing the results on the accuracy of the algorithm. This is a
benchmark on an aluminum and lung phantom. This represents the dose
difference in % of dmax. Within this phantom, the maximum deviations are at
the Al/lung interface with approx 0.6% maximum error.
5-46
If you look at a high z material, you also have comparing to EGS and VMC++
almost identical results.
5-47
This VMC++ is a class II Monte Carlo algorithm. The results are within sub
percent error agreement with EGS benchmark code. But, dose is calculated
50-100 times faster than EGS 4 code due to the modifications discussed in this
presentation. Typical electron fields are field calculated in less than a minute.
Typical photon fields would need a couple of minutes if the algorithm were
used for photons.
5-48
Head Model and Collapsed Cone Proton Algorithm for 3D Calculations
6-1
6-2
6-3
6-4
6-5
6-6
6-7
6-8
6-9
6-10
6-11
6-12
6-13
6-14
6-15
6-16
6-17
6-18
6-19
6-20
6-21
6-22
6-23
6-24
6-25
6-26
6-27
Monaco Optimization Processes
7-1
7-2 7-2
Why do we need two phases, and what is the point in optimizing undeliverable
fluence profiles first?
• The solution space needs to be explored in an interactive manner. MLC
sequencers and precise dose calculation are too slow.
• It is a long way to go from coarse field shapes to the patient-specific optimum
fluence distribution. It is very easy to get trapped in local minima when
directly optimizing field shapes. Therefore, Monaco uses a two step process.
• Because Monaco optimizes Dose Weights, you are able to see actual monitor
units at the end of Optimization Stage I.
• You can skip back to the previous steps at any point in the optimization. If you
skip back at the end of Stage I, you can adjust the calculation parameters and
cost function properties. You can then reoptimize to better meet the objective
doses and plan intent.
• If you skip back once at the end of Stage II, Monaco resets the optimized
segments back to optimized fluence. You can then edit the segmentation
parameters and generate new segments.
• If you skip back twice at the end of Stage II, you are brought back to the
beginning. You can adjust the calculation parameters and cost function
properties. You can then reoptimize to better meet the objectives doses and
plan intent. You will have to regenerate segments after you reoptimize.
7-3
• Each dose element has its own weight. For example, if a segment has 4.5
MU, its weight is 0.045.
• The total dose obtains as a weighted sum of the doses.
7-4
7-5
• In optimization, Quasi-Newton methods (also known as variable metric

methods) are algorithms for finding local maxima and minima of functions.
Quasi-Newton methods are based on Newton's method to find the stationary
point of a function, where the gradient is 0. Newton's method assumes that the
function can be locally approximated as a quadratic in the region around the
optimum, and use the first and second derivatives (gradient and Hessian) to
find the stationary point.
• In Quasi-Newton methods, the Hessian matrix of second derivatives of the

function to be minimized does not need to be computed. The Hessian is
updated by analyzing successive gradient vectors instead. Quasi-Newton
methods are a generalization of the secant method to find the root of the first
derivative for multidimensional problems. In multi-dimensions, the secant
equation is under-determined, and quasi-Newton methods differ in how they
constrain the solution, typically by adding a simple low-rank update to the
current estimate of the Hessian.
• The disadvantages are that this approach requires second derivatives and the
solution of a linear equation can be too expensive for large scale applications.
7-6
• In mathematical optimization, the method of Lagrange multipliers (named

after Joseph Louis Lagrange) provides a strategy for finding the maxima and
minima of a function subject to constraints.
• For instance, consider the optimization problem.

– maximize f(x,y)
– subject to g(x,y)=C( constraint function of x, y)
• We introduce a new variable lamda called a Lagrange multiplier, and study

the Lagrange function defined by Λ(x,y,lamds)=f(x, y) + lamda(g(x,y) –C)
where the lamda may be either positive or negative. If is a maximum for the
original constrained problem, then there exists such, that is a stationary point
for the Lagrange function (stationary points are those points where the partial
derivatives of Λ are zero). However, not all stationary points yield a solution
of the original problem. Thus, the method of Lagrange multipliers yields a
necessary condition for optimality in constrained problems.
7-7
7-8
For more detailed information regarding the dose voxel sampling process, refer to
LRMMON0001.
7-9
If 50% of a voxel is inside the contour, Monaco considers it to be part of the

structure and will include it in the optimization of that structure. Otherwise,
Monaco does not assign the voxel to that structure.
7-10
This slide contains a voxel in 3D divided into 27 subvoxels. Sampling is done in

the center of each of the 27 subvoxels. If the subvoxel is centered on a real slice,
then you use the information from the contour to determine the subvoxel
occupancy.
7-11
7-12
You can sum abutting pencil beam kernels to produce the open field dose
distribution in a phantom. The MLC geometry dictates the shape/dimension of the
beamlet. The beamlet computation time must be reasonable, properly predict the
penumbra anywhere in the field, and be able to be commissioned from broad-
beam measurements.
References:
1. Jelen U, Sohn M, Alber M “ A finite size pencil beam for IMRT dose
optimization’, Phys. Med. Biol. 50(2005), 1747-1766.
2. Jelen U, Alber M “A finite size pencil beam algorithm for IMRT dose
optimization: density corrections’, Phys. Med. Biol. 52(2007), 617-633.
7-13
7-14
This example illustrates a table of field margins and dose deposition thresholds.
7-15
It is necessary for you to use a wider field margin because typical beamlet size is
10*2 to 10*4 mm^2, where 10 is leaf width, and 4mm is step in leaf travel
direction. Therefore, when you set the margin, you want to compensate for the
beamlet’s rectangular shape. So, if the leaf travel direction margin is 8mm and it is
covered by two beamlets, then perpendicular to the leaf travel direction, you want
to have at least one beamlet. As a result, with ellipticity of 1.4 and margin of
11mm, you do well with a beamlet size of 10mm.
7-16
7-17
7-18
After you apply the dose criterion, the outline can appear ragged. This is a
consequence of the discrete nature of the dose and beamlet grids. For each
beamlet included in the provisional grid, the dose distribution is computed by the
finite pencil beam algorithm.
7-19
7-20
Definition:
• If a cost function is treated as a CONSTRAINT, the optimizer tries to keep the

actual value of the cost function smaller or equal to a prescribed constraint set
point (the iso-constraint). It may not be possible to achieve all constraints
simultaneously, especially if both DLC and DIC cost function are present.
• If a cost function is treated as an OBJECTIVE, the optimizer tries to maximize
the actual value of the cost function. A prescribed set point does not act as a
hard constraint, but does assign a relative importance to the objective, that is,
if the prescription is low, the optimizer works less hard to achieve it.
• Optimization modes offer different mechanisms to handle constraints with
different priorities and to resolve situations where constraints mutually
exclude themselves.
7-21
This slide shows the actual formulas used to calculate the isoeffects.
7-22
7-23
In mathematical optimization, the method of Lagrange multipliers provides a

strategy for finding the maxima and minima of a function subject to constraints.
If a cost function is managed by the optimizer, it aims to adjust the weight factor
such that Eq. 1, 2 are valid. The weight factor is subject to limits that control its
minimum and maximum size. These limits depend on the optimization mode, the
cost function type and user-selectable properties of the constraints. If a constraint
is hard to fulfil, the optimizer will increase its weight. Conversely, if it is easily
fulfilled, its weight is reduced. If a weight factor reaches its maximum limit, it is
labelled as INFEASIBLE.
The Lagrange Multipliers (lambda) tell you how a constraint affects the
optimization. If you relax a constraint, you will get a corresponding result.
7-24
7-25
Constrained (Normal Tissue Priority) - This is the default optimization mode

for Monaco. This option sets constraints on healthy tissue while it administers
dose to target volumes.
Pareto (Target Volume Priority) - When you select this option, Pareto Mode
effectively reverses how Monaco normally works. Pareto mode relaxes constraints
on healthy tissue and prioritizes target underdoses on tumor volumes.
7-26
At the end of optimization, if you sample the fluence in the BEV, the actual MUs are
displayed for each beamlet. Note the 4.92 value at the cursor location.
7-27
• From the fluence profiles to the segments
7-28
7-29
7-30
7-31
7-32
7-33
7-34
7-35
7-36
7-37
7-38
7-39
7-40
7-41
7-42
7-43
• The console shows a ‘0’ in the third column for Cost Functions with a Status of
‘Off.’ This column shows the final weight factor or Lagrange multiplier. Target
objectives always have a weight of 1. The console shows all target objectives as
‘L:value’.
• The fourth column is the final cost. A final cost of 0 means the goal is achieved,
<0 means the goal is overachieved or not taken into account, >0 means the
optimizer failed to reach the goal.
• The fifth column (IC) is the Isoconstraint. The constraint with the greatest
weight factor has the greatest influence on the result.
• The sixth column (IE) is the Isoeffect. When an isoeffect is smaller than the
prescription, its final cost is greater than 0.
• The maximum constraint violation is the convergence criterion.
• The constraints in this example are “active.” Some constraints may be too easy
to achieve and therefore do not influence the result.
• Their final cost is much smaller than 0. Their weight factors are small (but they
cannot drop below 0.01). These constraints are “slack.”
7-44
After you select to generate segments, the system checks leaf constraints and
adjusts leaves which are positioned illegally. The dose calculation then starts. This
is where the Monte Carlo simulation starts. Up to this point, the doses have been
calculated using the Pencil Beam algorithm.
7-45
Setting the Couch Densities
Elekta gives you a test beams package with predefined MLC shape and configuration
for you to use to evaluate your machine. You use this package in this exercise. The test
beam package is modeled after the recommendations in the AAPM TG-119 protocol.
In this exercise, you use the Elekta MLC beam model test beams to learn what tools are
available in Monaco. There are two plans available:
1. ExpressQAPlan: This plan contains eight beams. You can use these eight
beams to check and tune the model’s MLC parameters. You use these beams
in the MLC Parameters Exercise.
2. FullPackage: This plan contains 34-35 beams, which includes several beam
configurations, and includes oblique beams and Arc beams. The physicist can
use the beams to run comprehensive QA. You use the one of these beams to
determine the couch densities.
Open the Full Beams Package

1. Run Monaco to open a patient.
2. Click 30x30x30, Monaco in the Patient Selection dialog box on the Local Patient
tab.
Figure 8-1: Patient Selection dialog box
Monaco® 8-1
Open the Full Beams Package (cont.)
3. Click OK.
4. In the Workspace Control, there are QA plans: “ExpressQAPlan” and

“FullPackage” for Elekta, Siemens and Varian machines. You can use the plan
“ExpressQAPlan” for MLC offset tuning. The plan “FullPackage”contains more
beams. You can use it for comprehensive QA. You use the plan
“ExpressQAPlan” in the first part of this exercise. Click on FullPackage for the
MLC Model for the MLC model you have and select Load into Planning from
the mouse menu.
Figure 8-2: Workspace Control
8-2
Save the Plan as a Template
You must save the plan as a QA template before you can place the beams on your
phantom and use your beam models. The template is saved as a QA Template. You
must first create a dummy QA Plan, so you can import the QA Template onto the QA
Plan.
1. Click the Monaco Application button and select Save Template As from the
menu.
Figure 8-3: Save Template as icon
2. Type QAFullPackage in the Template Name field. The description is optional.
3. Select Other in the Anatomical Site field.
Figure 8-4: Save Template As dialog
4. Click Save to save the template. Since the original plan is a QA Plan, Monaco
saves the template as a QA template.
5. Select the Close Patient button to close the patient. Select No to saving the
changes.
Monaco® 8-3
Create the Dummy Plan
1. Select the Open Patient button to open the list of available patients.
2. Select the Patient with the Patient ID MapPHAN2.
Figure 8- 5: Patient Workspace
3. Click OK to load the patient.
4 Click on SS_MapPHAN2 and select New Monaco Plan from the mouse menu.
Monaco shows the New Monaco Plan dialog box.
5. Set the Delivery to 3D.
6. Set the Anatomical Site to All.
7. Select the Template: DEFAULT3D1beam.
8. Select a Treatment Unit, Modality, Algorithm and Energy.
8-4
Create the Dummy Plan (cont.)
Figure 8-6: New Monaco Plan dialog
9. Click OK. Monaco creates the plan.
Monaco® 8-5
Here are the steps to add a couch to the phantom, if a couch is not present on your
phantom.
10. (Optional) Click the Plan Options tab.
11. (Optional) Click the Import Positioning Device button.
12. (Optional) Select the couch TrainingSetDensities.
13. (Optional) Click OK. Monaco adds the couch to the plan.
Figure 8-7: Import Treatment Couch
14. (Optional) Click Done to accept the default couch position.
15. (Optional) Click the Planning tab.
16. Click the Calculate button to start the dose calculation.
17. Click Yes to save the studyset changes.
8-6
18. When dose is calculated, click the Monaco Application button and select
Save Plan As from the menu.
19. Type a Plan Name.
21. Click the New Plan button and select New QA Plan from the drop down
menu.
22. Use these parameters to setup the QA Plan:
Phantom QA Clinic: MapPHAN2

Calc Vol Grid Spacing (cm) 0.3
Statistical Uncertainty (%) 0.5, per Control Point
Calculate Dose to: Water
Include Beams from Rx ID: A
23. Click OK. Monaco creates the QA Plan.
24. Click the Import Plan Template button.
25. Click the Remove all existing beams prior to importing new beams option.
26. Set the Delivery field to QA.
Monaco® 8-7
27. Select the FullPackage template you just saved. If necessary, assign the
Treatment Unit and energy. If this is in your clinic, select your treatment unit.
Figure 8-8: Import Template into Existing Plan window
28. Click OK. Monaco loads the template.
8-8
Remove All Unnecessary Beams
1. Click the Beams tab on the Planning Control.
2. One by one, click on beams 1-22 and 24-34 and delete them. Use the Delete
Beam button. Do not Delete Beam 23, G225.
3. In the Delivery column, select Static.
Figure 8-9: Beam 23 is setup as a Static Beam
5. Click the Force ED option for the Carbon and Foam structures. These are the
structures which make up the couch.
6. Set the Relative ED of Carbon to 1.2 and the Relative ED of Foam to 0.02.
Figure 8-10: Define the Structure Densities
7. Click the Calculate button to calculate dose.
9. Type a Plan Name of G225.
Figure 8-11: Save Plan As window
Monaco® 8-9
Remove All Unnecessary Beams (cont.)
12. Click the Dose Plane button.
13. Select to export the Coronal slice at a position of 0.00 cm.
Figure 8-12: Dose Plane Output dialog
14. Click the Individual Beams option.
15. Click OK. Monaco exports the dose planes to the

