CK Vsi Tds 11.2 Manual

Treatment Delivery Manual
Treatment Delivery
Manual
Version 11.2.x
CyberKnife VSI® System

Date of Revision: 2021-06
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Manufacturer
Accuray Incorporated
1209 Deming Way
Madison, Wisconsin 53717 USA
Customer Support
For more information, to request documentation, or if you have a service issue, please contact
Accuray Customer Support (North America) at +1-866-368-4807, contact your Distributor, or visit
the For more information, to request documentation, or if you have a service issue, please contact
Accuray Customer Support (North America) at +1-866-368-4807, contact your distributor, or visit
the Services tab at www.accuray.com.
NOTE: If your facility works with a third-party service provider, please contact them directly for
your service-related issues.
Copyright Information
© 2001-2021 Accuray Incorporated. All rights reserved.
This document, software (© 2001-2021) and products to which this document refers, and any other
related materials are the copyrighted and proprietary information of Accuray Incorporated, with the
exception of open source software described below, and may not be used or distributed without
written authorization of Accuray Incorporated. No part of this document may be photocopied,
reproduced, or translated into another language without written permission from Accuray
Incorporated. TomoTherapy Incorporated is a wholly owned subsidiary of Accuray Incorporated.
Any references herein to Accuray Incorporated necessarily also include reference to TomoTherapy
Incorporated by definition.
Accuray Incorporated reserves the right to revise this publication and to make changes in content
from time to time without obligation on the part of Accuray Incorporated to provide notification of
such revision or change.
Accuray Incorporated provides this guide without warranty of any kind, either implied or expressed,
including, but not limited to, the implied warranties of merchantability and fitness for a particular
purpose. Accuray Incorporated and its directors, officers, representatives, subsidiaries,
employees, agents, heirs and assigns assume no responsibility or liability, either express or
implied, for injury, death, or losses to consumers, users or service personnel resulting from
improper handling of the Accuray products by unauthorized, untrained or otherwise unqualified
personnel. Accuray Incorporated expressly denies any responsibility or liability for abuse, neglect,
misuse or tampering with Accuray System components by persons not authorized, trained or
otherwise associated with Accuray Incorporated.
1075883-ENG A | iii
Accuray Incorporated Treatment Delivery Manual
Trademark Information
The stylized Accuray logo, CyberKnife, CyberKnife VSI, CyberKnife M6, CyberKnife S7,
TomoTherapy, H Series, Tomo, TomoH, TomoHD, TomoHDA, TomoEDGE, TomoHelical,
TomoDirect, Hi·Art, PreciseART, PreciseRTX, Radixact, Accuray Precision and iDMS, Iris,
Xchange, RoboCouch, InCise, MultiPlan, Xsight, Synchrony, Synchrony Fiducial Tracking,
Synchrony Skull Tracking, Synchrony Spine Tracking Supine, Synchrony Spine Tracking Prone,
Synchrony Spine Tracking Prone with Respiratory Modeling, Synchrony Lung Tracking with
Respiratory Modeling, Synchrony Fiducial Tracking with Respiratory Modeling, Synchrony Fiducial
Tracking with InTempo Imaging, TxView, PlanTouch, QuickPlan, ClearRT, CTrue, VoLO, Planned
Adaptive, TQA, TomoLink, TomoPortal, Accuray OIS Connect, and AERO Accuray Exchange in
Radiation Oncology are trademarks or registered trademarks of Accuray Incorporated, in the
United States and other countries and may not be used or distributed without written authorization
from Accuray Incorporated. Use of Accuray Incorporated trademarks requires written authorization
from Accuray Incorporated.Warranty Information.
Warranty Information
If any Accuray products are modified in any manner all warranties associated with such products
shall become null and void. Accuray Incorporated does not assume any responsibility or liability
with respect to unauthorized modification or substitution of subsystems or components.
With proper care and maintenance, the expected service life of the Accuray System is 10 years.
The Accuray System, including each computer workstation and associated system software, has
been validated to demonstrate that the system will perform as expected. The installation of
additional software not released by Accuray Incorporated (e.g. third party, off-the-shelf, etc.) on
these computer workstations is not permitted. This includes any operating system updates. Any
effect on the safe and intended operation of the Accuray System caused by the introduction of
additional software is unknown and Accuray cannot be responsible for any impact caused by
adding such software.
Hardware and Software Maintenance

Only qualified service personnel should service or maintain system hardware components. If you
feel that Accuray System hardware components or associated features or functions do not perform
as expected, or they provide results that are inconsistent with your established clinical and
research protocols, call Accuray Customer Support (North America) at 1-866-368-4807, contact
your distributor, or visit the Services tab at www.accuray.com.
Device Disposal
When an Accuray product reaches the end of its useful life and your facility desires to remove the
device, contact Accuray Customer Support to decommission, uninstall, and appropriately dispose
of the components
iv | 1075883-ENG A
Use of Third-Party Software

Accuray Incorporated software is being distributed together with certain third-party software that is
made publicly available under open source software licenses. Notices relating to such third-party
software and the license terms under which these software components were obtained by Accuray
are located in this user's guide, in any applicable release notes, or in the about box that displays
to the customer for the appropriate software program. Source code for an applicable open source
software component is available upon written request. Automatic image registration is based on
routines in Numerical Recipes: The Art of Scientific Computing, published by Cambridge University
Press, which are used with permission.
Instructions for Use of the Accuray System

Safe operation of the Accuray System requires careful attention to the serious hazards associated
with the use of linear accelerators and complex radiation therapy equipment and ways to avoid or
minimize the hazards, and familiarity with emergency procedures. Untrained or careless operation
of the Accuray System can damage the system, its components or other property; cause poor
performance; or lead to serious bodily injury and possibly death. Anyone who operates, services,
maintains, or is otherwise associated with the Accuray System must read, understand, and be
thoroughly familiar with the information in this manual, and take precautions to protect themselves,
their associates, patients, and the equipment. At each step in the installation, specific warnings and
cautions are given for specific actions.
Personnel must be trained by Accuray Incorporated before the Accuray System is used for
research or clinical purposes. Accuray System documentation was originally drafted, approved,
and supplied in English (US).
The following statements are intended to alert the user to potential conditions that could result in
injury to the patient (warning) or conditions that could affect system components (caution).
WARNING: Warning statements describe possible conditions that can result in serious
fatal injury to the patient or facility personnel. Each warning gives the possible condition
and how to avoid it.
CAUTION: Caution statements describe possible conditions that can affect system performance
or cause damage to system components. Each caution gives the possible condition and how to
avoid it.
Prescription Device Statement
CAUTION: Federal law restricts this device to sale by or on the order of a physician.
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Treatment Delivery Manual Table of Contents
Table of Contents
Chapter 1: Overview ................................................................1-1

Clinical Benefit............................................................................................ 1-1
Residual Risks ............................................................................................ 1-2
Incident Reporting ...................................................................................... 1-2
Conditions Required for Transport and Storage ..................................... 1-2
Virus Protection Software and Firewalls .................................................. 1-3
Performance Characteristics..................................................................... 1-3
Manuals ....................................................................................................... 1-3
Chapter 2: Safety......................................................................2-1
Introduction ...................................................................................... 2-1
Emergency Procedures ................................................................... 2-3
Emergency Stops (E-Stop) ........................................................................ 2-3
The E-Stop Button.............................................................................................. 2-4
Resetting an E-Stop ........................................................................................... 2-5
Software E-Stop Failure ..................................................................................... 2-5
E-Stop Button Failure ......................................................................................... 2-5
Emergency Power Off (EPO) ..................................................................... 2-6
Power Failure .............................................................................................. 2-7
LINAC Malfunction...................................................................................... 2-8
Fire or Fumes .............................................................................................. 2-8
Treatment Couch Failure ........................................................................... 2-8
Unexpected Robot Arm Motion ................................................................. 2-9
Safety Precautions........................................................................... 2-9