C:\.....\CMS\FocalData\DosePlanes directory. You can add this directory as a
networked drive to the system on which you have your QA software installed.
16. Import the exported dose plane and measured data into the QA Software. In the
training class, you use the SunNuclear MapCheck software and Elekta’s data to
evaluate the exported dose planes.
8-10
Edit the Couch Densities
Due to Monaco creates voxels out of the couch structure, the carbon density of 1.2
does not give you acceptable QA results. You have to edit the density of the Carbon to
get acceptable results.
1. Return to Monaco and open the QA Plan G225.
2. Click the Structures tab of the Planning Control.
3. Edit the Relative ED of the Carbon to be 0.4.
Figure 8-13: Set the Relative Electron Density
7. Type a Plan Name of G225.
Figure 8-14: Save Plane As window

9. Answer Yes to override the saved plan.
11. Click the Dose Plane button.
Monaco® 8-11
Edit the Couch Densities (cont.)
12. Select to export the Coronal slice at a position of 0.00 cm. Click the Individual
Beams option.
Figure 8-15: Dose Plane Output dialog

14. Import the exported dose plane and measured data into the QA Software. In
class, you use the SunNuclear MapCheck software and Elekta data to evaluate the
exported dose planes.
8-12
Post Modeling Adjustment of MLC Parameters
Elekta creates a beam model for you using your measured data. When Elekta sends you
the model, you must do acceptance testing before you use it in your clinic. As part of
the acceptance testing, the Elekta global product support physics team suggests that you
run post-modeling adjustment to better characterize the MLC per the actual settings of
the LINAC used in your clinic.
This exercise walks you through how to adjust MLC parameters in Monaco. This
document and its accompanying files are not and should not be considered as any form
of recommendation from Elekta on what constitutes a complete Monaco model
commissioning.
Elekta provides a test beams package with predefined MLC shapes and configuration so
you can use them to evaluate your machine. This package is used in this exercise. The
test beam package is modeled after the recommendations in the AAPM TG-119
protocol. In this exercise you will use the Elekta MLCi beam model test beams to learn
what tools are available in Monaco. There are two plans available:
• ExpressQAPlan: This plan contains eight beams, you can use these eight
beams to check and tune the model’s MLC parameters.
• FullPackage: This plan contains 34~35 beams, which includes several beam
configurations, including oblique beams and Arc beams. The physicist can use
the beams to run comprehensive QA.
The beams are organized as a single plan for DICOM RT Plan export purposes. You
can export all beams to R/V system or RT Desktop at one time. When you start to
calculate the beams, you can keep the beams that interest you. You then delete all other
beams from the original QA plan. Save the remaining beams as a new QA plan. This is
an important step, so you can calculate the beams of interest with the proper MC
Variance value. This saves you time, since you will not calculate clinical test beams with
a too-small MC Variance.
Monaco 9-1
Table 9-1: List of the beams in “ExpressQAPlan” for Elekta MLCi/MLCi2 machine
# Description Beam Configuration Comments
1 3ABUT Three 6x24cm abutted segments To check MLC major offset.
2 20x20 MLC + Jaw 20x20cm field To check field flatness, symmetry,
QA device detectors response.
3 10 x 10 MLC + Jaw 10 x 10cm field To check absolute dose calibration.
4 DMLC1 Jaw20x20, MLC2x20, -10>+10 To check MLC leaves major and
minor offset.
5 HIMRT A 33 segments HN IMRT beam To check IMRT performance.
6 HDMLC A 33 segments HN DMLC beam To check DMLC performance.
7 7SegA 7 segments 2 x 24cm beam A typical picket fence beam.
8 FOURL 4 "L" MLC Segments, Jaw20x20 To check MLC offset, leaf groove,
MLC transmission.
You can calculate the two clinical beams “HIMRT” and “HDMLC” with MC Variance
2~2.5%. Calculate all other beams with MC Variance 0.5%.
Refer to LRMMON0003 for the beams summary for other types of MLC.
9-2
Open the Test Beams Package

1. Run Monaco to open a patient.
2. Click 30x30x30, Monaco in the Patient Selection dialog box, in the Local Patient
tab.
Figure 9-1: Patient Selection

3. Click OK.
4. In the Workspace Control, there are two QA plans: “ExpressQAPlan” and
“FullPackage” for each MLC type. You can use the plan “ExpressQAPlan” for MLC
offset tuning. The plan “FullPackage”contains more beams. You can use it for
comprehensive QA. You use the plan “ExpressQAPlan” in the first part of this
exercise. Click on ExpressQAPlan for your MLC type and select Load into
Planning from the mouse menu.
Monaco 9-3
Open the Test Beams Package (cont.)
Figure 9-2: Workspace
9-4
Save the Plan as a Template
You must save the plan as a template before you can place the beams on your phantom
and use your beam models. The template will be saved as a QA Template. You then
create a dummy QA Plan, so you can import the QA Template onto the QA Plan.
menu.
Figure 9-3: Save Template As Menu option

2. Type QAExpressPlan in the Template Name field. The description is optional.
Figure 9-4: Save Template As dialog box

4. In the Workspace, click on the FullPackage plan and select Load into Planning
from the mouse menu.
5. Answer No to saving your changes.
6. Click Yes to use the Treatment Unit QASynergy.
menu.
Monaco 9-5
Save the Plan as a Template (cont.)
Figure 9-5: Save Template As Menu option

8. Type FullPackage in the Template Name field. The description is optional.
Figure 9-6: Save Template As

9. Click Save to save the new template.
10. Select the Close Patient button to close the patient. Select No to saving the
changes.
11. Select the Open Patient button to open the list of available patients.
12. Select the Patient with the Patient ID VirtualArcPlug.
Figure 9-7: Workspace

14. Click on SS_ACPlug27cm and select New Monaco Plan from the mouse menu.
15. Set Delivery to 3D.
9-6
16. Select the Template: DEFAULT3D1beam.

17. Select a Treatment Unit, Modality, Algorithm and Energy.

18. Click OK. Monaco creates the plan.

21. When dose is calculated, click the Monaco Application button and select Save
Plan As from the menu.
22. Type a Plan Name.
24. Click the New Plan button and select New QA Plan from the drop down
menu.
Monaco 9-7
25. Use these parameters to setup the QA Plan:
Phantom QA Clinic: ACPlug27cm

Calc Vol Grid Spacing (cm) 0.3
Statistical Uncertainty (%) 0.5, per Control Point
Calculate Dose to: Water
Include Beams from RX ID A
Figure 9-9: New QA Plan

26. Click OK. Monaco creates the QA Plan.
27. On the Planning Tab, click the Import Plan Template

button.
28. Set Delivery to QA.
29. Set Anatomical Site to All.
9-8
30. Select the Remove all existing beams prior to importing new beams.
31. Select the QAExpressPlan template. If you were in the clinic, at this point you can
change the Treatment Unit to your Treatment Unit. For this exercise, choose the
QASynergy Treatment Unit.
32. Click OK to load the template.
Figure 9-10: Import Template into Existing Plan

33. The imported template contains eight (8) beams. In the training, you use different
beams to test different parameters.
34. Click the Monaco Application button and select Save Plan As from the
menu.
35. Type a Plan Name of AllBeams. Click Save to save the plan. At this point, you
have a plan that contains the Express QA Beams. You will use the different plans to
evaluate the MLC parameters.
Monaco 9-9
Evaluate the First Beam

2. Evaluate the beams in small groups. You only have to wait for a couple of beams to
calculate at a time.
3. Highlight Row 8 (the beam with Description FOURL).
4. Click the Delete Beam button to delete Beam 8. Repeat this for beams
2-7. You will have Beam 1, 3ABUT left on the plan.
Figure 9-11: Beams
Figure 9-11: Planning Control - Beams tab

5. Select the Calculation Properties button.
6. Type 0.1 for the Statistical Uncertainty (%), Per Control Point.
7. Click OK to save the change.
9-10
Evaluate the First Beam (cont.)
8. Click the Calculate button to start the dose calculation. Wait for the dose
calculation to finish.
menu.
10. Type a Plan Name of 3ABUT.
11. Click Save to save the plan. At this point you have a plan that contains the 3ABUT
beam with calculated dose. You will evaluate the MLC parameters using the
different plans.
12. The first parameter you evaluate is MLC Major Leaf Offset. The Major Leaf Offset
is the offset of the leaf bank from the central axis of the beam.
14. Click the Dose Plane button. Monaco Shows the Dose Plane Output dialog
box.
15. Select to export Coronal Planes as Individual Beams.

17. Import the exported dose plane and measured data into the QA Software. In class,
you use the SunNuclear MapCheck software and Elekta data to evaluate the
exported dose planes.
Monaco 9-11
Tune the MLC Offset
Step 1: Check MLC Calibration
Evaluate MLC offset with “3ABUT”. This is a three-abutted 6x24cm segments beam.
Evaluate MLC bank major offset with AB or X direction profiles. Below is a picture that
shows the measurements of this beam on two LINACs.
Figure 9-14: MLC Major Offset Difference as Shown In 3ABUT measurement

Both LINACs are Elekta MLCi2 machines. In the comparison of 3ABUT beam
measurements, it clearly shows that LINAC1 has negative major offset in terms of MLC
bank, while LINAC2 has positive major offset. If you deliver the same VMAT/DMLC
beam, due to this offset difference, the delivered dose difference can be up to 8%, even if
both LINACs are calibrated the same in terms of dose rate, beam quality index and
profiles. So, it is important to evaluate the major offset correctly.
9-12
Tune the MLC Offset
Step 1: Check MLC Calibration (cont.)
In clinics that have two or three matched LINACs, the match is conventionally referred
to as PDDs and Profiles, but the MLC major offset of the two LINACs may not be the
same. It is important for the physicist to use the above method to check the match
status of MLC between or among the matched LINACs.
The MLC Offset is a tunable parameter within Monaco. The range is from -0.50mm to
+0.50mm. You can change the offset value to account for the actual position of MLC
bank.
Editing the MLC Offset in Monaco
1. If the MLC Offset needs changing, return to Monaco.

2. Click the Close Patient button in the Quick Access toolbar. You cannot access
many of the Settings while a patient is open.
3. Select the Monaco Applications button. Select Settings from the

menu.
4. Click the MLC Geometry option. You edit the Leaf Offset (mm) on this dialog
box.
5. Click OK to save the edit. You must then open and recalculate the treatment plan
to apply the changes.
Monaco 9-13
Tune the MLC Offset
Editing the MLC Offset in Monaco (cont.)
Figure 9-15: Settings window
6. Click the Open Patient button to show the Patient Selection dialog box.
7. Click the Patient ID ACplug27cm.
9. Click on the saved 3ABUT plan and select Load into Planning from the mouse
menu to open the plan.
11. You need to make a change to the plan to enable the dose calculation. In Planning
Control, edit the X(cm) value and then change it back to its original value.
9-14
Tune the MLC Offset
Editing the MLC Offset in Monaco (cont.)
13. Once the dose calculation completes, click the Save button to resave the plan.
15. Click the Dose Plane button to re-export the dose planes.
16. Return to the QA software to re-evaluate the calculated versus measured doses.
17. Repeat the steps in this section until you are satisfied with the MLC Offset.
18. You can also evaluate the MLC Leaf Minor Offset with GT or Y direction profiles.
The comparison below is an example from the same measurements as above.
Figure 9-16: MLC Leaf Minor Offset Evaluation

As you can see from this example, LINAC1 has a bigger variation in terms of
MLC leaf minor offset. Once you are satisfied with the MLC Leaf Offset, return
to Monaco to evaluate the next three beams.
Monaco 9-15
Evaluate the 20x20, 10x10 and DMCL1 beams from the Express QA Package
1. In the Monaco Workspace, click the QA Plan AllBeams and select Load into
3. One at a time, highlight beams 1 and 5-8 and use the Delete Beams button to
delete these beams from the plan. You are left with Beam 2, 20x20, Beam 3, 10x10
and Beam 4, DMLC1. These beams let you evaluate the beam symmetry and
flatness. Beam 4 (DMLC1) lets you evaluate MLC Leaf Minor Offset and use a
dynamically delivered beam.


6. Click OK.
9-16
Evaluate the 20x20, 10x10 and DMCL1 beams from the Express QA Package (cont.)
8. Wait for the dose calculation to complete. Click the Output tab.
menu.
10. Type a Plan Name of Beams345.
11. Click Save to save the plan. At this point, you have a plan that contains the three
beams with calculated dose.
12. Next, you evaluate the field flatness, symmetry, QA device detectors response, and
absolute dose calibration. Use the 20x20 and 10x10 plans. Verify the MLC Leaf
Major and Minor Offset with the DMLC1 plan.
13. Click the Dose Plane button. Monaco shows the Dose Plane Output dialog
box.
Figure 9-18: Dose Plane Output

Monaco 9-17
16. Import the exported dose planes and measured data into the QA Software. In the
training class, you use the SunNuclear MapCheck software and Elekta data to
The DMLC1 beam is configured as a 2.0cm x 20.0cm (2.0cm x 16.0cm for the BM
accelerator) MLC aperture sweeping from -10cm to 10cm. The jaws are fixed at
20x20cm. The gantry and collimator angles are set to 0.
Theoretically, the 2.0 cm x 20.0 cm sliding MLC aperture delivers almost uniform
dose in a typical flat phantom, as what Monaco calculated. But, the measurement
of this beam may show variations up to ±5% on the MLCi and ±3% on the
MLCi2/BM machine. As shown in the example below, the difference can be
demonstrated as high or low dose strips parallel to leaf motion direction.
Figure 9-19: Uniform Dose Evaluation
9-18
The DMLC1 delivered dose pattern is highly related to the GT or Y profile pattern
in the 3ABUT abutted line derived in Task 1. You take the data of LINAC1 1 as an
example, and compare the profiles of 3ABUT and DMLC1 as in this example:
Figure 9-20: Profile Evaluation

The above example demonstrates the relationship between these two dose
distributions very well. The profiles have almost the same pattern, though 3ABUT
is delivered in Step & Shoot mode, and DMLC1 is delivered in dynamic sweeping
mode. You can conclude that the delivered dose of DMLC1 is very sensitive to the
leaves’ minor offset variation. Thus, DMLC/VMAT delivery requires more
accuracy in terms of individual leaf offset.
The MLC auto calibration routine may not be able to account for this kind of
variation of single leaf minor offset. The physicist needs to analyze the
measurements of “3ABUT” and “DMLC1” carefully. When it is necessary; the
physicist and field service engineer may adjust MLC leaf minor offset parameters
manually.
Monaco 9-19
You use the 20th leaf pair as the reference pair in an Elekta LINAC. Physicists need
to pay special attention to this pair of leaves, and make sure it is at proper position.
You take the data from the LINAC1 used in the above analysis. In the example
below, you can see that improper calibration of the 20th pair causes high dose strips
at other leaf positions. This can vary up to 7~9% compared to the central point. In
this case, the only way to bring those high dose strips down to reasonable range is
to change the 20th leaf pair’s minor offset.
Figure 9-21: MLC Leaf Calibration

Both profiles in the above example are extracted from the same measured dose to
demonstrate the effect of the 20th leaf pair’s calibration. This is done in relative
mode.
9-20
When you compare the calculated and measured dose of “DMLC1”, it is

important to remember to do the comparison in absolute dose mode. Do not
normalize the dose to the central point.
Based on the analysis done on the first two beams, you should have a good idea of
the status of MLC bank major offset and leaves minor offset calibration. If you
need to make minor adjustments, contact your service engineer. Or, you can
return to Monaco and edit the Leaf Offset (mm) in the same manner as the
previous section.
17. Evaluate the dose output and QA device absolute dose calibration with “10 x 10”
field (or the proper reference field, for example, 10.4 x 10.4 cm field for Elekta
Beam Modulator MLC machine). Check to see if the measured absolute dose is the
same as expected. If it is not, you can recalibrate the QA device or simply calculate
a daily output correction factor and scale the MU of the test beams accordingly.
You can also evaluate the field flatness and symmetry with the “20x20” field.
Monaco 9-21
Evaluate Plans 7SegA and FOURL for MLC Offset and Leaf Transmission
1. In the Monaco Workspace, click on the QA Plan AllBeams and select Load into
3. One at a time, highlight beams 1-6 and use the Delete Beams button to delete
these beams from the plan. Monaco leaves you with Beam 7, SegA and Beam 8,
FOURL. These beams let you evaluate the MLC offset and MLC transmission. The
comparison of the leaf groove region is for reference purposes only.
4. Select the Calculation Properties button. Type 0.1 for the

Statistical Uncertainty (%), Per Control Point.