X-ray Radiation ......................................................................................... 2-10
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Implanted or Body-Worn Electronic Medical Devices .......................... 2-11

Essential Performance ............................................................................. 2-12
Electromagnetic Interference ................................................................ 2-12
Laser Radiation ......................................................................................... 2-17
Sulfur Hexafluoride ................................................................................... 2-17
Implosion ................................................................................................... 2-18
Explosion ................................................................................................... 2-18
Electric Shock ........................................................................................... 2-19
Precautions to Avoid Electric Shock ................................................................ 2-19
Heavy Equipment ...................................................................................... 2-20
The Patient Safety Zone ........................................................................... 2-22
Proximity Detection Program ........................................................................... 2-22
Supplemental Proximity Detection Program .................................................... 2-23
Patient Safety Zone Dimensions (Standard Treatment Couch and
RoboCouch Flat Table Top Configuration) ...................................................... 2-24
Required Measurements Before Treatment Delivery ....................................... 2-28
Responding to PDP and SPDP Errors ............................................................. 2-29
Contact Detection Sensor Check ............................................................ 2-32
Hot Surfaces .............................................................................................. 2-34
Facility Responsibilities ..................................................................2-35

General Use ............................................................................................... 2-35
Disinfection Instructions .......................................................................... 2-35
Safety Operations ..................................................................................... 2-35
Emergency and Safety Training .............................................................. 2-36
Radiation Overdose .................................................................................. 2-36
Chapter 3: CyberKnife Treatment Delivery System Overview3-1

Introduction.......................................................................................3-1
CyberKnife System Components .....................................................3-2
Target Locating System (TLS) ................................................................... 3-3
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X-ray Sources and Generators........................................................................... 3-3

Digital X-ray Detectors ....................................................................................... 3-4
Isopost Calibration Tool...................................................................................... 3-4
Detector Windows .............................................................................................. 3-4
Operator Control Systems ......................................................................... 3-6
Treatment Delivery Computer ............................................................................ 3-6
Synchrony Skull Tracking................................................................................... 3-6
Synchrony Fiducial Tracking .............................................................................. 3-6
iDMS Data Management System ....................................................................... 3-6
User Control Console Equipment....................................................................... 3-7
Accuray Precision Treatment Planning System ...................................... 3-7
LINAC and Control Systems...................................................................... 3-8
LINAC................................................................................................................. 3-8
X-ray Head ......................................................................................................... 3-8
Secondary Collimators ....................................................................................... 3-8
Laser Alignment Check Sensor.......................................................................... 3-9
Modulator Control Chassis (MCC) ..................................................................... 3-9
Modulator (MOD)................................................................................................ 3-9
Chiller ................................................................................................................. 3-9
Target Locating System (TLS) computer ........................................................... 3-9
Target Locating System Control Console (TLSCC) ........................................... 3-9
Interface Control Chassis (IFCC) ..................................................................... 3-10
Treatment Robot ....................................................................................... 3-10
Power Distribution Unit (PDU)................................................................. 3-11
E-Stop Control Chassis (ESCC) .............................................................. 3-11
Uninterruptible Power Supply (UPS) ...................................................... 3-11
Miscellaneous Equipment (Supplied by Customer) .............................. 3-11
CyberKnife System Options........................................................... 3-12

Synchrony Spine Tracking (Option) ....................................................... 3-12
Synchrony Lung Tracking with Respiratory Modeling (Option) .......... 3-12
Lung Optimized Treatment (Option) ....................................................... 3-12
Synchrony Respiratory Tracking System (Option) ............................... 3-13
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Synchrony Tracking™ with InTempo Imaging (Option) ........................ 3-13

Standard Treatment Couch ...................................................................... 3-14
RoboCouch Patient Positioning System (Option) ................................. 3-15
RoboCouch Flat Table Top Configuration........................................................ 3-15
Iris Variable Aperture Collimator (Option) .............................................. 3-16
Xchange Robotic Collimator Changer (Option Model B) ...................... 3-17
Equipment Locations......................................................................3-17
Control Room ............................................................................................ 3-18
Treatment Room........................................................................................ 3-18
Equipment Room ...................................................................................... 3-19
Chapter 4: System Startup and Shutdown ............................4-1

Introduction.......................................................................................4-1
Pre-startup Checklist ........................................................................4-2
Powering On the CyberKnife System...............................................4-6
Power Scheduler ..............................................................................4-8
Weekly power-on policy ..................................................................................... 4-9
Date exceptions ................................................................................................. 4-9
After automatic power-on ................................................................................. 4-10
Error Handling ................................................................................4-10

Power-on Errors ........................................................................................ 4-10
Errors Occurring After Power-on ............................................................ 4-11
Post-startup Checklist ....................................................................4-12

Logging into the CyberKnife System ..............................................4-13
X-ray System Warmup ...................................................................4-14
Powering Off Equipment ................................................................4-18
System Shutdown Checklist...........................................................4-19
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Power-on After Power Interruption ................................................ 4-19

Step 1: Establish "Normal" Power-off Status ........................................ 4-20
Step 2: Hardware Power On..................................................................... 4-21
Equipment Operating Instructions ................................................. 4-22

Collimator Controls in Physics Mode ..................................................... 4-22
Operator Control Panel ............................................................................ 4-25
High Voltage Interlock (Key Switch) ................................................................. 4-25
Turning High Voltage On or Off........................................................................ 4-25
Target Locating System (TLS) Imaging System Components ............. 4-26
X-ray Image Detector AC Power Switches....................................................... 4-26
Treatment Robot Operation ..................................................................... 4-27
Controller Power-up ......................................................................................... 4-27
Using the Teach Pendant................................................................................. 4-27
Turning the LINAC Laser On and Off ............................................................... 4-35
Uninterruptible Power Supply (UPS) ...................................................... 4-35
Chapter 5: Treatment Delivery System Overview .................5-1

Introduction ...................................................................................... 5-1
CyberKnife System Menu ................................................................ 5-2
CyberKnife System Menu Buttons............................................................ 5-3
Logging into a Delivery Mode............................................................................. 5-4
Adding Participants to Your CyberKnife Session ............................................... 5-4
Changing Your Login Password......................................................................... 5-6
Computer Menu .......................................................................................... 5-7
Help Menu.................................................................................................... 5-9
Error Handling System................................................................... 5-10

Error Handling System Controls ............................................................. 5-10
Device Status Icons.......................................................................................... 5-10
E-Stop/Interlock Controls ................................................................................. 5-13
Error Handling System Screen................................................................ 5-15
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Function Keys.................................................................................5-21
Transferring System Data for Remote Diagnostics ............................... 5-22
Obtaining Screen Captures...................................................................... 5-22
Equipment Power Status................................................................5-23

Physics Mode .................................................................................5-30
LINAC Menu............................................................................................... 5-32
Warmup Screen ............................................................................................... 5-33
Calibration Check Screen ................................................................................ 5-35
Calibration Adjustment Screen......................................................................... 5-36
Treatment Mode .............................................................................5-39

Load Patient Data Screen......................................................................... 5-39
Overview Phase......................................................................................... 5-43
Left and Right Screens of the Delivery Phase........................................ 5-46
Image Display Area.......................................................................................... 5-48
Start Button ...................................................................................................... 5-48
Resume Button ................................................................................................ 5-49
Pause Button.................................................................................................... 5-50
Acquire Button.................................................................................................. 5-51
Current Robot Position Indicator ...................................................................... 5-51
Mark Image as Blocked Button ........................................................................ 5-52
Move to Imaging Node Button.......................................................................... 5-53
Treatment Monitoring Graphs .......................................................................... 5-53
Image Interval Slider Bar.................................................................................. 5-56
Max Image Age Slider Bar ............................................................................... 5-56
Image Burst Interval Slider Bar ........................................................................ 5-57
Images Counter................................................................................................ 5-58
Estimated Imaging Dose (cGy/Gy) Display ...................................................... 5-58
Beam Delivery and Delivery Progress Panels ................................................. 5-59
Demonstration Mode ......................................................................5-60

Bypassing the X-ray Imaging System ..................................................... 5-62
Bypassing the Secondary Collimator System........................................ 5-62
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Phantom Mode .............................................................................. 5-64

Phantom Treatment Plans ....................................................................... 5-64
Unlimited Deliverable Fractions .............................................................. 5-64
Plan QA Mode ............................................................................... 5-65

QA Plans.................................................................................................... 5-65
Load Patient Data Screen ........................................................................ 5-66
Overview Phase ........................................................................................ 5-68
Left and Right Screens of Delivery Phase.............................................. 5-70
Chapter 6: Patient Preparation................................................6-1

Introduction ...................................................................................... 6-1
Patient Immobilization Devices........................................................ 6-2
Head and Neck Immobilization.................................................................. 6-2
Treatments Without Fiducials............................................................................. 6-2
Treatment with Synchrony Fiducial Tracking ..................................................... 6-3
Treatment with Synchrony Spine Tracking......................................................... 6-3
Body Immobilization................................................................................... 6-4
Pretreatment Scanning Guidelines .................................................. 6-7

Patient Positioning for Pretreatment Scanning ....................................... 6-7
Supported Image Types ............................................................................. 6-8
Primary CT Image Studies ................................................................................. 6-8
Secondary Images ............................................................................................. 6-8
CT Imaging Guidelines............................................................................... 6-8
Basic Parameters for CT Imaging ...................................................................... 6-9
Guidelines for Acquiring Intracranial CT Image Studies................................... 6-10
Guidelines for Acquiring Extracranial CT Image Studies ................................. 6-11
MRI Imaging Guidelines ........................................................................... 6-15
PET Imaging Guidelines........................................................................... 6-16
Angiography Imaging Guidelines ........................................................... 6-17
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Key Identifiers for DICOM Images ........................................................... 6-18
Fiducial Placement .........................................................................6-18

Fiducial Placement Principles ................................................................. 6-18
Fiducial Supplies....................................................................................... 6-19
Fiducials Approved for Soft Tissue Tracking.................................................... 6-20
Fiducials Approved for Implantation in Bone or Spine ..................................... 6-21
Fiducial Placement Procedure................................................................. 6-21
Post-placement Guidelines .............................................................................. 6-21
Lung ................................................................................................................. 6-22
Pancreas/Liver ................................................................................................. 6-25
Cleaning and Sterilization ........................................................................ 6-27
Chapter 7: Treatment Room Operations ................................7-1

Introduction.......................................................................................7-1
Preparing the Treatment Room........................................................7-2
Power On the CyberKnife System ............................................................. 7-2
Turn on Patient Monitoring System .......................................................... 7-2
Load Patient Data........................................................................................ 7-2
Move Treatment Robot to the Perch Position .......................................... 7-2
Manually Changing Fixed Collimators..............................................7-3

Manually Removing a Fixed Collimator .................................................... 7-5
Manually Installing a Fixed Collimator...................................................... 7-7
Xchange Robotic Collimator Changer .............................................7-8

Xchange Collimator Table (Model B)....................................................... 7-10
Receptacle for Fixed Collimator Secondary Housing....................................... 7-11
Receptacle for Iris Collimator ........................................................................... 7-12
Collimator Cups................................................................................................ 7-13
Xchange System Safety Considerations ................................................ 7-15
Xchange System Operation ..................................................................... 7-16
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Changing Fixed Collimators ............................................................................. 7-17

Automatic Collimator Housing Change ............................................................ 7-17
Treatment Delivery Using the Xchange System .................................... 7-18
Error Handling With the Xchange System.............................................. 7-21
Switching to Manual Operation ............................................................... 7-22
Patient Immobilization Devices...................................................... 7-23

Standard Treatment Couch ........................................................... 7-23
Manual Operation of the Treatment Couch ............................................ 7-23
Treatment Couch Hand Controller ................................................................... 7-23
Readout Display Unit........................................................................................ 7-26
Optional Foot Extension for Feet-First Positions.................................. 7-28
Loading the Patient onto the Standard Treatment Couch .................... 7-30
RoboCouch Patient Positioning System (Option) .......................... 7-31

RoboCouch System Components........................................................... 7-32
RoboCouch Manipulator................................................................................... 7-32
RoboCouch Column Cover .............................................................................. 7-33
RoboCouch Controller...................................................................................... 7-35
RoboCouch Flat Table Top Configuration........................................................ 7-36
RoboCouch Hand Controller and Cradle.......................................................... 7-36
RoboCouch Hand Controller Functions............................................................ 7-37
RoboCouch Teach Pendant ............................................................................. 7-45
RoboCouch System Safety Features...................................................... 7-46
Bypassing a RoboCouch Contact Sensor E-Stop ............................................ 7-46
Lowering the Patient During a Power Interruption............................................ 7-47
Error Handling With the RoboCouch System ........................................ 7-47
Resolving an E-Stop Condition ........................................................................ 7-47
Treatment Delivery Using the RoboCouch System............................... 7-48
Powering On the RoboCouch System.............................................................. 7-48
Loading Patient Data........................................................................................ 7-49
Using the RoboCouch System to Load the Patient .......................................... 7-50
Patient Alignment ............................................................................................. 7-50
Pausing Treatment Couch Movement.............................................................. 7-52
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Treatment Delivery ........................................................................................... 7-52

Patient Realignment......................................................................................... 7-53
Chapter 8: Treatment Delivery ................................................8-1

Introduction.......................................................................................8-1
Workflow for Patient Alignment and Treatment Delivery..................8-3
Approving Plans for Treatment Delivery and DRR Generation ........8-5
Loading Patient and Treatment Data ...............................................8-5
Select the Patient, Plan, and Fraction ....................................................... 8-6
Verify Patient and Treatment Data............................................................. 8-8
Initial Patient Positioning ................................................................8-10

Supported Patient Positions .................................................................... 8-10
Initial Alignment of the Treatment Couch............................................... 8-12
Aligning the Standard Treatment Couch .......................................................... 8-13
Aligning the RoboCouch System ..................................................................... 8-14
Visually Aligning the Patient ...........................................................8-15

Acquiring Live X-ray Images.................................................................... 8-16
Analyzing the Images ............................................................................... 8-18
Moving the Couch in the Alignment > Couch Phase............................. 8-19
Using Couch Mode........................................................................................... 8-19
Pausing Movement of the Treatment Couch.................................................... 8-20
Patient Realignment During Treatment Delivery .............................................. 8-21
Performing a Patient Safety Zone Check................................................ 8-21
Performing a Collimator and Laser Alignment Check........................... 8-21
Proceeding to the Next Treatment Phase ............................................... 8-21
Optimizing the X-ray Technique .....................................................8-22

Acquiring Live X-ray Images ............................................................................ 8-22
Modifying X-ray Parameters............................................................................. 8-25
Performing Patient Alignment.........................................................8-27
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Analyzing Imaging Results ...................................................................... 8-29

Evaluating Calculated Offsets .......................................................................... 8-29
Visually Identifying Features to Be Used for Tracking...................................... 8-32
Monitoring and Adjusting Algorithm Parameters .............................................. 8-41
Analyzing the Image History............................................................................. 8-46
Moving the Couch in the Alignment > Align Phase............................... 8-48
Using the Automatic Patient Positioning Controls ............................................ 8-48
Manual Alignment Using the Hand Controller .................................................. 8-51
Physician Setup Approval of Patient Alignment ................................... 8-52
Requesting Remote Approval of Patient Alignment (TxView Option) . 8-53
Requirements for Remote Approval ................................................................. 8-53
Checking Readiness for Treatment Delivery ................................. 8-56

Checking the Patient Safety Zone........................................................... 8-58
PDP Measurement Tool ................................................................................... 8-58
Patient Size Control Area ................................................................................. 8-60
Positioning the Patient Within the Patient Safety Zone ........................ 8-61
Displacement Corrections During Treatment Delivery ......................... 8-62
Translational Corrections ................................................................................. 8-62
Rotational Corrections...................................................................................... 8-63
Setting Treatment Automation Parameters............................................ 8-65
Performing a Collimator and Laser Alignment Check .......................... 8-66
Checking Equipment Readiness ............................................................. 8-67
Treatment Delivery ........................................................................ 8-69