5. Click OK.
9-22
Evaluate Plans 7SegA and FOURL for MLC Offset and Leaf Transmission (cont.)
7. Wait for the dose calculation to complete. Click the Monaco Application
button and select Save Plan As from the menu.
8. Type a Plan Name of SegAFOURL. Click Save to save the plan. At this point, you
have a plan that contains beams SegA and FOURL with calculated dose.
10. Click the Dose Plane button. Monaco Shows the Dose Plane Output dialog
box.

Monaco 9-23
Evaluate the FOURL Field
The field of “FOURL” is configured with four abutted “L” shape segments.
Figure 9-24: MLC Parameters Evaluation using the ‘FOURL’ plan

You can divide the field into three regions:
• MLC only
• Picket Fence
• Leaf Groove region.
You can use this beam to evaluate MLC offset, leaf groove, and MLC transmission.
9-24
Evaluate the FOURL Field (cont.)
The example below is of the comparison of this field.
Figure 9-25: Field Comparison using the FOURL Plan

A. Load both measured and calculated dose in QA analysis software. Set the
comparison in absolute dose mode. Analyze profiles in AB direction first. You
can evaluate both the MLC transmission as well as MLC major offset.
When you check the profile in the picket fence region, you can decide if the MLC
offset value in the model needs to be changed or not.
Monaco 9-25
In the examples below, you see the calculated profile changes when the MLC offset
value is set to -0.10 mm, -0.05 mm, 0.00 mm, 0.05 mm, and 0.10 mm, respectively.
Figure 9-26: Effect of Changing the MLC Offset
9-26
When you increase the MLC offset, Monaco can calculate higher dose in the matched
line in the picket fence region. In this example, the MLC is well–calibrated. You do not
need to change the offset in the MLCGeometry file.
Figure 9-27: Result when the MLC is well calibrated

B. Now draw the profiles in GT direction. You can evaluate both the MLC
transmission as well as MLC Leaf Groove. (For Elekta MLC Leaf Groove, please
refer to the document “Monaco Dose Calculation Technical Reference
(LRMMON0001).”
If the QA device detectors are diodes, the dose in the leaf groove region may be affected
by a QA device setup deviation like shift or rotation and shown as different pattern.
You need to be careful to make sure the diodes are at the right position when you check
the dose in this region.
This applies especially for ArcCHECK, as the diodes are aligned in helical, and the
position of the diodes change consistently. You may see the measurements vary from
one position to another. Thus, it is important for you to interpret the measurement
accordingly.
If necessary, you can decrease or increase the leaf groove value in Monaco.
Monaco 9-27
Evaluate the field of “7SegA”
Most of IMRT or VMAT segments are delivered by the central section of MLC in the
central part of the beam. The actual leaves offset may vary a little bit at different
positions. The “7SegA” is a picket-fence type beam that is used to check the MLC in
that region, in terms of both major and minor offset of the MLC.
In this example, you calculate the beam of 7SegA, by setting the MLC offset as -0.1mm,
0.0mm and 0.1mm, respectively, while keeping the MLC leaf transmission as 0.012,
MLC Tip Leakage as 1.03.
Figure 9-28: Picket Fence Evaluation for a Range of Leaf Offsets
9-28
MLC Leaf Offset 7SegA (TipLeakage=1.03, LeafTransmission=0.012)
140
120
Leaf Offset -0.1mm

100
Leaf Offset 0.0mm
Leaf Offset 0.1mm
80
60
40
20
0
-200 -150 -100 -50 0 50 100 150 200
Figure 9-29: MLC Leaf Offset 7SegA

Editing the Leaf Transmission and Leaf Groove Width (mm) in Monaco
1. If you need to change either the Leaf Transmission or Leaf Groove Width (mm),
return to Monaco.
2. Click the Close Patient button in the Quick Access toolbar. You cannot access
many of the Settings while a patient is open.
3. Select the Monaco Applications button. Select Settings from the

menu.
Monaco 9-29
(cont.)
4. Click the MLC Geometry option. You edit the Leaf Transmission and Leaf
Groove Width(mm) on this dialog box.
Figure 9-30: Settings window

5. Click OK to save the edit.
6. You must open and recalculate the treatment plan to apply the changes.
7. Click the Open Patient button to show the Patient Selection dialog box. Click
the Patient ID ACplug27cm.
9. Click on the saved 7SegAFOURL plan and select Load into Planning from the
mouse menu to open the plan.
9-30
(cont.)
11. You need to make a change to the plan to enable the dose calculation. In the
Planning Control, edit the X(cm) value and then change it back to its original
value.
13. Once the dose calculation completes, click the Save button to resave the plan.
15. Click the Dose Plane button to re-export the dose planes.
16. Return to the QA software to re-evaluate the calculated versus measured doses.
17. Repeat the steps in this section until you are satisfied with the Leaf Transmission
and Leaf Groove Width (mm).
Monaco 9-31
The Effect of MLC Leaf Offset on Test Beams Dose
The example below shows you the effect of MLC leaf offset changing on the dose
distribution of simple test beams.
The beams 3ABUT, 10 x 10, DMLC1, 7SegA and FOURL were calculated on a flat
phantom, with SSD 89cm setup. The dose reference point is at the isocenter, except for
beam FOURL, which is at the isocenter plane, but with -3cm shift in X direction.
Different MLC offset values were used. The dose values are single point dose reading.
Table 9-2: The Absolute Dose (cGy) with different MLC Leaf Offset (mm)
Offset(mm) 3ABUT 10 x 10 DMLC1 7SegA FOURL
-0.50 48.40 87.50 20.00 96.10 90.30
-0.25 48.90 88.70 21.90 98.40 93.10
-0.15 48.80 88.40 22.50 99.50 94.20
-0.10 48.80 88.30 22.90 99.90 94.90
-0.05 48.70 88.00 23.30 101.00 95.70
0.00 48.60 88.00 23.70 101.90 96.20
0.05 48.90 87.90 24.00 102.20 96.60
0.10 49.00 88.00 24.60 102.80 96.80
0.15 49.00 88.00 25.00 103.40 97.20
0.25 48.90 88.10 25.40 104.50 97.80
0.50 49.60 88.00 27.00 107.90 99.70
9-32
The Effect of MLC Leaf Offset on Test Beams Dose (cont.)
Plot Of Absolute Dose Change With Different MLC Leaf Offset
120.00
100.00
3ABUT 80.00
10x10
Dose (cGy)
DMLC1
7SegA 60.00
FOURL
40.00
20.00
0.00
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
MLC Leaf Offset (mm)
Figure 9-31: Plot of Absolute Dose Change with Different MLC Leaf Offsets
Table 9-3: The Relative Dose Change (%) with different MLC Leaf Offset (mm)
Offset(mm) 3ABUT 10 x 10 DMLC1 7SegA FOURL

-0.50 0.996 0.994 0.844 0.943 0.939
-0.25 1.006 1.008 0.924 0.966 0.968
-0.15 1.004 1.005 0.949 0.976 0.979
-0.10 1.004 1.003 0.966 0.980 0.986
-0.05 1.002 1.000 0.983 0.991 0.995
0.00 1.000 1.000 1.000 1.000 1.000
0.05 1.006 0.999 1.013 1.003 1.004
0.10 1.008 1.000 1.038 1.009 1.006
0.15 1.008 1.000 1.055 1.015 1.010
0.25 1.006 1.001 1.072 1.026 1.017
0.50 1.021 1.000 1.139 1.059 1.036
Monaco 9-33
The Effect of MLC Leaf Offset on Test Beams Dose (cont.)
Plot Of Relative Dose Change With Different MLC Leaf Offset
1.200
3ABUT
10x10
DMLC1 1.100
7SegA
FOURL
Dose (%)
1.000
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
0.900
0.800
MLC Leaf Offset (mm)
Figure 9-32: Plot of Relative Dose Changes with Different MLC Leaf Offsets
The data in the above example shows you that the MLC offset can strongly affect the
DMLC and segmented IMRT beams delivered dose. It has only a small effect on
20x20cm and 10 x 10cm fields. As DMLC1 delivers 10MU/1cm, its absolute dose is low,
but its relative change is the biggest one.
9-34
Evaluate the fields of “HIMRT” and “HDMLC”
Once you check and update the proper MLC offset value with the simple beam
configurations shown in “FOURL” and “7SegA”, you can use “HIMRT” and “HDMLC”
beams to check the model performance with typical clinical head and neck
IMRT/DMLC beams.
Once you complete the data analysis in this exercise, you will have a good idea of the
performance of the MLC as well as the beam model. Then, you can use the other beams
in the “FullPackage” plan to do further commissions. You can also follow the protocols
you use in the clinic.
1. In the Monaco Workspace, click on the QA Plan AllBeams and select Load into
3. One at a time, highlight beams 1-4 and beams 7-8 and use the Delete Beams
button to delete these beams from the plan. You will be left with Beam 5, HIMRT
and Beam 6, HDMLC. These are both clinical treatment plans.

Monaco 9-35
Evaluate the fields of “HIMRT” and “HDMLC” (cont.)
7. Wait for the dose calculation to complete. Click the Monaco Application
button and select Save Plan As from the menu.
8. Type a Plan Name of HIMRTHDMLC.
9. Click Save to save the plan. At this point you have a plan that contains beams
HIMRT and HDMLC with calculated dose.
11. Click the Dose Plane button. Monaco shows the Dose Plane Output dialog
box.
9-36
Evaluate the fields of “HIMRT” and “HDMLC” (cont.)

A clinical IMRT or VMAT beam consists of many segments with different sizes as well
as weights. The effect of leaf offset change may not be manifested so drastically. In the
next example, you see the effect of MLC leaf offset changing on clinical beams dose
distribution.
Monaco 9-37
Interest Points at Different Dose Levels in a Typical HN Case
The beams of HIMRT and HDMLC were calculated on a flat phantom, with SSD 89cm
setup. Five interest points at different dose level were defined, as illustrated in the
picture below. Monaco lists the absolute dose and relative changes at those five interest
points for both beams.
Figure 9-35: Dose Plane in a Flat Phantom

The data and plots appear in next pages:
Table 9-4: Absolute Dose (cGy) with different MLC Leaf Offset (mm) (HIMRT)
Offset(mm) 1 2 3 4 5
-0.50 78.90 68.30 55.90 39.50 15.20
-0.25 79.60 69.00 57.90 39.60 17.10
-0.15 79.90 69.40 58.60 39.60 17.90
-0.10 80.10 69.70 59.00 39.70 18.30
-0.05 80.40 69.80 59.30 39.90 18.40
0.00 80.50 70.40 59.40 39.70 19.00
0.05 80.50 70.00 60.10 39.90 19.50
0.10 80.50 70.00 60.50 40.00 19.90
0.15 80.50 70.10 60.90 40.00 20.40
0.25 81.10 70.00 61.40 40.20 21.00
0.50 81.10 70.90 63.10 40.10 23.40
9-38
Interest Points at Different Dose Levels in a Typical HN Case (cont.)
Absolute Dose At Different Position With Different MLC Leaf Offset

(HIMRT)
90.00
1
2 80.00
3
4 70.00
5
60.00
Dose (cGy)
50.00
40.00
30.00
20.00
10.00
0.00
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
MLC Leaf Offset (m m )
Figure 9-36: Absolute Dose at Different Positions with Different MLC Leaf Offsets
(HIMRT)
Monaco 9-39
Table 9-5: Relative Dose (%) with different MLC Leaf Offset (mm) (HIMRT)
-0.50 0.980 0.970 0.941 0.995 0.800
-0.25 0.989 0.980 0.975 0.997 0.900
-0.15 0.993 0.986 0.987 0.997 0.942
-0.10 0.995 0.990 0.993 1.000 0.963
-0.05 0.999 0.991 0.998 1.005 0.968
0.00 1.000 1.000 1.000 1.000 1.000
0.05 1.000 0.994 1.012 1.005 1.026
0.10 1.000 0.994 1.019 1.008 1.047
0.15 1.000 0.996 1.025 1.008 1.074
0.25 1.007 0.994 1.034 1.013 1.105
0.50 1.007 1.007 1.062 1.010 1.232
Relative Dose At Different Position With Different MLC Leaf Offset