Starting Treatment Delivery .................................................................... 8-71
Turning on the High Voltage.................................................................... 8-72
Monitoring Treatment Delivery................................................................ 8-73
Treatment Path Progress ................................................................................. 8-73
Visual Inspection of Tracking Results .............................................................. 8-76
Imaging Artifacts from LINAC Beam Strikes to the X-Ray Image Detectors .... 8-79
Adjusting the Image Interval Parameter ........................................................... 8-80
Monitoring Treatment Data Graphs.................................................................. 8-81
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Interrupting Treatment....................................................................8-82
Hardware E-Stop Button........................................................................... 8-82
Interlock Button......................................................................................... 8-82
Pause.......................................................................................................... 8-83
Error Handling ................................................................................8-84

Soft Stops .................................................................................................. 8-84
E-Stops....................................................................................................... 8-85
Resetting a Recoverable E-Stop.............................................................. 8-86
Exiting Treatment After an E-Stop........................................................... 8-87
Error 623: Contact Detection Sensor ...................................................... 8-89
Patient Realignment After a Pause or Error ...................................8-91

Makeup Fractions...........................................................................8-92
Phantom Mode ...............................................................................8-93
Demonstration Mode ......................................................................8-93
BB Test....................................................................................................... 8-93
Required Phantoms ......................................................................................... 8-94
BB Test Procedure........................................................................................... 8-95
Plan QA Mode ..............................................................................8-100

Plan Approval and DRR Generation...................................................... 8-100
Loading Patient and Treatment Data for QA Plan................................ 8-100
Select the Patient, Treatment Plan, and QA Plan .......................................... 8-101
Verify Patient and Treatment Data for the QA Plan ....................................... 8-102
Treatment Delivery of a QA Plan ........................................................... 8-103
Chapter 9: Synchrony Fiducial Tracking ...............................9-1

Introduction.......................................................................................9-1
Overview of the Synchrony Fiducial Tracking System Algorithm .....9-2
Rigid Body Error ......................................................................................... 9-2
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Workflow for Synchrony Fiducial Tracking Mode............................. 9-4

Verifying Patient and Treatment Data.............................................. 9-5
Visually Aligning the Patient ............................................................ 9-5
Optimizing the X-ray Technique ...................................................... 9-6
Acquiring Live X-ray Images ..................................................................... 9-6
Modifying X-ray Parameters ...................................................................... 9-7
Performing Patient Alignment .......................................................... 9-8

Analyzing Imaging Results ........................................................................ 9-9
Evaluating Calculated Offsets ............................................................................ 9-9
Ensuring Fiducial Identification and Tracking................................................... 9-10
Monitoring and Adjusting Algorithm Parameters .............................................. 9-16
Enable or Disable Fiducials Used For Tracking ............................................... 9-22
Responding to a Rigid Body Error.................................................................... 9-23
Analyzing the Image History............................................................................. 9-25
Moving the Couch..................................................................................... 9-26
Checking Readiness for Treatment Delivery ................................. 9-27

Treatment Delivery ........................................................................ 9-28
Starting Treatment Delivery..................................................................... 9-29
Treatment Monitoring Graph ................................................................... 9-29
Error Handling........................................................................................... 9-30
Patient Realignment ................................................................................. 9-30
Chapter 10: Synchrony Spine Tracking (Option) ..10-1

Introduction .................................................................................... 10-1
Overview of Synchrony Spine Tracking ........................................ 10-2
Accuracy of Synchrony Spine Tracking................................................. 10-2
Requirements for Visual Evaluation............................................... 10-3

Workflow for Synchrony Spine Tracking........................................ 10-4
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Verifying Patient and Treatment Data ............................................10-5

Generating DRR Images ........................................................................... 10-5
Downloading Treatment Files .................................................................. 10-6
Visually Aligning the Patient ...........................................................10-7

Optimizing the X-ray Technique .....................................................10-8
Acquiring Live X-ray Images.................................................................... 10-8
Modifying X-ray Parameters................................................................... 10-10
Performing Patient Alignment.......................................................10-11

Analyzing Imaging Results .................................................................... 10-12
Evaluating Calculated Offsets ........................................................................ 10-12
Using Image Panel Controls for Image Analysis ............................................ 10-13
Monitoring and Adjusting Algorithm Parameters ............................................ 10-20
Moving the Couch ................................................................................... 10-27
Checking Readiness for Treatment Delivery................................10-27

Treatment Delivery .......................................................................10-28
Treatment Monitoring Graph.................................................................. 10-30
Error Handling ......................................................................................... 10-31
False Nodes Error .......................................................................................... 10-31
dxAB Error...................................................................................................... 10-32
drAB Error ...................................................................................................... 10-32
Synchrony Spine Tracking Prone with Respiratory Modeling ......10-33

CT Acquisition......................................................................................... 10-33
Placement of the Synchrony Respiratory External LED Markers....... 10-34
Synchrony Spine Tracking Algorithm Parameters .............................. 10-34
Rotational Corrections and Rotational Bounds Checking.................. 10-34
Respiratory Correlation Error ................................................................ 10-35
Chapter 11: Synchrony Lung Tracking with Respiratory Model-

ing (Options) ...........................................................................11-1
xx | 1075883-ENG A
Introduction .................................................................................... 11-1

Overview of the Synchrony Lung Tracking with Respiratory Modeling11-
2
Synchrony Lung Tracking with Respiratory Modeling Algorithm ....... 11-2
Quality Metrics .......................................................................................... 11-3
Tumor Region DRR Images ..................................................................... 11-4
Preferred Projection ................................................................................. 11-4
Treatment Planning Overview ................................................................. 11-4

Workflow for Synchrony Lung Tracking with Respiratory Modeling11-6
Verifying Patient and Treatment Data............................................ 11-8
Generating DRR Images........................................................................... 11-8
Downloading Treatment Files.................................................................. 11-9
Visually Aligning the Patient .......................................................... 11-9

Optimizing the X-ray Technique .................................................. 11-10
Performing Patient Alignment ...................................................... 11-11
Initial Alignment Using Synchrony Spine Tracking ............................ 11-12
Transition to the Synchrony Lung Tracking with Respiratory Modeling11-13
Optimizing the X-ray Technique............................................................ 11-17
Acquiring Live X-ray Images .......................................................................... 11-18
Modifying X-ray Parameters........................................................................... 11-19
Alignment for Treatment Using the Synchrony Lung Tracking with Respira-
tory Modeling .......................................................................................... 11-20
Analyzing Imaging Results ............................................................................. 11-21
Respiratory Alignment and Building a Respiratory Model .............................. 11-32
Treatment Delivery ...................................................................... 11-34

Visual Inspection During Treatment Delivery ................................................. 11-35
Treatment Monitoring Graph ................................................................. 11-36
Error Handling ................................................................................................ 11-37
1075883-ENG A |xxi
Patient Realignment................................................................................ 11-39
Chapter 12: Synchrony Respiratory Tracking System

(Option) ...................................................................................12-1
Introduction.....................................................................................12-1
Synchrony Respiratory Tracking System Components..................12-2
Synchrony Respiratory Tracking Interface Module ............................... 12-2
Wireless Interface Module................................................................................ 12-2
Charging Cradle ............................................................................................... 12-3
Non-wireless Interface Module......................................................................... 12-6
Synchrony Respiratory Camera Array .................................................... 12-7
Synchrony Respiratory Vest .................................................................... 12-8
Synchrony Respiratory External LED Marker Visibility Indicator...................... 12-9
Synchrony Respiratory Tracking User Interface...........................12-10

Overview Phase....................................................................................... 12-10
Respiratory Phase................................................................................... 12-12
Respiratory Model Table ................................................................................ 12-13
Image Display Area........................................................................................ 12-17
Algorithm Parameters and Thresholds........................................................... 12-22
Manual Setup Controls................................................................................... 12-22
Move Couch Controls..................................................................................... 12-23
Automatic Setup Controls (Option) ................................................................ 12-24
Rotational Bounds Checking Enabled Checkbox........................................... 12-25
Skip Respiratory Checkbox ............................................................................ 12-25
Reset Respiratory Model Button .................................................................... 12-26
Image History Table ....................................................................................... 12-28
Breathing Waveform Snippet ......................................................................... 12-29
Comet Graphs ................................................................................................ 12-30
Respiratory Details Tab.................................................................................. 12-31
Acquisition Details Tab................................................................................... 12-35
Images Tab .................................................................................................... 12-35
Markers Control Area ..................................................................................... 12-36
Tracking Markers Graph ................................................................................ 12-37
xxii | 1075883-ENG A
Readiness Phase .................................................................................... 12-39

Left and Right Screens of the Delivery Phase ..................................... 12-41
Respiratory Model Table ................................................................................ 12-44
Image Burst Interval Slider Bar (Option) ........................................................ 12-45
Treatment Monitoring Graphs ........................................................................ 12-47
Markers Control Area ..................................................................................... 12-48
Summary Info Section .................................................................................... 12-49
Model Information Section.............................................................................. 12-49
Tracking Markers Graph................................................................................. 12-50
Comet Graphs ................................................................................................ 12-50
Patient Preparation for Pretreatment Scanning ........................... 12-51

Putting on the Synchrony Respiratory Vest ........................................ 12-51
Preparing the Patient Immobilization Device....................................... 12-52
Pretreatment Scanning .......................................................................... 12-53
Treatment Planning ................................................................................ 12-53
Patient Setup for Treatment......................................................... 12-54

Putting on the Synchrony Respiratory Vest ........................................ 12-54
Using the Patient Immobilization Device.............................................. 12-54
Connecting the Synchrony Respiratory External LED Markers......... 12-54
Adjusting the Synchrony Respiratory Camera Array.......................... 12-56
Patient Alignment and Tracking................................................... 12-57

Verifying Patient and Treatment Data................................................... 12-57
Acquiring Live X-ray Images ................................................................. 12-58
Manually Shifting the Region of Interest .............................................. 12-59
Building a Respiratory Correlation Model .................................... 12-60

Overview of Respiratory Modeling........................................................ 12-60
Using Manual Setup ............................................................................... 12-63
Overview of Phase Selection ......................................................................... 12-64
Aligning the Patient at the Respiratory Center ............................................... 12-66
Image-by-Image Phase Selection .................................................................. 12-67
1075883-ENG A |xxiii
User Defined Respiratory Phase Selection.................................................... 12-69

No Phase Selection........................................................................................ 12-70
Using Automatic Setup (Option)............................................................ 12-73
Perform Respiratory Alignment ...................................................................... 12-73
Acquire a Respiratory Dataset ....................................................................... 12-75
Analyzing the Respiratory Model .......................................................... 12-77
Review Images in the Respiratory Cycle. ...................................................... 12-77
Evaluate Offset Values................................................................................... 12-77
Respond to Errors and Threshold Violations ................................................. 12-78
Move the Couch ............................................................................................. 12-78
Evaluating Placement of Tracking Markers.......................................... 12-79

Starting Synchrony Respiratory Tracking Treatment.......................... 12-81
Visually Verifying the Target.................................................................. 12-84
Displacement Corrections During Treatment....................................... 12-84
Monitoring Synchrony Respiratory Tracking ....................................... 12-85
Interrupting Treatment............................................................................ 12-85
Error Handling ......................................................................................... 12-85
Chapter 13: Synchrony Tracking with InTempo Imaging (Option)

13-1
Introduction.....................................................................................13-1
Overview of the Synchrony Fiducial Tracking with InTempo Imaging13-2
Image Age .................................................................................................. 13-2
Beam Segments ........................................................................................ 13-2
Calculation of Target Offsets ................................................................... 13-3
Adaptive Imaging ...................................................................................... 13-3
Workflow for Treatments with the InTempo System.......................13-4
xxiv | 1075883-ENG A
InTempo in the Overview Phase.................................................... 13-4

InTempo in the Patient Alignment Phase ...................................... 13-4
InTempo Settings in the Readiness Phase.................................... 13-5
Setting the Maximum Allowed Motion of the Target ............................. 13-5
Selecting the InTempo Response ........................................................... 13-6
InTempo in the Treatment Delivery Phase .................................... 13-6

Starting Treatment.................................................................................... 13-7
Pausing Treatment ................................................................................... 13-8
Interrupting Treatment ............................................................................. 13-8
InTempo Controls in Delivery Phase ..................................................... 13-8
Adjusting the Maximum Image Age.................................................................. 13-9
Enabling and Disabling Adaptive Imaging...................................................... 13-10
Chapter 14: Simulation Application Overview (Option)......14-1

Introduction .................................................................................... 14-1
Starting the Simulation Application ................................................ 14-2
Overview of Simulation Application Screen ................................... 14-4
Treatment Data Display............................................................................ 14-6
Simulation Phase Selection Tabs ........................................................... 14-6
Simulation Phase Images and Data ........................................................ 14-7
Mode Selection Buttons (Automatic or Manual).................................... 14-7
CyberKnife System Device Status Icons................................................ 14-8
Error Information, E-Stop Status, and Pause Controls......................... 14-9
Automatic Mode User Interface ................................................... 14-10

Spine Phase ............................................................................................ 14-10
Image Panels in the Spine Phase .................................................................. 14-11
Skip Spine Checkbox ..................................................................................... 14-16
dxAB, drAB, and False Nodes Slider Bars ..................................................... 14-16
1075883-ENG A |xxv
Image Correlation Parameters Panel ............................................................. 14-17

X-ray Parameters Panel ................................................................................. 14-19
Algorithm Errors Panel ................................................................................... 14-20
Patient Position Display ................................................................................. 14-21
Patient Positioning Controls ........................................................................... 14-22
Lung Phase.............................................................................................. 14-24
Image Panels in the Lung Phase ................................................................... 14-24
Treatment Couch Position Display ................................................................. 14-27
X-ray Phase.............................................................................................. 14-31
Image Panels in the X-ray Phase................................................................... 14-31
Image Acquisition Controls ............................................................................ 14-33
Offset Phase ............................................................................................ 14-34
Image Panels in the Offset Phase.................................................................. 14-34
Dataset Acquisition Controls .......................................................................... 14-38
Offset Specification Controls .......................................................................... 14-40
Camera Visibility Controls .............................................................................. 14-42
Confirmation Phase ................................................................................ 14-43
Image Panels in the Confirmation Phase ....................................................... 14-43
Controls for Confirming Correlation Results................................................... 14-47
Uncertainty and dxAB Bar Graphs ................................................................. 14-48
Review Phase .......................................................................................... 14-48
Manual Mode User Interface ........................................................14-53

Spine Phase............................................................................................. 14-53
Lung Phase.............................................................................................. 14-53
X-ray Phase.............................................................................................. 14-53
Respiratory Phase................................................................................... 14-54
Image Panels in the Respiratory Phase ......................................................... 14-54
Offset Specification Controls .......................................................................... 14-56
dxAB and Uncertainty Slider Bars .................................................................. 14-57
Image Correlation Parameters Panel ............................................................. 14-58
xxvi | 1075883-ENG A
Algorithm Errors Panel ................................................................................... 14-61

Patient Position Display.................................................................................. 14-61
Respiratory Modeling Controls ....................................................................... 14-63
Review Phase.......................................................................................... 14-67
Simulation Application Workflow.................................................. 14-69