(HIMRT)
1.300
1
2
3 1.200
4
5
1.100
Dose (%)
1.000
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
0.900
0.800
0.700
Figure 9-37: Relative Dose at Different Positions with Different MLC Leaf Offsets
(HIMRT)
9-40
Table 9-6: Absolute Dose (cGy) with different MLC Leaf Offset (mm) (HDMLC)
-0.50 75.60 70.70 61.70 41.50 15.80
-0.25 76.40 71.70 63.50 41.60 17.90
-0.15 76.80 71.90 64.30 41.60 18.70
-0.10 77.10 72.00 64.70 41.70 19.10
-0.05 77.30 72.00 65.10 41.70 19.40
0.00 77.40 72.60 65.60 41.80 19.80
0.05 77.40 72.20 65.80 41.80 20.30
0.10 77.40 72.30 66.20 42.00 20.80
0.15 77.50 72.50 66.60 42.00 21.20
0.25 77.90 72.20 67.30 42.00 21.80
0.50 78.10 73.30 68.80 42.20 24.00
Absolute Dose At Different Position With Different MLC Leaf Offset

(HDMLC)
90.00
1
2 80.00
3
4 70.00
5
60.00
Dose (cGy)
50.00
40.00
30.00
20.00
10.00
0.00
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
Figure 9-38: Absolute Dose at Different Positions with Different MLC Leaf Offsets
(HDMLC)
Monaco 9-41
Table 9-7: Relative Dose (cGy) with different MLC Leaf Offset (mm) (HDMLC)
-0.50 0.977 0.974 0.941 0.993 0.798
-0.25 0.987 0.988 0.968 0.995 0.904
-0.15 0.992 0.990 0.980 0.995 0.944
-0.10 0.996 0.992 0.986 0.998 0.965
-0.05 0.999 0.992 0.992 0.998 0.980
0.00 1.000 1.000 1.000 1.000 1.000
0.05 1.000 0.994 1.003 1.000 1.025
0.10 1.000 0.996 1.009 1.005 1.051
0.15 1.001 0.999 1.015 1.005 1.071
0.25 1.006 0.994 1.026 1.005 1.101
0.50 1.009 1.010 1.049 1.010 1.212
Relative Dose At Different Position With Different MLC Leaf Offset

(HDMLC)
1.300
1
2
3 1.200
4
5
1.100
Dose (%)
1.000
-0.60 -0.40 -0.20 0.00 0.20 0.40 0.60
0.900
0.800
0.700
Figure 9-39: Relative Dose at Different Positions with Different MLC Leaf Offsets
(HDMLC)
9-42
Summary
MLC major offset and the leaves minor offset are important properties of a LINAC,
which can affect IMRT and VMAT plan delivered dose. MLC bank major offset can
vary from one LINAC to another, and the MLC leaves minor offset may also have
variation. A set of test beams has been designed to help you evaluate the MLC
calibration of a certain LINAC. You must make sure the MLC is properly calibrated.
Then, based on the comparison of the test beams, you can update the pertinent
parameters, especially, “Leaf offset” in the Monaco model’s “MLCGeometry.xml” file,
so the model can calculate more accurate dose.
Monaco 9-43
Folder Structure
10-1
Folder Structure
This slide describes the file structure for Monaco data. The data used by the
software is arranged under a main Folder “FocalData.” Under “FocalData,”
we have multiple folders like “AnatGroups” which contains the library of
anatomical structure. “Couches” which contains files that will defines the
electron density settings for different couches.
One of the important folders from Physics point of view is “Installation”
which contains the clinic details and the physics data which will be used by
the customer. Within “Installation” folder in this example you can see there is
a “QA clinic” folder which in turn contains (a) ~anatomy, (b) idv individual
preference folder for CT to electron density and electron density to physical
density file, and (c) tele. This contains the linac model data which includes
the Pencil beam kernel and Beam data table file from XVMC.
For a non-standalone system, that is, Monaco along with XIO, “FocalData”
will also have a XiO server folder like “rtp1.”
10-2
Monaco Beam Modeling
11-1
11-2
1. The system can fully track one electron and all of its descendents from the
accelerator head through fixed elements of the head (targets, scattering foils,
primary collimators, monitor chambers, flattening filter, beam shaping
devices which are patient specific [jaws, MLC]). Patient data is specified by
CT data or some other data set.
2. A phase-space file (containing parameters as energy, position, direction,

charge, region of creation). When transporting particles through patient
independent elements, you can use a variation reductions technique since
many bremstrahlung photons strike the primary collimator, and do not reach
the patient.
3. It does not require direct MC simulation of the accelerator for each treatment.
(VSMs that can come as a MC simulation of the accelerator head or based
purely on measured beam data.)
11-3
1. The parameters of VSM were extracted from the full space data simulated
with MC code BEAMnrc. The algorithm uses parameters to calculate a set of
MONOENERGETIC depth dose curves in water called monoenergetic
kernels. You use discrete energies from Emin to Emax to calculate primary
kernels and secondary kernels separately.
Three Gaussian-shaped photon sources describe the source distributions. The

planar photon sources, 0 and S are located near the bremsstrahlung target
(primary source) and the millstone (secondary source), respectively. The
electron contamination source is located in the plane defining the lower end
of the filter.
11-4
Three Gaussian-shaped photon sources describe the source distributions. The

location of the planar photon sources, 0 and S, is near the bremsstrahlung target
(primary source) and the millstone (secondary source), respectively. The location
of the electron contamination source is in the plane defining the lower end of the
filter.
The standard deviation and relative weight of each source are free parameters,
with other parameters correcting for fluence variations such as the horn and
central depression effects. Along with the field size in X and Y directions, these
parameters are employed to analytically calculate the corresponding energy
fluence, which you can compare to measured dose distributions.
The algorithm uses these distributions to generate a set of monoenergetic central

axis depth dose distributions in water. The depth doses are used to derive the
energy spectrum by deconvolving the measured depth dose curves. This spectrum
and the source distribution functions are then passed to the XVMC dose
calculation engine.
11-5
• Primary photons spectrum describes the energy distribution of the primary

photons above flattening filter.
• You use the primary parameters ENERGY-MAX, ENERGY-MIN, B-

VALUE and effective thickness of flattening filter t (calculated from A-
VALUE and Z-VALUE) to describe the spectrum. There are also other
parameters that are not controlled by the modeler ( BIN1-START, BIN1-
WEIGHT). ENERGY-MAX and ENERGY-MIN are for both primary and
secondary
• The secondary source energy spectrum parameters are: ENERGY-MAX,
ENERGY-MIN, SEC-B-VALUE, BIN1-START, BIN-SEC-WEIGHT.
• The energy distribution changes off-axis. The phenomena is modeled by

DELTA-B-OAS and SEC-DELTA-B parameters which determine the relative
change of exponents with respect to the tangent of angle between CAX and
direction of the particle at the MC starting plane.

MEAN is electron spectrum fitting parameter, NOMINAL ENERGY and
CHARGED-E-MAX, as max-min energy for electrons –ln(0.95).
• Fluence correction is either h0, h1, … or OAS table.
11-6
Presenter notes continued from previous page.

MEAN, which is the mean energy of the contamination source, and
NOMINAL ENERGY.
• Primary photons fluence distribution, located at the target position, is a
Gaussian distribution with a standard deviation PRIMARY-SIGMA (Σpri).
• Secondary photons fluence distribution is a Gaussian distribution situated at
the base of primary collimator with a standard deviation BDT parameter
SCATTER-SIGMA (Σscat).
• Electron fluence distribution is also a Gaussian distribution with standard
deviation dependent on energy σecon(E), which is a function of a parameter
CHARGED-RADIUS(Σecon ).
• Primary fluence correction parameters are multipliers on primary photon
weight relative to central axis or Padé function coefficients' PRIMARY-H0,
H1, H2, H3, H4.
• The system calculates the dose separately for each source. The total dose is
the sum of the weighted doses for subsources. Weights (or relative
contributions) are PRIMARY-PHOTONS and CHARGED-PARTICLES .
11-7
The system calculates the dose separately for each source. The total dose is the
sum of the weighted doses for subsources. Weights (or relative contributions) are
PRIMARY-PHOTONS and CHARGED-PARTICLES .
11-8
Quality data is very important.
11-9
Quality data is very important.
11-10
Quality data is very important. Measure 2x2cm2 to 40x40cm2 output factors,

PDDs, and profiles with the same device (DO NOT USE micro chamber or
diodes!!). Measure 1x1, 2x2, 3x3cm2 output factors with a small device. Measure
1x1cm2 PDD and profiles with a small device also. Measure PDD starting from the
bottom of the water tank toward the surface. There are more details in the Beam
Data Collection Worksheets.
11-11
1. This is usually data sent by the customer in a scanning software format.
2. To process data, you:
• Check PDD data (3x3, 10x10, 30x30cm) versus a standard data before
doing the data transfer in areas like:
- buildup region ( shift for the effective point of measurement)
- dmax (to make sure that for 10x10cm field falls where it supposed
to be)
- tail (expected differences within 0.5-1.5%, if seen more than the
device used was not within specifications or bad measurement)
• Check the output factors versus the Output factor library.
• Check the profiles for 10x10, 30x30 and 40x40cm. Unusual high or low
horns can indicate a measurement device or/and water tank problem.
3A. To process PDDs, you:

• Shift for the effective point of measurement.
• Resample the points every 1mm so XiO will not cut the tail of the pdd.
When you shift the PDD curve by -0.6 x rcav, the points that have depths
between -1.8mm to 0, except 0 has to be removed. Otherwise, in the
transfer process to XiO, XiO only reads the first point that it sees as
having a depth coordinate of 0.
• XiO accepts 402 points for PDD, 1000 points for profiles.
11-12
(continued from previous page)
3B. To process Profile s, you:

• Center the curves.
• Make sure both sides of the curve are symmetric .
• Resample the points every 1mm.
• When importing diagonals to VCT, type an output factor of 1 so the
diagonal data will be imported.
4. Spectrum fitting is time consuming and it is not used too much. You import
spectrum parameters from other models.
5. The MC calculated doses for the primary source, the secondary source, and
the electron source are weighted and added to give the total MC dose. The
iteration continues until the total MC calculated PDDs, Profiles, and OFs fit
well with the measured data.
6. Horn fitting creates horns parameters or OAS ratios that model the fluence.
11-13
Good results are found with MC calculation. The calculated OF are within 1% with the
measured data, after days of working on the model. Not as good results for high
energies. The buildup and after dmax region have problems.
11-14
1. Pencil beams are fit using MC calculated profiles in a water phantom, in a

isocentric setup (SSD=90cm) for a set of open square fields (the default
fields are the field sizes of the measured data set, but you can freely change
them). The depths for the MC calculated profiles is your choice (example,
0.2cm from 0 to 5cm depth and 1cm from 5cm to the end of the water
phantom.)
2. The LMFIT function does a non-linear least squares fit to a function with an
arbitrary number of parameters. LMFIT uses the Levenberg-Marquardt
algorithm, which combines the steepest descent and inverse-Hessian function
fitting methods. The function may be any non-linear function.
11-15
The Pencil beam algorithm gives good results in water. But, even in water, it does
not fit very well the dose outside of the field in the transmission area. PDDs do
not fit well in the build-up region, dmax. Pencil Beam Algorithms do not behave
well for fields greater than 26x26 which is the maximum calculated field during
Pencil Beam Commissioning.
You should not use the Pencil Beam for final calculation or QA. Calculate with
the pencil beam algorithm in the first phase of the optimization to have some dose
with which to start the optimization.
11-16
The Pencil beam algorithm gives good results in water. But, even in water, it does
not fit very well the dose outside of the field in the transmission area. PDDs do
not fit well in the build-up region, dmax. Pencil Beam Algorithms do not behave
well for fields greater than 20x20 which is the maximum calculated field during
Pencil Beam Commissioning.
You should not use the Pencil Beam for final calculation or QA. Calculate with
the pencil beam algorithm in the first phase of the optimization to have some dose
with which to start the optimization.
11-17
Most customers do not need to edit these parameters. We do not recommend you
edit your MLC Parameters until after you consult with Customer Support.
11-18
See Appendix G of the Monaco Training Guide for more information the MLC
Parameters you can edit.
11-19
1. Beam Model Installation is a one page instruction sheet.
2. The personalized Letter to the physicist informs about energy and linac
modeled and recommendation to review, verify, and commission the beam
model.
3. Monaco Physics Services Acceptance Letter is a legal document that certifies

that the model was verified, validated, and accepted clinically by the
physicist.
4. The report shows parameters of the model after output verification/calibration

in Monaco planning (.bdt file). There might be a difference between Gy/MU
at DMAX reported in this report versus the bdt file that comes from the VCT.
The model has been adjusted to fit the calibrator of the Linac.
11-20
(Presenter notes continued from previous page)
5. Output Verification/Calibration plan reports calibration of the model using

10x10 cm field, SAD setup and the dose/MU information at 10cm depth. The
modeling is done by fitting the measured data under SSD=100cm setup using
Virtual Commissioning Tools. The verification is done in Monaco Planning
under SAD =100cm setup, for a 10x10 cm field, 100MU. If the dose at 10cm
depth does not match the dose provided by you (the customer) under the same
conditions, the GY/MU-DMAX is adjusted. During this
verification/calibration , 2mm voxels are used for calculation. When reading
the dose to isocenter, a spherical sampling tool or radius 4mm is used to
average over more voxels. Note that the mean dose in that volume does not
equal the total dose to isocenter, which is the dose to only one point.
6. Calibration Plan screenshots show the mean dose at isocenter for both Monte
Carlo Calculation and Pencil Beam Calculation.
7. Flatness and Symmetry report with penumbra information.
8. Virtual Commissioning Tools Report with Monte Carlo calculated open fields
and measured data.
9. CD with the model and soft copy of the reports.
11-21
The above example illustrates parameters of the model after output

verification/calibration in Monaco planning (.bdt file). There might be a difference
between “NORM-VALUE“ reported in this report versus the Validation Report
that comes from the VCT. The model sent to the customer has the adjusted
“NORM-VALUE“ file. In the example above, the difference between “NORM-
VALUE“ is only 0.3%.
11-22
The above example illustrates output Verification/Calibration plan reports

(calibration of the model using 10x10 cm field, SAD setup and the dose/MU
information at 10cm depth). The modeling is done fitting the measured data under
SSD=100cm setup using Virtual Commissioning Tools. The verification is done
in Monaco Planning under SAD =100cm setup, for a 10x10 cm field size,
100MU. If the dose at 10 cm depth does not match the dose provided by you (the
customer) under the same conditions, then the GY/MU-DMAX is adjusted.
During this verification/calibration, 2mm voxels are used for calculation.
11-23
The above example illustrates Calibration Plan screenshots with the mean dose at
isocenter for both Monte Carlo Calculation and Pencil Beam. When reading the
dose to isocenter, a spherical sampling tool of radius 4mm is used to average the
dose over more voxels. Note that the mean dose in that volume does not equal the
total dose to isocenter (which is the dose to only one point).
11-24
Appendix A
Volume IV of IV Monaco Training Guide
User Authorization Setup for Plan Approval
User Authorization
The User Authorization Database is where the systems administrator assigns users and
groups specific permissions in Monaco. To access the User Authorization database,
you must have administrator rights to the Monaco system. In order to do an approval,
the administrator must set up a user in the database and give the appropriate
permissions to approve plans in Monaco.
Create Users and Permissions in User Authorization