Overview of Simulation Workflow......................................................... 14-69
Simulation Using Automatic Mode ....................................................... 14-69
Set Up the Patient .......................................................................................... 14-70
Acquire a Simulation Dataset ......................................................................... 14-72
Review the Simulation Dataset ...................................................................... 14-73
Simulation Using Manual Mode............................................................. 14-74
Set Up the Patient .......................................................................................... 14-75
Review the Simulation Dataset ...................................................................... 14-75
Chapter 15: Lung Optimized Treatment (Option) ................15-1

Introduction .................................................................................... 15-1
Overview of Lung 1-View Tracking with Respiratory Modeling...... 15-2
CT Acquisition and Reproducibility........................................................ 15-2
Spine Supine Tracking ITV, Lung 1-View Tracking ITV, ITTV, and PTV15-3
Spine Supine Tracking ITV............................................................................... 15-3
Lung 1-View Tracking with Respiratory Modeling ITV...................................... 15-3
ITTV.................................................................................................................. 15-5
PTV .................................................................................................................. 15-5
Lung 1-View Tracking with Respiratory Modeling Algorithm............... 15-6
Quality Metrics .......................................................................................... 15-7
Tumor Region DRR Images ..................................................................... 15-8
Treatment Planning Overview ................................................................. 15-8

Qualitative Alignment Check Using the Untracked Image.................... 15-8
1075883-ENG A |xxvii
Workflow for Lung 1-View Tracking with Respiratory Modeling .....15-9

Verifying Patient and Treatment Data ..........................................15-11
Generating DRR Images ......................................................................... 15-11
Downloading Treatment Files ................................................................ 15-12
Visually Aligning the Patient .........................................................15-12

Optimizing the X-ray Technique ...................................................15-13
Performing Patient Alignment.......................................................15-14
Initial Alignment Using Synchrony Spine Tracking............................. 15-14
Transition to Lung 1-View Tracking with Respiratory Modeling ........ 15-15
Optimizing the X-ray Technique ............................................................ 15-19
Acquiring Live X-ray Images .......................................................................... 15-19
Modifying X-ray Parameters........................................................................... 15-19
Alignment for Treatment Using Lung 1-View Tracking with Respiratory Mod-
eling.......................................................................................................... 15-20
Analyzing Imaging Results ............................................................................. 15-21
Respiratory Alignment and Building a Respiratory Model .............................. 15-32

Visual Inspection During Treatment Delivery ................................................. 15-34
Treatment Monitoring Graph.................................................................. 15-34
Error Handling ......................................................................................... 15-35
References ...................................................................................15-36
Appendix A: Error Messages ................................................. A-1

What To Do About Errors ................................................................ A-1
Error Handling System Screen Errors ..................................................... A-2
Readiness Phase Error Messages.......................................................... A-64
Delivery Phase Error Messages.............................................................. A-68
xxviii | 1075883-ENG A
Appendix B: Compliance........................................................ B-1

Classification.................................................................................... B-1
Standards Compliance .................................................................... B-1
Radiiation Leakage .......................................................................... B-2
System Labels ................................................................................. B-2
Appendix C: Glossary............................................................. C-1

Acronyms and Abbreviations ...........................................................C-1
Definitions ........................................................................................C-2
1075883-ENG A |xxix
xxx | 1075883-ENG A
Chapter 1: Overview
This manual contains instructions for multiple features of the CyberKnife System. Since some
features of the CyberKnife System are optional, some of the instructions in this manual may not
apply to your system.
The availability of options is dependent on regulatory approvals in a particular country and varies
from country to country.
Indications for Use

The CyberKnife® Treatment Delivery System is indicated for image-guided stereotactic
radiosurgery and precision radiotherapy for lesions, tumors and conditions anywhere in the body
when radiation treatment is indicated.
Intended Use
The CyberKnife Treatment Delivery System is indicated for image-guided stereotactic radiosurgery
and precision radiotherapy for lesions, tumors and conditions anywhere in the body when radiation
treatment is indicated. The CyberKnife Treatment Delivery System may be used to treat
astrocytoma, glioma, skull base tumors, metastases (brain and bony), nasopharyngeal carcinoma,
meningioma, acoustic neuroma, schwannoma, pituitary adenoma, hemangioblastoma,
craniopharyngioma, arteriovenous malformation, cavernous malformation, trigeminal neuralgia,
and tumors of the neck, spine, pancreas, liver, lungs, ovary, prostate, and bladder. Patients should
be examined by a team of physicians to determine if they are candidates for CyberKnife treatment.
Undesirable Side Effects

The treatment system delivers ionizing radiation that can have undesirable side effects such as
nausea, burns, nerve damage, and even death. To help prevent these side effects, all personnel
who operate the treatment system should be appropriately educated and trained.
Clinical Benefit
At high doses, radiation therapy kills cancer cells or slows their growth by damaging their DNA.
Cancer cells whose DNA is damaged beyond repair stop dividing or die. When the damaged cells
die, they are broken down and removed by the body.
1075883-ENG A | 1-1
Residual Risks
Below are the residual risks of the device, please reference the appropriate sections of the
documentation for further details:
• Exposure to infection from cross-contamination
• High voltage warnings in service procedures, service training, and on-component labeling
• Electromagnetic compatibility and susceptibility
• Adventitious, primary, leakage, and scatter radiation levels for treatment beam
• Adventitious, primary, leakage, and scatter radiation levels for kV Imaging
• kV imaging dose
• Electromagnetic immunity
• Treatment delivery dose related to user configuration of tracking algorithm threshold
parameters
• Disabling the application of respiratory motion modeling
• Possible side-effects of radiation treatment
• Mechanical hazard from drive train
• Laser light
• Patient information privacy breach
Incident Reporting
Any serious incident that occurs while using the Accuray CyberKnife System must be reported to
the manufacturer and the competent authority of the Member State in which the user and/or patient
is established. Contact Accuray Customer Support for more information.
Conditions Required for Transport and Storage

If the CyberKnife System must be stored for any length of time in a crated or uncrated condition,
please follow these guidelines:
• Provide an environmentally protected indoor area free from dust and free from
potential water damage.
• Maintain an atmospheric pressure between 56 - 103 kPa.
• Ensure the area is temperature controlled between -22° F and 122° F (-30° C to
50° C).
• Maintain 10 - 90 % humidity, non-condensing.
• Maintain a secured area to prevent against potential theft and damage.
• Approximately 400 square ft (37.2 square m) is needed for storing a crated CyberKnife
System.
1-2 | 1075883-ENG A
Treatment Delivery Manual Chapter 1: Overview
Virus Protection Software and Firewalls

Accuray Incorporated employs an off-the-shelf whitelist anti-virus malware solution.
Periodic updates are not necessary because the software only allows previously
authorized applications per the whitelist to run. The iLinkSM system employs a single
Security Appliance as its main point of connection to the hospital's network, and additional
Security Appliances per connection to each system or vault.
All Security Appliances come standard as part of your Accuray System, and are required
for complete iLink. Each of the Security Appliances has its configuration tuned to the exact
needs of each deployment location and its users. These configurations include providing
product and location-specific access control rules and network address translation to
each of the devices behind the Security Appliances. The access control rules and network
address translations restrict incoming and outgoing traffic to a few select applications and
programs approved by Accuray Incorporated.
For more information about the CyberKnife System network environment and its security features,
refer to the System Administration section of the Physics Essentials Guide.
For a more detailed description, of CyberKnife Treatment Delivery System security requirements,
see the Accuray publication Network System Requirements.
Performance Characteristics
General Specifications, Commissioning, Equipment, QA Performance, and other topics related to
performance characteristics of the device can be found in the Physics Essentials Guide.
Manuals
Accuray Incorporated provides a set of user manuals (instructions for use) and a reference manual
for the CyberKnife System. Manuals in the documentation set are described below.
WARNING: Example data depicted in this manual is not intended to represent realistic
clinical data. Use of example data for treatment planning or delivery could result in patient
mistreatment. The user is solely responsible for determining appropriate data values for
any given situation.
NOTE: In countries where required, the manuals have been

translated by Accuray Incorporated into the native language.
NOTE: Images in the manuals may not exactly match your

specific CyberKnife System.
1075883-ENG A | 1-3
Data Management Manual

The Data Management Manual provides instructions for using the iDMS Data Management
System, which provides the storage of CyberKnife System patient, user and system data, as well
as applications and interfaces to access, add, modify, export, delete, generate reports for and
validate CyberKnife System patient, user and system data. The Data Management Manual also
describes the patient data archive and restore processes and the Beam Data Import application.
Treatment Planning Manual

The Treatment Planning Manual provides information about using the Accuray Precision
Treatment Planning System to load image studies; create, modify, and evaluate treatment plans;
create and modify treatment plan templates; work with commissioning tools; export data; and print
plan data. The Treatment Planning Manual also describes the use of Accuray Precision System
options such as the AutoSegmentation™, QuickPlan™, Monte Carlo Dose Calculation, and
Sequential Optimization.