You can assign users to certain groups based on the different group’s permissions.
1. Select the Monaco Application button. Select the Setup | User
Authorization menu item.
Figure A-1: User Authorizations
In the User Authorization database there are four pre-defined groups, with
default permissions which you can assign a user:
• Administrator: Administrators can change global settings and change

information in the User Authorization database.
• Approver: Approvers can edit, export, and approve plans in Monaco.
• Physicist: Physicists can edit physics data and overwrite existing IMRT
or SIM plans. (Physicists cannot approve plans.)
Monaco® A-1
Appendix A
User Authorization
Create Users and Permissions in User Authorization (cont.)
• Planners: Planners have permissions to edit and export plans with or

without approval.
Click on a Group to select it. Click on the Permissions tab to change the
permissions for each user type. For example, you could allow Physicists to
approve plans.
NOTE: When you are connected to XiO, you have the default rights of the
user group to which you are assigned in XiO.
Create a New User
1. Click Add at the bottom of the Entity Selection column.
2. The Create User dialog box opens and you fill in the information accordingly:
Figure A-2: Create User
3. Click Ok to create the new user.
OR
Click Cancel to leave the Create User dialog box.
4. In the Entity Editor column, select the MemberOf tab.
5. Click Join.
A-2
Appendix A
User Authorization
Create a New User (cont.)
6. In the Select Group window, highlight the group you want to assign the user to
and click Ok.
Figure A-3: Select Group ….
7. In order to remove a user, highlight the user name in the Entity Selection
column and click Remove.
8. Click Commit to add the new user to the system.
NOTE: You must click Commit to apply your changes. When the User
Authorization database is successfully committed, a message is
written to the general log file on the server’s machine that includes
the date, time, and user who changed the database.
Monaco® A-3
Appendix A
User Authorization (cont.)
Create a New Group
1. In the List Selection column, highlight Groups.
2. Click Add at the bottom of the Entity Selection column to show the Create
Group dialog box.
Figure A-4: User Authorization
3. Type the name and description of the new group.
4. Click Ok.
5. You can edit the group Description from the Properties tab in the Entity Editor
column.
6. Select the Members tab in the Entity Editor column.
7. Click Add and select the users you want to add to this group.
8. Click Ok.
9. Click on the Permissions tab in the Entity Editor column and enable the
appropriate rights for the new group.
10. When you are done, click Commit to apply the changes.
A-4
Appendix A
User Authorization (cont.)
Edit Group’s Permissions and Users
Although we provide logical predefined groups for you to use, you may need or want
to create additional groups with different permissions than the predefined groups.
Complete these steps to create a new group.
1. Select Groups in the List Selection column.
2. Highlight the group you want to edit in the Entity Selection column.
3. In the Entity Editor column, click on the Permissions tab.
4. You can enable or disable certain pre-defined permissions for the group.
5. If you create a new group, add new users under the Members tab.
6. Click the Add button and select the users you want to add to the group.
7. You can remove users from an existing group. Select Remove in the Members
tab and highlight the group’s users you want to remove.
8. Click Commit to apply your changes.
Monaco® A-5
Appendix B
Machine Configuration and Jaw Labeling (Standalone Users)
Those who use this system in a standalone configuration can configure their machine
files and customize the jaw labeling per machine. You must have all patients closed to
configure the machine files. For those using Monaco with a XiO machine,
configuration and jaw labeling transfers from XiO. Therefore, no configuration on the
Monaco application is necessary.
NOTES: You must have all patients closed to access the machine configuration
information.
You must have Physics rights to access Machine Information.
Edit Machine Configuration
1. Click the Monaco Application Menu button, and then the Setup | Machine
Configuration option to show the Machine Configuration dialog box.
Figure B-1: Machine Configuration dialog box
2. Click the drop-down arrow next to the Machine ID field and select the machine
you want to edit.
3. Edit any of the machine parameters.
4. Click OK to save your changes.
Monaco® B-1
Appendix B
Copy to Create a New Machine
1. Click on the Monaco Application Menu button, and then the Setup |
Machine Configuration option to show the Machine Configuration dialog box.
2. Click the Copy button next to the Machine ID field to show the Copy Machine
Configuration dialog box.
3. Type a New Machine Name.
4. Click OK when done to return to the Machine Configuration dialog box and
shows the configuration for the newly copied machine so that you can edit, if
necessary.
5. Click OK on the Machine Configuration dialog box to save any changes.
B-2
Appendix B
Customize the Jaw Labels
1. Click on the Monaco Application Menu button, and then the Setup |
Machine Configuration option to show the Machine Configuration dialog box.
2. Click the drop-down arrow in the Machine ID field and select the machine in for
which you would like to customize the jaw labels.
3. Click the Customize labels button to show the Collimator Jaw Labels dialog box.
Figure B-2: Collimator Jaw Labels dialog box
4. Type the desired symmetric and asymmetric jaw labels for collimator width and
length. Type the desired leaf bank labels if you have MLC leaves on this machine.
5. Click OK to save and close.
6. Repeat these steps for all machines where you would like to change the jaw
labeling.
7. Click OK on the Machine Configuration dialog box when done.
Monaco® B-3
Appendix C
Settings
There are certain settings that are only available if you have the Full version of Monaco
while others are available for both Monaco and Monaco Sim. See the available settings
below:
NOTE: The settings under Physics are only seen if you have the Physics Group
permissions.
Monaco and Monaco Sim-Available Settings:

• Servers:
- Data Location
- XiO Server (Connected to XiO) OR User Authorization (Stand-alone)
- Focal Share
• Workflow:
- Preferences
- Graphical Preferences
- Tolerance Tables
- Rx Sites
• Physics:
- Ports & Materials
- Laser System
- DICOM Machine Mapping
- Wedge Param.
- Treatment Unit Mapping
Monaco Full Features-Available Settings:

• Physics:
- MLC Dynamics
- MLC Geometry
- MLC Leakage
- Stereo Cone Param.
Monaco® C-1
Appendix C
Settings
General Information
You can set the preferences below per workstation. These preferences apply to all new
patients created on that workstation.
NOTE: Standalone -You must have the edit physics permission in User
Authorization for Ports and Materials, Laser System, Tolerance Tables, Rx
Sites, Map Machines, MLC Dynamics, and MLC Geometry to be available
in the Settings dialog box. You must have either Physics or Administrator
permission to access the Treatment Unit Mapping option. Refer to
Appendix A for detailed information on User Authorization.
1. Click the Monaco Application button. Select Settings from the menu.
2. Click the Preferences option (Figure C-1).
Figure C-1: Preferences Option
3. Type the Hospital/Clinic: name you want to show on printed reports.
4. Keep Log messages for X days. Here you can change the number of days for
which you would like to keep the Log File entries. The system automatically
purges log file entries older than this number of days.
C-2
Appendix C
Settings
General Information (cont.)
5. (Optional) Uncheck the Allow users to save over approved plans box if you do
not want users to save over approved plans. (Refer to the Plan Review section of
this guide for additional information.)
6. (Optional) Uncheck the Allow users to DICOM export unapproved plans box
if you want ONLY approved plans to be DICOM exported. (Refer to the Plan
Review section of this guide for additional information.)
7. Check the Activate single export for Apex and DICOM Applicator ID for
Micro-MLC if you want to export only one DICOM RT PLAN file to the
destination selected.
8. Check the Calculate SUV for loaded PET data automatically box if you want
the SUV icon to automatically display the SUVs for a PET image.
9. Type the maximum time between when you inject the radiotracer and acquire
images for PET image sets. If the time is greater than the value you enter, the
system will not calculate SUV. Type a value between 1 and 24. Field defaults
to 3.
10. Type the diameter of the sphere that the system uses to calculate peak value for
PET data.
11. Type the Grid Spacing(cm) and select whether you want to Calculate Dose
Deposition to Medium or Water. Type the Statistical Uncertainty(%) and
whether you want it to be per control point or per calculation. Monaco uses
these values when you DICOM import a plan and recalculate dose.
Monaco® C-3
Appendix C
Settings
Graphical Preferences
These are the options you have for setting the Graphical Preferences. You can view
this dialog box to set preferences on how 2D/3D isolines and cone visualization appear
in Monaco.
2. Click the Graphical Preferences option.
3. Select a 2D isoline thickness in the Default thickness of 2D isoline drop-down

menu. There are three different thickness options from which you can choose.
4. Select W, T25, T50, or T75 from the Default 3D Rendering Style.
5. In the 3D Static Arc Preferences section, type a value in degrees for the Visual
Increment (Figure C-2). The Visualization Increment gives you a graphical
representation of the beam at defined increments throughout the arc. It does not
affect the dose calculation.
6. (Optional) Uncheck the Insert Oblique View option if you do not want the
oblique SPV to replace the SPV when you load an oblique studyset.
Figure C-2: 3D Static Arc Preferences
C-4
Appendix C
Settings
Tolerance Tables
This setting lets you add a list of tolerance tables that match those you have defined in
MOSAIQ and ARIA for DICOM export. The lists are created and saved per clinic.
2. Click the Tolerance Tables option.
3. Select an installation from the Installations drop-down menu.
4. Select a clinic from the Clinic drop-down menu.
5. Left-click to highlight a tolerance table in the list.
6. If you have not created a tolerance table, type a name in the Name box.
NOTE: When you create a name, it is important to place a number in front of the
name that matches the number of a defined tolerance table in MOSAIQ. In
MOSAIQ, the number is the only part of the name that is read.
8. You can click on a tolerance table in the list and click Remove to delete a table
from the list.
Monaco® C-5
Appendix C
Settings
Rx Sites
This setting lets you create a pre-defined list of Rx sites to match those defined in
MOSAIQ. The lists of Rx sites are created and saved per clinic.
2. Click the Rx Sites option.
3. Select an installation from the Installations drip down menu.
5. Left-click to highlight a name in the list.
6. If you have not created an Rx site, type a name in the Name box.
8. You can click on an Rx site in the list and click Remove to delete a table from
the list.
C-6
Appendix C
Settings
Ports and Materials
These are the settings for Ports and Materials (Figures C-3 and C-4). Understand, if
you send the patient to XiO for dose calculation, XiO uses these values and overrides
any XiO values previously set. We recommend you set these values to the same values
as what is set in XiO to avoid any confusion.
Figure C-3: Connected to Another System Figure C-4: Standalone User Preferences
1. Click the Ports and Materials option.
2. The Height Step, Width Step, and Depth Step represent the grid spacing you
plan to use for dose calculation.
3. If you place a checkmark in the Heterogeneity Pixel by Pixel box, the system
uses pixel-by-pixel heterogeneity during dose calculation. Bulk density override
is available within the software on a structure-by-structure basis.
4. For each Server and each Clinic within a server, you can set default for the port
Materials, Material Thickness and HVL. One-by-one, you must select a server
and clinic, then set the default Material, Thickness, and HVL for Sim and
Monaco planning.
5. For bolus, you can set a default value for the bolus electron density. This value is
set per clinic.
Monaco® C-7
Appendix C
Settings
DICOM Machine Mapping
This setting lets you map a machine to an Exported Machine Name, Applicator ID,
and Accessory Code. The lists of mapped machines are created and saved per clinic.
You can also change the mapped machine name in the DICOM Export dialog box.
NOTE: You must check the Activate single export for Apex and DICOM
Applicator ID for Micro-MLC option in Preferences in order to map to
an Applicator ID or Accessory Code.
1. Click the DICOM Machine Mapping option (Figure C-5).

2. Select an installation in the Installations drop-down menu.
4. Type a name in the Exported Machine Name column.
Figure C-5: DICOM Machine Mapping dialog box
5. Type information in Applicator ID. You can click on the drop-down arrow to
select an Applicator ID used before in the list.
6. Type information in Accessory Code. You can click on the drop-down arrow to
select an Accessory Code used before in the list.
C-8
Appendix C
Settings
Parameters
MLC Dynamic Parameters
The system uses MLC dynamic parameter values during dynamic sequencing of
VMAT or dMLC plans. These parameters are specific to your treatment machine and
MLC type and have default values that we have already optimized for the best
performance. In most cases, the default values are best for VMAT and dMLC
sequencing. You can change the MLC dynamic parameters values from their default
values, but use caution as changing these values too extensively can lead to
undeliverable segments/sequences.
1. To access the MLC dynamic parameters, close any open patient(s).
2. Click the MLC Dynamics option.
3. Select your Machine. The system shows each parameter and its default value.
4. To override any parameter, uncheck the Default? checkbox associated with the
parameter and change the value as needed.
5. Click Save to save the changes.
Monaco shows a warning if you changed any parameters (Figure C-6). You must
recalculate plans that existed previously to use the updated parameters. Monaco uses
the updated parameters for all new plans. Read and respond to the warning before you
use the machine in a treatment plan. Answer ‘Yes’ to the warning message to accept
the changes and continue. Answer ‘No’ to the warning message to return to the dialog
box and edit the parameters.
Figure C-6: MLC Dynamic Parameters warning message
Monaco® C-9
Appendix C
Settings
Parameters
MLC Dynamic Parameters (cont.)
MLC Dynamic Parameter Description

Max. Leaf Travel Per Second (mm) The maximum distance any leaf can travel per second, at the
minimum dose rate.
Max. TJaw Travel Per Second The maximum distance the Y jaw (transverse to leaf
(mm) movement) can travel per second, at the minimum dose rate.
Max. PJaw Travel Per Second The maximum distance the X jaw (parallel to leaf movement)
(mm) can travel per second, at the minimum dose rate.
Max. Gantry Travel Per Second The maximum number of degrees the gantry can travel per
(deg) second, at the minimum dose rate.
Max. Collimator Travel Per MU (Not currently used in Monaco VMAT.)
(deg)
Min. Dose Rate (MU/min) The minimum allowable dose rate on your treatment machine.
Max. Dose Rate (MU/min) The maximum allowable dose rate on your treatment
machine.
Continuous Dose Rate True (checked) if the dose rate on your treatment machine is
continuously variable during dynamic delivery.
Beam Startup Time (sec) Amount of time in seconds for the beam to startup and
become stable in output, used to compute estimated delivery
times.
Min. Moving Gap (mm) Minimum allowable leaf gap during dynamic delivery. This
parameter is only available for Beam Modulator.
Min. MU Per Static CP (MU) The minimum allowable MU per static control point.
Min. MU Per Dynamic CP (MU) The minimum allowable MU per dynamic control point.
Min. Gantry Deg Per CP (deg) The minimum allowable number of gantry degrees per control
point.
Open Guard Leaves Marked if you allow guard leaves (the superior and inferior
leaves on Elekta and Siemens machines) to open.
Maximize Gantry Speed Available only for TrueBeam and other Varian Machines
licensed by Varian: Takes advantage of variable gantry speed.
When unchecked, you can type in a value for Max. Leaf
Travel Per Gantry Rotation.
Max. Leaf Travel Per Gantry The maximum leaf travel of a machine per gantry degree of
Rotation rotation in mm/degree.
C-10
Appendix C
Settings
Parameters (cont.)
MLC Geometric Parameters
Monaco uses the MLC geometric parameters during segmentation and dose
calculation. These parameters are specific to your treatment machine and MLC type
and have default values that we optimized for the best performance. You can change
the MLC geometric parameters values from their default values, but use caution
(Figure C-7). Changes to these values can lead to undeliverable segments/sequences
and incorrect dose calculations. The changes you make to a machine are immediate.
Future plans are affected by these changes. Plans that already exist are not affected by
the changes.
Figure C-7: MLC Geometry dialog box
1. To access the MLC geometric parameters, close any open patient(s).

2. Click the MLC Geometry option.
3. Select your Machine. The system shows each parameter and its current value.
5. Click Save to save the changes.
When you select a machine, if the system does not find a parameter in the
MlcGeometry.xml file, then it populates the dialogue with the default value and sets
the Default checkbox for that parameter. The dose calculation uses the default value if
the parameter is not present.
Monaco® C-11
Appendix C
Settings
Parameters
MLC Geometric Parameters (cont.)
If you check a default box, the system changes the value for that parameter to the
default value. If you manually change a default value, the box is shown as unchecked.
Monaco shows a warning if you changed any parameters (Figure C-8). You must
recalculate existing plans with the updated parameters. Monaco uses the updated
parameters for all new plans. Read and respond to the warning before you use the
machine in a treatment plan. Answer ‘Yes’ to the warning message to accept the
changes and continue. Answer ‘No’ to the warning message to return to the dialog box
and edit the parameters.
Figure C-8: MLC Geometry Warning Message
C-12
Appendix C
Settings
Parameters
MLC Geometry Parameter Description

Select the installation containing the machine
Installation
data.
Clinic Select the clinic containing the machine data.
Machine Select the machine to verify or edit.
Check the Default box for any MLC Geometry
Default? parameter to reset the parameter to the default
value.
The minimum separation between opposite
leaves, defined at isocenter. Use a value equal to
Static Leaf Gap (mm)
or slightly higher than the manufacturer's
specification.
The fractional transmission value of the MLC
Leaf Transmission Leaves. Use only values in the range of the
manufacturer specifications.
The extent of the leaf groove outside the leaf
Leaf Groove Width (mm) boundary. Use only values in the range of the
manufacturer specifications.
The transmission value of the Transverse Jaws
(moving transverse to the leaf direction,
TJaw Transmission
normally the "length" [GT] jaw). Use only values
in the range of the manufacturer specifications.
The transmission value of the Parallel Jaws
(moving parallel to the leaf direction, normally
PJaw Transmission the "width" [AB] jaw). For Elekta machines, this
is the backup jaw. Use only values in the range of
the manufacturer specifications.
The Interleaf Leakage describes the increased
transmission under the leaves, around the
Interleaf Leakage
boundary regions between adjacent leaves.
Higher values correspond to increased leakage.
Monaco® C-13
Appendix C
Settings
Parameters

The distance between the source (target) and the
PJaw Plane Position (mm) upper face of the Parallel Jaws. Use only the
manufacturer specified value.
The full width of the maximum field, in the
Full Width (mm) direction perpendicular to the leaves motion
(used for add-on MLCs only).
The TJaw Backscatter factor measures the
radiation backscattered by the Transverse Jaws
into the MU chamber. A value of zero models
the situation when no radiation is being
TJaw Backscatter backscattered. Increasing the Transverse Jaw
Backscatter factor simulates an increased
amount of radiation backscattered by the
Transverse Jaws and reaching the MU chamber,
resulting in an increased MU count and hence in
a reduced dose per MU delivered to the patient.
The PJaw Backscatter factor measures the
radiation backscattered by the Parallel Jaws into
the MU chamber. A value of zero models the
situation when no radiation is being
PJaw Backscatter backscattered. Increasing the Parallel Jaw
Backscatter factor simulates an increased
amount of radiation backscattered by the Parallel
Jaws and reaching the MU chamber, resulting in
an increased MU count and hence in a reduced
dose per MU delivered to the patient.
The difference between the prescribed leaf
position and the actual value used for dose
calculation. The Leaf Offset is adjusted to match
the calibration of the leaves' positions. Increasing
Leaf Offset (mm)
the Leaf Offset results in an increased segment
width used for calculation.
The Leaf Offset is defined in the MLC plane, not
at isocenter.
C-14
Appendix C
Settings
Parameters

Use to save the changes and close the dialog box.
A warning (shown above) is given to the user
stating that future calculations are affected by the
OK
change and have to be verified against measured
data before accepting the machine for clinical
use.
Cancel Use to close the dialogue and discard all changes.
Monaco® C-15
Appendix C
Settings
Parameters (cont.)
MLC Leakage
You can set the leaf tip corner transmission factor per leaf pair. This lets you take the
MLC beveled leaf tip dosimetric effect into account as well as get better beam
modeling results and clinical QA acceptance testing. Refer to Monaco Technical
Reference: Post-Modeling Adjustment of MLC Parameters in Support Plus for
additional information about MLC leakage parameters. Refer to the Monaco Dose
Calculation Technical Reference for additional information to review the physics
discussion.
Figure C-9: MLC Leakage dialog box
1. To access the MLC Leakage, close any open patient(s).
2. Click the MLC Leakage option (Figure C-9).
3. Select your Machine.
5. Click on the link icon in a column to set a common value for all fields. (Refer to
the Planning and Workflow: Workflow Diagram, Contouring, and Beam and
Delivery Setup section of this guide for additional information about linking.)
C-16
Appendix C
Settings
Parameters
MLC Leakage (cont.)
6. Hover over the MLC image to see an enhanced version.
Monaco shows a warning if you changed any parameters (Figure C-10). You
must recalculate existing plans with the updated parameters. Monaco uses the
updated parameters for all new plans. Read and respond to the warning before
you use the machine in a treatment plan. Answer ‘Yes’ to the warning message
to accept the changes and continue. Answer ‘No’ to the warning message to
return to the dialog box and edit the parameters.
Figure C-10: MLC Leakage warning message
Monaco® C-17
Appendix C
Settings
Parameters (cont.)
Wedge Parameters
You can view the machines’ wedges and associated parameters. These parameters are
defined during Collapsed Cone beam modeling and are view-only. They are saved per
machine in each clinic. This dialog box (Figure C-11) is only available to users with
Physics Group permissions. In order to access this dialog box, click the Monaco
Application button| Settings | Wedge Param.
Figure C-11: Wedge Param. dialog box
C-18
Appendix C
Settings
Parameters
Wedge Parameters (cont.)
Name Description
Installation Select an installation location from the drop-down list.
Clinic Select your clinic from the drop-down list.
Machine Select the machine identifier from the drop-down list.
Select the wedge from the drop-down list. If no wedge is available for the
Wedge Name
machine, the Wedge Name field is disabled.
This field has multiple alternatives for a value depending on the wedge type.
If a wedge is a:
Wedge Angle, • physical wedge, the value is blank.
deg
• software wedge, the value is the range for the wedge.
• motorized wedge, the value is the real value.
This field automatically adds data when a Wedge Name is chosen. A wedge
Wedge Type
can be physical, software, or motorized.
This field automatically adds data when a Wedge Name is chosen and it
Material
shows the substance of which the wedge is made.
Source to Wedge This field automatically adds data when a Wedge Name is chosen and it
Distance, cm shows the distance from the gantry to the wedge.
The orientation information includes a view of the wedge orientation, the
Orientation
Monaco orientation tag, and the value shown in the DICOM file.
This is the orientation of the wedge. This field shows for an active Sim plan
Orient
or when 3D and 3D Static Arc delivery modes are active.
You can change the value for non-XiO machines. The value of this column is
Monaco
shown in the Orientation field on the Beam Summary report.
The default value is the wedge ID. You can change this field for non-XiO
machines. The DICOM value is shown on the DICOM file. For a software
DICOM
wedge, the value of maximum field size will be updated based on the wedge
information.
Monaco® C-19
Appendix C
Settings
Parameters
Wedge Parameters (cont.)
Name Description
The Maximum Field Size includes LW, RW, UL, LL columns. For
software wedge, the value of maximum field size updates based on the
Field Size Limits: wedge information. For motorized and physical wedge, LW/RW = Max.
Field size non-wedged direction/2; UL/LL = Max. Field size wedged
direction/2
For motorized and physical wedge, LW/RW = Max. Field size non-
LW(cm)
wedged direction.
For motorized and physical wedge, LW/RW = Max. Field size non-
RW(cm)
wedged direction.
UL(cm) UL/LL = Max. Field size wedged direction/2.
LL(cm) UL/LL = Max. Field size wedged direction/2.
C-20
Appendix C
Settings
Stereotactic Cone Parameters
Use the Settings window when you configure your clinic’s stereotactic cones
(Figure C-12).
NOTE: The Settings window is not available while a patient is open or more than
one session of Monaco.
Figure C-12: Settings Window Showing the Stereo Cone Parameters
1. Under Physics, select Stereo Cone Param.
2. In the upper part of the dialog box, from the options menu, make the desired
selection for Installation, Clinic, Machine, and Applicator ID.
3. Verify that the data collection information in the center of the dialog box is
accurate. This data is associated with the Machine and Applicator ID values.
Note that the Field Size here is the default jaw or leaf bank setting based on the
stereotactic cone you select.
Monaco® C-21
Appendix C
Settings
Stereotactic Cone Parameters (cont.)
4. In the DICOM Export Values section, type the appropriate Oncology

Information System (OIS) and treatment console values for the applicator
device. These values provide a map of the stereotactic cone device to the
receiving system.
NOTE: Leave the DICOM Accessory Code field blank, because is not used at
this time.
Refer to Monaco Help files for more information.
C-22
Appendix C
Settings
Treatment Units
Treatment Unit Storing
If your clinic uses the Collapsed Cone or electron Monte Carlo algorithm, you need to
install the treatment units. To do this, you use the Treatment Unit Store application.
Adding Treatment Units
NOTE: It is important that you drop the treatment unit onto an empty space in the
database window; otherwise the data will not be stored. The system
displays a warning message if the treatment unit is not dropped to the
correct location.
Before you do these steps, you must have the modeled treatment unit information
from Elekta. For each treatment unit, this includes:
• An XML file
• Several data files
You must close Monaco before you open Treatment Unit Storing. Do not start
Monaco while you install your treatment unit machines.
1. Insert the CD or media used that contains the treatment unit data.
2. Open the Treatment Unit Store application:
• Windows 8: Open the Charms bar, and select Treatment Unit Store
from the list of apps.
• Windows 7, Windows Server 2008 and XP: Select Start | All Programs
| Elekta > Physics | Treatment Unit Store.
3. Select File > Select File to open a browse window.
Monaco® C-23
Appendix C
Settings
Treatment Units
Adding Treatment Units (cont.)
4. Browse to the media that contains your treatment unit data.
5. Select the XML files, and click Open. The treatment units will appear in the left
column of the application.
6. Click on a machine and drag it into the right column. To store a wedge or
applicator, drag it from the left column to below the treatment unit in the right
column.
7. Type the User name and Password in the confirmation window. Contact Elekta
Global Support for the User name and Password.
8. Click Yes to confirm you want to transfer the machine data. Once the machine
data is transferred, you can start Monaco.
C-24
Appendix C
Settings
Treatment Units (cont.)
Treatment Unit Mapping
Navigate to the Treatment Units option on the Settings dialog box to make or edit
treatment units. The Treatment Unit Mapping dialog box (Figure C-13) is only
available to users with Physics Group permissions. The units are only available to the
local clinic.
A treatment unit lets you group Monaco machines associated with a specific linear
accelerator together. For example, you can assign all the electron and photon energies
for a linear accelerator to the same Treatment Unit. You cannot have multiple
machines with the same energy and calculation algorithm assigned to the same
Treatment Unit. For example, for the same physical linear accelerator, if you have a 3D
machine and a machine specifically for extended SSD treatments with the same energy
and calculation algorithm, you cannot assign them to the same Treatment Unit.
Figure C-13: Treatment Unit Mapping dialog box
To open the dialog box select the Monaco Application button followed by the
Settings button.
Monaco® C-25
Appendix C
Settings
Treatment Units
Treatment Unit Mapping (cont.)
This dialog box is not available while a patient is open or more than one session of
Monaco is open.
In the spreadsheet, the treatment unit fields show options in alphabetic sequence. For
fields that have one option, the spreadsheet populates the information. If a change is
made to the beam model and the related fields no longer map to a valid logical
machine, the cells turn red until conflicts are resolved. You are not able to plan with
Treatment Units which have beams with conflicting fields.
Table C-1: Treatment Unit Mapping dialog box field descriptions
Name Description
Select an installation location from the drop-
Installation
down list.
Clinic Select your clinic from the drop-down list.
Select a name from the treatment unit list or
Treatment Unit type a name with a maximum of 16
characters.
Click the button to bring up the Treatment
Unit Characterization Configuration dialog
TU Characteristics box. You can only edit Treatment Units with
an Approval Status of Testing. Otherwise, you
can review the TU Characteristics.
Select the status of the plan approval. The
options are available once the treatment unit
orientation is set:
• Testing – This is the default status for new
treatment units. Treatment units with this
Approval Status status are available for users that have
Physics permissions. This is the only state
where you can change treatment unit
orientation fields. Warnings show on this
screen and on reports when treatment
units are not approved for clinical use.
C-26
Appendix C
Settings
Treatment Units
Name Description
• Clinical – Treatment units with this status
are available to all users.
• Archived – Archive the treatment unit if
it is no longer necessary. The system keeps
the mapping and other information for
the unit. Treatment units with this status
are not available when you select a
treatment unit for a new plan or change a
current plan. This status is only for use
with a bias dose. It is not available for new
plans. You can map a machine which is
part of an Archived Treatment Unit to a
new Treatment Unit. These functions are
disabled when the active selection is
Archived:
- Dose Calculation or Dose
Optimization
- DICOM export
- Change the treatment unit mapping

Warning messages show on single plane views
and reports when the plan is not approved for
clinical use.
Mark this check box to list all of the source
Show Unselected options. It turns on/off machines that are not
marked.
Monaco® C-27
Appendix C
Settings
Treatment Units
Name Description
Mark this check box to show the plans that are
inconsistent.
When a logical machine is active, other logical

machines that are inconsistent with the
selected machine parameters are disabled.
This machine shows a warning icon with the
inconsistencies shown in the tooltip. You can
print a warning list that records the
inconsistencies.
You cannot open an inconsistent plan until

you resolve the inconsistency.
Show Inconsistent Select to show machines that are inconsistent

with the current machine. Monaco compares
these criteria to find a match:
• MLC Model
• MLC Leaf Number
• MLC Leaf Width – this has a 0.1mm
tolerance, if the first and last leaf pairs
are different
• MLC Direction
• MLC Position – this has a 1mm
tolerance
• SAD – this has a 1mm tolerance
A warning message shows in the spreadsheet
to show the type of inconsistency.
C-28
Appendix C
Settings
Treatment Units
Name Description
You must click Save to save your changes and
when you define a new Treatment Unit. This
button is active before you save a new or
edited treatment unit. Once saved, a treatment
unit is available based on approval status.
This button is disabled if there are no changes

to the mapping of if the machine orientations
are not defined.
Save A warning message appears when you click
the Save button to confirm edits made to an
existing treatment unit mapping. A message
appears if changes to these fields are made
when completing a new mapping:
• OK
• Installation
• Clinic
• Treatment Unit
• Change tabs in the Settings dialog box
This field shows a warning message icon when
necessary. A warning icon appears:
• as a tooltip when you hover over an
Warnings inconsistency (triangle shaped)
warning icon
• as a printable warning that states
inconsistencies when the round icon
is clicked.
Select a machine for treatment unit mapping.
You cannot select machines with a warning
Check boxes icon. The machine information comes from
the Focal machine files or an Oncentra
database.
Monaco® C-29
Appendix C
Settings
Treatment Units
Name Description
Shows the source of the treatment machine
data. Click the column head to sort the source
Source
in alphabetic sequence. Click again to reverse
the order.
Shows the ID of the treatment machine. Click
the column head to sort the machines in
Machine ID
alphabetic sequence. Click again to reverse the
order.
Shows the type of treatment machine. Click

the column head to sort the modality in
Modality alphabetic sequence. If you click the column
heading once again, the sort reverses its
sequence.
Shows the energy for the treatment machine.
Click the column header to sort the energy in
Energy
order.
Shows the algorithm the machine uses. Click
the column head to sort the algorithm in
Algorithm
order.
C-30
Appendix C
Settings
Treatment Units
The Treatment Unit Characterization Configuration dialog box (Figure C-14) is

available for Treatment Units with a TU Approval Status of Testing. For each machine
assigned to the Treatment Unit you can change the default geometric settings.
1. Click the Define/View button. Monaco opens the Treatment

Unit Characterization Configuration dialog box.
2. You can edit the values for each machine which are mapped to the selected
Treatment Unit. The new values you enter are used in planning.
Figure C-14: Treatment Unit Characterization Configuration dialog box
Monaco® C-31
Appendix C
Settings
Treatment Units
3. Select the Customize Labels button to enter labels for the X and Y jaws. Monaco
shows the Collimator Jaw Labels dialog box (Figure C-15).
4. If the Treatment Unit is in Testing state, you can enter labels for symmetric jaws,
asymmetric jaws and the MLC leaf banks.
5. Click OK to save your changes. Monaco shows the labels when you use this
machine in a treatment plan.
6. Click Save on the Settings dialog box to save the Treatment Unit.
Figure C-15: Collimator Jaw Labels dialog box
C-32
Appendix D
MLC Geometry Definitions
General Information
You must understand the nomenclature used in Monaco when you update the MLC
Geometry Parameters. The diagrams in this section illustrate the MLC Geometry
Parameters.
The positions of all elements are given relative to their axis of motion, with the
direction (x,y) being implicit. Units are mm for all parameters.Positions of paired
elements are given on the same scale and with the same orientation (that is, in this
example, Right Parallel Jaw has a positive position, while Left Parallel Jaw has a
negative one). Hence, openings between paired elements are (Left-Right) and (Upper-
Lower) respectively. You see the MLC assembly from the source, that is, in the
direction of the beam.
Monaco® D-1
Appendix D
Below is the direction of movement for the parallel jaws:
D-2
Appendix D
Below is the direction of movement for the transverse jaws:
Monaco® D-3
Appendix D
Below is the MLC Leaf Constraint Definitions:
D-4
Appendix E
DICOM
Import Utility Scenarios
The three import scenarios below are outlined in this appendix section.
Select one or multiple image series from multiple modalities that may or may not
include structure set, plan, and dose data, then import them. Import image data that
you would like to fuse and use image fusion. Merge multiple image series from the
same studyset into one studyset for import.
Import One or Multiple Series for the Selected DICOM Patient
Use this scenario when you want to import any of these items:
• DICOM CT images
• DICOM PET images
• DICOM MRI images
• DICOM 4D Images
• Images for the same patient from multiple modalities (example, CT and MRI)
• RT Structure Sets
• RT Plans
• RT Dose
In the window where you choose the patient, you can make any of these selections:
• Select the Image data for one modality. Left-click on the modality (CT, PET,
or MRI) under the selected patient name.
• Select the Structure Set data for one image set. Left-click on the RTSS file.
Since the structure set is linked to an image set, the system automatically
selects the referenced images.
• Select the RT Plan data for one image set. Left-click on the RTPLAN file.
Since the plan is linked to a structure and image set, the system automatically
selects the referenced structure set and images.
• Select the RT Dose data for one image set. Left-click on the RT Dose file.
Since the dose is linked to a plan, a structure set and image set, the referenced
plan, structure set and images are automatically selected.
• Select Multiple Image Sets, Plan sets, or Dose Data Sets. Left-click on the
first set of data to select it. Hold down the control button [Ctrl] on your
computer keyboard and select the second, third, etc.
Monaco® E-1
Appendix E
DICOM
Import Utility Scenarios
Selecting Image Sets that have Different Patient IDs for Fusion
Use this scenario to import images under the same patient ID so you can fuse them.
• Select and import the first image set for one modality. Left-click on the
modality (CT, PET or MRI) under the selected patient name.
• Select and import the second image set and change the Patient ID to the same
name you used to import the primary image dataset.
The two image sets now reside under the same patient ID. You can fuse them in Image
Fusion.
Merge and Import Multiple Image Series for the Selected DICOM Patient
Use this scenario if you have a patient with multiple scan series. Use the same Study ID
and frame of reference that you want to merge for planning purposes.
Select multiple series for the same modality. Hold down the control [Ctrl] button on
the keyboard and left-click multiple series.
Click the Merge button. This action populates the destination column with the
selected source data and merges them into one complete series.
Enter or Edit DICOM Settings
These settings apply to data that you want to export to any application that receives
DICOM. They do not apply when you send data to XiO. Use the DICOM Export
button on the Output tab of the ribbon to do the actual export. An explanation of the
export appears in detail after this section.
E-2
Appendix E
DICOM
Export Utility
Setup your DICOM File Export Data Location

Type the location where you would like to store DICOM Export data when you choose
to export to a file.
1. To type or edit the DICOM Export Settings, click on the Monaco Application
Menu button then the Setup| DICOM Settings to show the DICOM
Settings dialog box (Figure E-1).
Figure E-1: DICOM Settings dialog box

2. The default location for the DICOM File Export data automatically appears.
However, you can click the Browse button to set a new data location, if desired.
3. The SCU Name is the name of the Monaco PC where you enter these settings. A
default name is also given. However, you can edit it. The receiving application
must have this name assigned in its DICOM Import program in order to receive
the exported data.
Monaco® E-3
Appendix E
DICOM
Export Utility (cont.)
Setup Storage of Incoming Images for Future Export
If you plan to export image data that was previously transferred into Monaco, you
must have the Store Incoming DICOM Images box checked before you import the
images. This makes a copy of the image data that you use when you export. Should
you not want to export image data, do not put a checkmark  in this box. This will
prevent your hard drive from filling with unnecessary image data.
Setup DICOM Export Locations
Type the location(s) where you would like to send DICOM Export data when you
choose to export to an SCP location.
1. Type the Label for the location. This is the location label you select from the
DICOM Export dialog box when you export to an SCP location.
2. Type the AE Title for the receiving system.
3. Type the resolvable hostname or a valid IP address for the receiving system.
4. Type the Port Number you want to use for this DICOM transfer.
5. Once you type in all the information for an export location, highlight the export
location you want to test, and then click the Test button to verify
communication between the two systems.
6. If the test was successful, click OK when you are done entering or editing these
settings.
7. Add or Delete Export locations. Highlight the location you want to remove and
click the Add or Delete button.
E-4
Appendix E
DICOM
Export Utility (cont.)
Exporting via DICOM
You can export these modalities via DICOM to a record and verify system or another
treatment planning computer:
• Images
• Specialty Images
• Structure Sets and/or individual structures
• RT Plans
• RT Images (DRR’s)
• Monaco dose - total and/or individual beam doses for single prescription,
multiple prescription, and MR plans
• Monaco QA dose - total dose and/or individual beam doses
• DVH
In Planning, click the DICOM Export button on the Output tab.
NOTE: If the Export option is not available, verify these two items:
(1) You have a patient loaded.
(2) You have turned on the proper DICOM license features.
Complete these steps to export data via DICOM:
1. Click on the DICOM Export button on the Output tab to show the DICOM
Export dialog box (Figure E-2).
Figure E-2: DICOM Export dialog box
Monaco® E-5
Appendix E
DICOM
Export Utility

2. Select the modalities you want to export.
NOTES: (1) Images and Structure Set options are only available if you
checked the Store Incoming DICOM Images checkbox located in
DICOM Settings.
(2) The RT Plan option is only available if you have a plan loaded.
(3) Dose options are only available if you have RT Plan selected.
(4) You cannot DICOM export composite plans.
3. (For Elekta non-micro MLC: Step and Shoot IMRT, VMAT, Conformal RT, and
dMLC plans. Siemens: Step and Shoot IMRT and Conformal RT Plans only)
When you check the RT Plan option, you can also check Composite Field
Sequencing to group beams with a common couch angle into a single control
point sequence. (For detailed information about composite field sequencing,
refer to the Online Help).
4. When you check the Include Setup Beams option, the system exports the setup
beams created in the beam spreadsheet. The SetupBeams/Sequences are DICOM
exported as SETUP with the RT plan.
5. When you click on the Addt’l Options button, the Additional Plan Export
Options dialog box shows a table of options you can DICOM export. You use
these options to match the information defined in your record & verify system.
Figure E-3: Additional Plan Export Options dialog box

6. If you have RT images associated with your plan, you can select to export all the
images, or select individual beam images. The RT images are exported with a
fine resolution. Under RT Image Options, you can check the respective boxes
to Add Overlays, Add Anatomy, and Add Annotation.
E-6
Appendix E
DICOM
Export Utility

7. When you check Total Dose, the system exports the total composite dose for all
the beams.
8. When you check individual beams under total dose, the system exports
individual beam doses.
9. When you select RT Plan as a modality to export, the system activates the Map
Machine feature. Click Map Machine to show the modeled machine names.
10. Next to each modeled machine name, type a name that the receiving system
recognizes.
11. Select the Destination to where you want to export, such as the record and
verify system. If you select File, the file is saved on your Monaco PC in a folder
called DCMXprtFile.
12. To export a plan and use an add-on micro-multileaf MLC, you have additional
export options to select.
Figure E-4: RT Plan Options

13. To send the data to the Add-on TCS controller, select the SCP location in the
Add-on TCS field. This information includes the complete plan that contains
actual leaf and jaw positions.
14. Select the special Accessory Tag for the Built-in MLC in the OIS Accessory field.
15. You can edit the Patient ID, Patient Name, Block/Aperture ID, and Plan ID
before you export it. Check the box next to Use Monaco Patient ID and Patient
Name, if desired.
16. Click the Export button to export the selected modalities.
Monaco® E-7
Appendix F
Patient Information Management
General Functionality
The topics reviewed in this section introduce additional information necessary

when Monaco is used with XiO.
You can import and evaluate calculated plans from XiO or other vendors in
Monaco Plan Review.
Configuration of the Monaco and XiO Interface
You must set up a data location and server so that XiO and Monaco can share
data. See the Monaco Installation Guide for more information on Monaco
preferences.
When you use Monaco with XiO, you must use usernames and passwords for the
systems to communicate. Valid usernames and passwords in XiO are valid on
Monaco.
Send and Unget Overview
The Send and Unget features are available for users to send patients to XiO for
planning or calculation. Use Send to transfer the patient with all the contours
and/or plan information. Use Unget to send the patient to XiO with none of the
contours or plan information saved.
Monaco® F-1
Appendix F
Send a Patient to XiO
This section shows you how to send patients back to XiO with all the saved
changes.
1. Click Monaco Application button | Send Patient to show the Send dialog
box.
Figure F-1: Send dialog box
2. Check the box next to the patient you want to send to XiO.
3. If you want to copy the patient data to the recycle bin when you send it to
XiO, instead of it being removed completely from the PC, check the box
next to the Copy Patient to Recycling Bin. It is important that you use this
option to prevent lost of patient data. But, you need to empty your recycle
bin periodically.
4. Click the Send button to send the patient data to the clinic identified during
the initial transfer of image data.
5. In XiO, you can open the patient data file and select Permanent Plan to
retrieve the saved plan.
NOTE: XiO ignores all boli you add to the patient in Monaco.
F-2
Appendix F
Unget a Patient to XiO
This section shows you how to send patients back to XiO without saving any
changes made in Monaco. This option completely removes any changes made in
Monaco.
1. Click Monaco Application button | Unget Patient to show the Unget

dialog box.
Figure F-2: Unget dialog box
2. Check the box next to the patient you want to push back with no changes to
XiO.
3. If you want to copy the patient data to the recycle bin when you send it to
XiO, instead of it being removed completely from the PC, check the box
next to the Copy Patient to Recycling Bin. It is important that you use this
option to prevent loss of patient data. However, you need to empty your
recycle bin periodically.
4. Click the Unget button to show a warning that all changes will be lost when
you send this patient back to XiO.
5. Click the Yes button to acknowledge the warning to send the patient data to
the clinic identified during the initial transfer of image data.
6. In XiO, you can open the patient data file and restore the patient with no
changes.
Monaco® F-3
Appendix F
Handling XiO Patients
Opening a Remote XiO Patient in Monaco
There are two ways to open a patient in Monaco that resides on XiO. You can
push the data from XiO or while on Monaco, pull the data from XiO (described
in the General Operation and Navigation section).
Open Pushed data from XiO
On XiO, there is an option on the main screen to Transfer data to Focal PC.
Once you select and send the data from XiO, a blue folder under the Local Patient
tab designates patients that have been pushed from XiO and are waiting to be
opened in Monaco. While this patient is in use on Monaco, the patient is
inaccessible in XiO until it is sent back.
Select a Batch of Patients to Import from XiO
These instructions demonstrate how to select a batch of patients from XiO to

bring into Monaco for planning or review. This function only applies to those
using Monaco with XiO.
1. Click the Monaco Application button | Batch Get to open the Batch Get
dialog box.
2. Select the Installation and Clinic from the location where you would like to
get these patients.
3. Select as many patients from the list as you need by clicking on them to
highlight them.
4. (Optional) To de-select a patient name, click on it again to remove the

highlight.
5. (Optional) Place a checkmark in the Sort the Patients by Name box.
When left unchecked, the system sorts the patients by patient ID.
6. Click OK when you are done to download the selected patients.
F-4
Appendix F
Anatomical Groups
Structures List
You can create new structure names when you type the new name in the field.
The structures list automatically contains a select few default structure names.
If your system is connected to XiO and you would like to take advantage of the
anatomical groups created on XiO, click the Contouring tab and select the Add
Anatomical Groups option to show the Select Anatomy Group dialog box
(Figure F-3).
Figure F-3: Select Anatomy Group dialog box
Left-click the groups you want to add. Click OK to close the dialog box. The
system shows the contours associated with the selected group(s) in the structures
list.
Monaco® F-5
Appendix F
Plan Review
There are a few specific tools available in Plan Review to those who plan to review
XiO plans on Monaco. These tools are View images from XiO, Plan Comments
and Electronic Approval. Use of View images from XiO is outlined here.
View Images from XiO
If you captured images in XiO and saved them with your XiO plan, you can view
them in Plan Review. For more information on how to capture bitmap images in
XiO, see the XiO Training Guide.
1. Click Plan Options tab | Image Viewer to show the dialog box with images
associated with the shown plan(s).
2. Select a plan from the Plan column to show the thumbnail images available
for the selected plan.
3. Double-click on an image to select a single thumbnail image.
4. Select multiple images. Hold down the Shift key on the keyboard and left-
click the first and last image of the set. Then, click the Open Images button.
OR
Hold down the Ctrl key on the keyboard and left-click on each image to
select several images. Then, click the Open Images button.
F-6
Appendix G
Workflow Scenario for Margin Recipe Usage
Creating and Customizing the Advanced Margin Template
Introduction and Background
Radiotherapy uses safety margins to account for the uncertainties associated with
the complete (imaging -> delineation -> planning -> set-up -> delivery) treatment
process. All margins are designed using some form of statistical method. As an
example, to have 100% probability that the CTV for every patient receives at least
100% of the prescription dose, the PTV margins would have to be calculated from
the maximum errors across all patients that will ever occur. However, this would
clearly result in many of the patients being treated with unnecessarily large fields,
which relates to larger than required volumes of high dose (and consequent normal
tissue toxicity) A solution where the majority of patients are treated with
appropriate margins at the expense of a potential under dose to the CTV for a few
patients seems a better compromise.
You can formally express this as: ‘The margin required to deliver at least X% of the
prescription (Rx) dose to the CTV for Y% of the population.’ As an example, deliver
at least 95% of the Rx dose to the CTV for 90% of the population.
Monaco uses the formula below, which describes the isotropic margin in a single
dimension from the GTV to the PTV:
M PTV , X %,Y % = α Y Σ + β X σ 2 + σ p2 − β X σ p
,
Where:
α Y = unitless, constant α Y relates to the percentage of the population, for which you
desire the margin to apply, values of α Y (see Table 2) are shown below.
Σ = the standard deviations in cm of the systematic errors (errors during
preparation (planning, imaging)).
β X = unitless, constant β X relates to the distance between the prescription isodose

line and the 50% isodose line, values for β X (see Table 1) are below.
Monaco® G-1
Appendix G
Creating and Customizing the Advanced Margin Template
Introduction and Background (cont.)
σ = the standard deviations in cm of the random errors (errors during treatment

execution).
i
Σ≡ ∑Σ
n =1
2
Si
is the sum in quadrature over all systematic errors.

i
σ 2 ≡ ∑ σ 2 Ri is the sum of the squares of all the random errors.
n =1
σ p = the penumbra width in cm modeled by a cumulative Gaussian.

For prostate, the penumbra width used in the ‘classic van Herk’ margin recipe is 0.32
cm for an 8 MV beam in water.
For lung (assumed homogeneous density of 0.25 g/cm3) a penumbra width of 0.64
cm for an 8MV beam is used. For simplicity, it is assumed that the tumor is the same
density as the lung and there are no adjacent solid tissues.
G-2
Appendix G
Example: Lung SBRT
Monaco includes the Advanced Margin Template Lung SBRT which is based on the
following work1.
Figure G-1: Advanced Margin dialog box
Caution: Values in the template have to be modified to represent data valid for your
clinic.
In order to determine the systematic and random components of localization

uncertainty, many patients are scanned, shifted, and re-scanned. The difference
between pre shift and post shift (pre treatment) are compared to arrive at the mean
and the systematic and random components. To determine the systematic and
random components of intra-fraction variability, the post-shift scan is then
compared to a post-treatment scan for each patient in the group. Note that the
assumption that differences between pre-treatment and post-treatment position
increase linearly with the time. Therefore, divide the magnitude of the systematic
component for infra-fraction stability by two when computing the margin1.
Monaco® G-3
Appendix G
Example: Lung SBRT (cont.)
All systematic and random components are specific to an institution and patient set-
up, treatment technique, and treatment time length (generally speaking, the longer
the patient is in treatment position, the greater the intra-fraction variability). You
should assess delineation uncertainty locally as well, via blind studies, as it may
depend on imaging technique and physician training2. Tumor motion is the most
easy to determine and is assessed by the use of 4-D scans for each patient.
The Margin Recipe formula uses parameters α Y and β X which correspond to the
Confidence Level (%) and the Prescription Line (%). The effect of treatment
preparation (systematic) errors and execution (random) errors is fully separated.
Therefore, a margin to account for the preparation errors (a margin to compensate
for an unknown shift of the CTV) and a margin to account for execution variations
(a margin to compensate for the blurring of the dose distribution due to day to day
variation) are in separate tables. For the source of the α Y and β X (both unitless)
tables3.
Table 2: Values for βX (table 3 from Ref. 3)
(Dosimetric part of the margin):
Prescription Line % βX
80% 0.84
85% 1.03
90% 1.28
95% 1.64
99% 2.34
G-4
Appendix G
Note that (from Ref. 3), the value of αY is related to the percentage of the population
for which you desire the margin to be applicable.
Table 3: Values of α Y (from table 2 from Ref. 2) are listed below:3
Confidence Level α Y 3D
(% of patients)
80% 2.16
85% 2.31
90% 2.50
95% 2.79
99% 3.36
As an example, the equation which relates the margin from the GTV to the PTV
necessary to deliver at least 95% of the Rx dose to the CTV for 90% of the population
is:
M PTV ,95%,90% = 2.5Σ + 1.64 σ 2 + σ p2 − 1.64σ p
.
You can input values for the Confidence Level (%) and the Prescription Line (%).
The system calculates and shows the corresponding α Y and βX values based on the
alpha and beta tables above. You can edit and save these tables with new data. For
example, in the default Confidence Level dependency table, perfect conformation in
3D is assumed. Because, in reality this is not always true, you can use a different
values for α Y which corresponds to 2D conformation (for example when using
opposed block fields). Notice that it is impossible to reach 100% confidence level, as
this would require infinite margins (example: total body irradiation).
Monaco® G-5
Appendix G
The advanced margin template (when used to calculate the required margin) can be
saved with empty cells (example, Respiratory Motion of the tumor in each direction)
for the patient-specific component.
How to Establish Margin Recipe Input Data for Your Clinic
An end-to-end test of the entire patient imaging -> delineation -> treatment
planning -> set-up -> delivery treatment process using an anthropomorphic
(patient-like) phantom, can assist to establish the possible uncertainties in each
process activity.
Using the standard image acquisition protocol, the possible geometric errors and
Hounsfield Unit reproducibility can be established using this system. In order to
store values and trend results over time, you could use MOSAIQ (example:
MOSAIQ supplies multiple default assessment views that you can use). Refer to
MOSAIQ User Guide for more information on Clinical Assessments. You can also
use the same approach for MR image studies.
Monaco 4D supports both the multi-observer input and display/comparison of

different structure sets based upon a single CT study (image series). If Monaco is
used, then instead of separate structure sets, different clinician users may draw
different structures for the same structure set, and display/compare them on a single
CT study.
Although a user can establish a 3D set-up error using orthogonal or stereoscopic

MV portal images and bony (landmark) anatomy, image guided radiotherapy
practice using cone beam CT (CBCT) and the Elekta XVI application in 3D is
expected.
XVI R4.5 supports a dual-registration technique in which a user can register the
reference CT study to the pre-treatment CBCT using bony landmark anatomy,
hence establishing the set-up error, followed by registration to the GTV itself (the
tumor or organ motion). The values of calculated translations are the data required
for margin recipe input. Conversion of rotations to translations and applying them
as patient (couch) shifts, or applying the calculated rotations using the Hexapod
patient support system, is not accounted for.
G-6
Appendix G
How to Establish Margin Recipe Input Data for Your Clinic (cont.)
MOSAIQ captures the applied shifts from the XVI application. However, with a
shrinking action level protocol, there may be sessions in which the XVI calculated
data is not actually applied, and hence this data would be missing when the session
(treatment fraction) should be included in margin calculations.
References
1. Sonke JJ, Rossi C, et al. ‘Frameless stereotactic body radiotherapy for lung
cancer using four-dimensional cone beam CT guidance’, Int. J. Radiat.
Oncol. 74(2), 567-574 (2009).
2. Remeijer P, Rash C, Lebesque JV et al. A general methodology for three-

dimensional analysis of variation in target volume delineation, Med Phys.
1999; 26:931-940).
3. van Herk M, Remeijer P, et al, The probability of correct target dosage:

Dose-population histograms for deriving treatment margins in
radiotherapy, IJROBP, 2000; 47:1121-1135.
Monaco® G-7
Appendix G
G-8
Manufacturer European Union Authorized Representative
Elekta Business Area Software Systems
IMPAC Medical Systems, Inc. Elekta Limited
13723 Riverport Drive Linac House, Fleming Way
Suite 100 Crawley, West Sussex
Maryland Heights, MO 63043 RH10 9RR,
USA United Kingdom
Phone: +1.800.878.4267 Phone: +44 129 365 4242
Fax: +1 314 812 4491 Fax: +44 1293 471347
Email: eu_ar@elekta.com
Monaco
www.elekta.com Human Care Makes the Future Possible

Corporate Head Office: Regional Sales, Marketing and Service:
Elekta AB (publ) North America Europe, Latin America, Asia Pacific
Box 7593, SE-103 93 Atlanta, USA Africa, Middle East & India Hong Kong, China
Stockholm, Sweden Tel +1 770 300 9725 Tel +44 1293 544 422 Tel: +852 2891 2208
Tel +46 8 587 254 00 Fax +1 770 448 6338 Fax +44 1293 654 321 Fax: +852 2575 7133
Fax +46 8 587 255 00 info.america@elekta.com info.europe@elekta.com info.asia@elekta.com
info@elekta.com

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Monaco® Training Guide

IMPAC Medical Systems, Inc.

XiO® is a registered trademark of IMPAC Medical Systems, Inc.

Monaco™ is a registered trademark of IMPAC Medical Systems, Inc.

Hewlett-Packard™ is a trademark of Hewlett-Packard Corporation.

Copyright © 2015 by IMPAC Medical Systems, Inc. All rights reserved.

Document Number. LTGMON0510

Volume I of IV – Monaco Sim

Section 2. General Operation and Navigation

Section 2. General Operation and Navigation (cont.)

Section 2. General Operation and Navigation (cont.)

Section 2. General Operation and Navigation (cont.)

Section 3. CT Simulation Options

Section 4. Fusion Activity

Section 5. Contouring Tools

Section 5. Contouring Tools (cont.)

Section 5. Contouring Tools (cont.)

Section 6. Planning Tools

Section 6. Planning Tools (cont.)

Section 7. Plan Review Activity

Section 7. Plan Review Activity (cont.)

Section 8. Practice Exercises

Section 9.Treatment Couchtop Inclusion

Section 2. Planning and Workflow: Workflow Diagram, Contouring,

Section 2. Planning and Workflow: Workflow Diagram, Contouring,

Section 3. 3D Lung Case

Section 4. 3D Breast Case

Section 4. 3D Breast Case (cont.)

Section 5. 3D Prostate Case

Section 5. 3D Prostate Case (cont.)

Section 6. IMRT Tools

Section 6. IMRT Tools (cont.)

Section 7. Planning and Workflow: Calculation Parameters and IMRT

Section 7. Planning and Workflow: Calculation Parameters and IMRT

Section 7. Planning and Workflow: Calculation Parameters and IMRT

Section 8. Planning and Workflow: Optimization and Sequence

Section 8. Planning and Workflow: Optimization and Sequence

Section 9. Planning and Workflow: Plan Analysis and Evaluation

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

Section 10. Monaco Planning Suggestions

Section 10. Monaco Planning Suggestions (cont.)

Section 11. Prostate IMRT Case

Section 12. Prostate VMAT Case

Section 13. Head and Neck Case

Section 14. Breast Case

Section 15. Brain Case – Two Partial Arcs

Section 16. mARC Brain Case

Section 17. Multiple Prescription

Section 17. Multiple Prescription (cont.)

Section 18. Bias Dose – Head and Neck

Section 19. MR Planning

Section 20. Additional Cases

Section 21. QA Tools

Section 22. QA Exercise

Section 23. Stereotactic Planning with Monaco

Section 23. Stereotactic Planning with Monaco (cont.)

Section 23. Stereotactic Planning with Monaco (cont.)

Volume III of IV – Physics

Section 1. Monaco Patient Model (Presentation)

Section 2. Dose to Medium / Dose to Water Considerations

Section 3. MU Workflow in Monaco (Presentation)

Section 4. Monaco Optimization Dose Calculation Algorithms

Section 5. Electron Monte Carlo Algorithm (Presentation)

Section 6. Head Model and Collapsed Cone Photon Algorithm for 3D