The Treatment Delivery Manual provides information on treatment delivery, including safety
information, system startup and shutdown procedures, treatment delivery system overview, patient
preparation, treatment room operations, treatment delivery procedures, and other topics. It also
describes treatment using Synchrony® Skull Tracking™, Synchrony® Fiducial Tracking™,
Synchrony® Spine Tracking™ Supine, Synchrony® Lung Tracking™ with Respiratory Modeling,
Synchrony® Fiducial™ Tracking with Respiratory Modeling, and the InTempo® Adaptive Imaging
System.
Physics Essentials Guide

The Physics Essentials Guide provides critical information that each physicist must know in order
to commission the Accuray Precision System, the linear accelerator (LINAC), and the CyberKnife
System for use with patients. The Physics Essentials Guide presents detailed procedures that are
part of initial and ongoing Quality Assurance (QA) and commissioning programs. Accuray
Incorporated recommends that the program described in this guide be incorporated into the
institutional Radiation Safety program at each CyberKnife System site.
Numeric Display Format

The CyberKnife System, iDMS System, and Accuray Precision System use the following notation
convention to display numerals:
• The period character (.) is used as a decimal separator.
• The comma character (,) is used as a thousands separator.
WARNING: Regardless of the language translation, all numeric data that you enter or that
is displayed in the software uses the period character (.) as a decimal separator. Be aware
of this notation convention when interpreting or entering numeric data. Incorrect
interpretation or entry of numeric data could result in patient mistreatment.
1-4 | 1075883-ENG A
Treatment Delivery Manual Chapter 1: Overview
Computer Terminology
This manual uses standard personal computer terminology. Accuray Incorporated assumes you
know how to use a standard personal computer to navigate through windows and files on your
workstation. See the documentation that came with the computer. The following conventions are
used in this manual.
Click Press the left mouse button.
Right-click Press the right mouse button.
Double-click Press the left mouse two times in rapid succession. If you
need to use the right mouse button, the instructions specify
double right-click.
CTRL-click Hold down the CTRL key and press the left mouse button.
SHIFT-click Hold down the SHIFT key and press the left mouse button.
Scroll Rotate the scroll wheel on the mouse. A backward scroll

rotates the scroll wheel with the finger moving away from the
hand. A forward scroll rotates the scroll wheel with the finger
moving toward the hand.
Hold Press the mouse button and hold it down while you perform
another function.
Drag Position the cursor over an area of interest, click, hold the
button down, and move the mouse to select an area, create a
window, or relocate a selected item.
Select Place the cursor over a name or button and click once, or
place the cursor at the beginning of the name, click, hold, and
drag across the name until it is highlighted (changes colors).
Open Double-click the name of a window to open it.
1075883-ENG A | 1-5
1-6 | 1075883-ENG A
Chapter 2: Safety
Introduction
This chapter provides information about the emergency procedures and safety features of the
CyberKnife Treatment Delivery System and describes safe operating practices. Review the
information in this chapter before using the equipment It is the customer’s responsibility to
schedule quarterly and annual preventative maintenance by Accuray Service personnel or other
qualified personnel designated by Accuray.
Address any questions regarding the safe and efficient use of the CyberKnife System directly to
Accuray Customer Support.
This chapter covers the following topics:
• “Emergency Procedures” on page 2-3: This section describes what to do in emergency
situations.
• “Safety Precautions” on page 2-9: This section describes how to avoid hazards.
“Facility Responsibilities” on page 2-35: This section describes user responsibilities for the training
and safety of the staff and patients who come into contact with the CyberKnife System.
WARNING: The CyberKnife System can emit lethal doses of high energy radiation. The
assemblies contain high voltage circuits that can deliver lethal electrical shocks. Always
observe safety precautions when operating or working on or around the CyberKnife
System.
WARNING: The CyberKnife System is a highly complex product. It is your responsibility

to operate the equipment knowledgeably and safely and to ensure the service and the
quality assurance (QA) of each component that may be required, as detailed in this user
manual and the Physics Essentials Guide. Improper operation or service can result in
injury or death of the user or patient.
WARNING: Do not alter the software or any of the components in the CyberKnife System.
Results of these actions can result in injury or death.
1075883-ENG A Introduction | 2-1

WARNING: Multiple Portable Socket-Outlets (MPSO) provided with the CyberKnife

System are only to be used for powering equipment which forms part of the system.
MPSO's should only be connected by Accuray personnel.
• Do not connect additional MPSO's or extension cords to the CyberKnife System.

• Do not connect items to the CyberKnife System that are not part of the system
configuration.
Otherwise, damage to CyberKnife System components can occur that potentially poses a
risk of injury or death to the user or patient.
2-2 | Introduction 1075883-ENG A

Treatment Delivery Manual Chapter 2: Safety
Emergency Procedures
You are responsible for on-site procedures that follow the guidelines outlined here. The following
emergencies and procedures are described:
• Emergency Stop (E-Stop) procedure.
• The Emergency Stop button does not work.
• Emergency Power Off (EPO) procedure.
• The LINAC X-ray beam does not shut off.
• Power failure.
• Fire or fumes are detected.
• The treatment couch does not operate properly.
• The robot arm moves in an unexpected way.
Being prepared for an emergency is essential to operate this equipment safely.
Emergency Stops (E-Stop)

If the CyberKnife System detects an error in its operation, it executes a system Emergency Stop
(E-Stop). When an E-Stop is executed, CyberKnife System status changes to the following:
• The imaging X-ray sources turn off so that no radiation is emitted.
• The LINAC radiation producing circuits power down so that no radiation is emitted.
• Essential LINAC circuits remain warmed up to allow quick resumption of treatment.
• The treatment robot stops moving and remains in its current location. The power to the
treatment robot remains on.
• Patient treatment couch movement is disabled.
• The treatment delivery computer remains on and receives status reports from equipment
components.
An E-Stop is different from an Emergency Power Off (EPO). An E-Stop stops movement and
radiation, but does not shut off power to the equipment. If the error that triggers an E-Stop is
recoverable, you can correct the error, reset the E-Stop, and then choose to resume treatment or
create a makeup fraction.“Chapter 8: Treatment Delivery”
When an EPO is executed, however, power to all non-computer equipment is shut off. It is possible
for equipment to be damaged by an EPO. For more information about an EPO, see “Emergency
Power Off (EPO)” on page 2-6.
1075883-ENG A Emergency Procedures | 2-3

The E-Stop Button

You can manually execute an Emergency Stop (E-Stop) by pressing the E-Stop button (see
“Example of an Emergency Stop (E-Stop) button” on page 2-4). The E-Stop button interacts
directly with CyberKnife System hardware to stop operation.
WARNING: If any situation has the appearance of an emergency, immediately stop

movement and radiation by pressing the nearest E-Stop button.
NOTE: Do not hesitate to press the E-Stop button, even if you

are unsure of the severity of the situation.
Figure 1 Example of an Emergency Stop (E-Stop)

button
NOTE: The appearance of the E-Stop buttons at your facility

may differ from the above figure.
E-Stop buttons are located in the following locations:

• on the operator control panel.
• on the Modulator Control Chassis (MCC) front panel
• on the Treatment robot controller.
• on the standard treatment couch (one on each end, located under the table top).
• on the RoboCouch Controller.
• on the treatment robot Teach Pendant.
• in additional locations at the facility chosen during installation, for example, on the
Treatment Room walls.
 To immediately stop operation in an urgent situation:
• Press the nearest E-Stop button.
2-4 | Emergency Procedures 1075883-ENG A

The Error Handling System window is displayed, indicating the reason for the E-Stop and
suggesting options for resolving it.
NOTE: The Interlock button in the E-Stop controls on the

treatment delivery computer has the same function as the E-Stop
button. However, it performs a software E-Stop that interacts
indirectly with CyberKnife System hardware. For more
information on the Interlock button, see “Chapter 5:
Treatment Delivery System Overview”.
Resetting an E-Stop
After an Emergency Stop, when the status indicates that the radiation is off, you can enter the
Treatment Room.
• If the E-Stop was not caused by pressing one of the standard treatment couch E-Stop
buttons, you can manually move the standard treatment couch using the treatment couch
Hand Controller.
• If the error is recoverable, you can correct the error, reset the error, and resume
treatment. If the error is unrecoverable, you cannot reset the error. In this case, a makeup
fraction will be created. For more information on resuming treatment after an E-Stop, see
“Chapter 8: Treatment Delivery”.
Software E-Stop Failure

When the Error Handling System reports an E-Stop, the Error Handling System window is
displayed indicating the reason for the E-Stop and suggesting options for resolving it.
If the Error Handling System window is displayed while the treatment robot LINAC, or X-ray
imaging system is still operating, the Error Handling System has failed. You must manually stop
the system by pressing the nearest E-Stop button.
WARNING: Visually observe the CyberKnife System during operation at all times.
Manually initiate an E-Stop if an unsafe condition is imminent to prevent injury or death of
the user or patient.
 To manually execute an E-Stop if the Error Handling System fails to stop operation:
1. Press the nearest physical E-Stop button.
2. Contact Accuray Customer Support.
E-Stop Button Failure

If you press the E-Stop button during an emergency and the treatment robot is still moving, or the
operator control panel still indicates that the LINAC beam or the imaging X-ray system is still on,
the E-Stop system has failed. You must manually shut off power to the system.

The CyberKnife System has an Emergency Power Off (EPO) system that shuts off power to all
non-computer equipment (see “Emergency Power Off (EPO)” on page 2-6).
 To manually shut off power if an E-Stop button fails:
• Press the nearest EPO button, or turn off the main circuit breaker in your facility.
NOTE: All users must know the location of the main circuit
breaker in their facility.
The E-Stop button is fail-safe and does not require any operator intervention.
Emergency Power Off (EPO)

The CyberKnife System has an Emergency Power Off (EPO) system that removes power from all
non-computer equipment when actuated. An example of an EPO button for the activating switch is
shown in Figure 2 on page 2-6.
Figure 2 Example of an Emergency Power Off (EPO) button
NOTE: The appearance of the EPO button for your facility may
differ from the above figure.
An EPO is different from an E-Stop. When an EPO is executed, power to all non-computer
equipment is shut off. An E-Stop, however, stops movement and radiation, but does not shut off
power to the equipment. For more information about an E-Stop, see “Emergency Stops (E-Stop)”
on page 2-3.
WARNING: In case of fire or electric shock, press the nearest EPO button to immediately
shut off power to all non-computer equipment and minimize injury to the user or patient as
much as possible.
CAUTION: It is possible for equipment to be damaged by an Emergency Power Off.
EPO buttons are located in the following locations:

• near the treatment delivery computer.
• in the Treatment Room.
• on the Power Distribution Unit (PDU) in the Equipment Room.

• in additional locations chosen during installation.

 To shut off power to non-computer equipment in an urgent situation:
1. In an emergency, do one of the following, as applicable:
• Press the EPO button to shut off power to non-computer equipment.
• Or, turn off the main circuit breaker in your facility.
2. After actuating the EPO switch, follow the steps for loss of power described in “Power
Failure” on page 2-7.
 To shut off power to a CyberKnife System that does not have a PDU in an urgent situation:
CyberKnife Systems without a PDU do not have an EPO system. These sites should disregard
references to the EPO button in this manual and use their site-specific means of removing power.
• Remove power by turning off the main circuit breaker in your facility through the means
provided at the particular site.
 To shut off power to computer equipment in an urgent situation:
The computer equipment is powered from an Uninterruptible Power Supply (UPS). The treatment
delivery computer, Target Locating System (TLS) computer, and CyberKnife System data server
are powered from a UPS.
• To remove power from the computer equipment in an urgent situation, turn off the UPS
using the power switch on the UPS front panel.
Power Failure
The CyberKnife System operates from 3-phase electrical power. If the power fails, all treatment
actions stop.
In the event of a partial loss of power, resulting in abnormally low voltage on one or more phases
of the input power, the system performs an Emergency Power Off. For more information, see
“Emergency Power Off (EPO)” on page 2-6.
 To recover from a power failure:
Use the following emergency procedure to protect the patient.
1. If necessary, turn on emergency lighting.
2. Enter the Treatment Room and carefully help the patient off the treatment couch.
3. When power is restored, start the CyberKnife System using normal startup procedures,
as applicable to the specific situation. For information on startup procedures, see
“Chapter 4: System Startup and Shutdown”.
Uninterruptible Power Supply (UPS)

The Uninterruptible Power Supply (UPS) is located in the computer rack. It provides power to
workstations for up to 5 minutes. For more information, see “Chapter 4: System Startup and
Shutdown”.

• The UPS automatically switches to battery operation if utility power fails and supplies
power to connected equipment until the battery is fully discharged.
• While on battery operation, an alarm beeps every 30 seconds. Press the TEST button to
silence the alarm.
LINAC Malfunction
If the dose in the Beam Data window (see “Chapter 5: Treatment Delivery System Overview”)
exceeds by 1% or 1 cGy the treatment dose at a node and an E-Stop was not automatic, the LINAC
has not functioned properly. You must turn off the LINAC.
 To turn off the LINAC:
• Press the nearest E-Stop button.
Fire or Fumes
If you smell smoke or fumes, or if you detect a fire, initiate the emergency shutdown procedure
below.
 To shut down immediately:
1. Press the nearest EPO button.
2. Activate the fire alarm in the facility.
3. Attend to the patient.
4. Evacuate everyone from the facility according to facility protocols.
5. If in treatment mode, verify that the system has executed the abort sequence. All the
treatment information is recorded automatically and the remaining undelivered dose will
be saved as a makeup treatment plan for use later.
6. If the smoke or fumes are coming from the computer equipment, manually turn off the
Uninterruptible Power Supply (UPS).
Treatment Couch Failure

The standard treatment couch of the CyberKnife System uses a hand-held motor controller and
electro-mechanical actuators. These actuators have sufficient friction and mechanical stops to
prevent a runaway condition.

If your CyberKnife System includes the optional RoboCouch® Patient Positioning System, the
RoboCouch actuators use over travel switches and software limits to prevent a runaway condition.
WARNING: If a malfunction occurs when a patient is on the treatment couch, do not

attempt to use the control that malfunctioned (if possible). The cause of the problem (for
example, an electrical malfunction) may cause permanent injury or death of the user or
patient. To stop treatment couch movement, press the nearest E-Stop button.
For instructions on operating the standard treatment couch and the optional RoboCouch System,
see “Chapter 7: Treatment Room Operations”.
Unexpected Robot Arm Motion

If the robot arm moves in any unanticipated way, shut down the system by pressing the nearest E-
Stop button and contact Accuray.
Safety Precautions
This section describes the hazards and safety precautions associated with the CyberKnife System.
If the equipment is not operated safely, the following hazards could result in injury or death for
patients and personnel.
• X-ray radiation
• Radio frequency radiation
• Electromagnetic interference
• Laser radiation with power up to 1 mW at 632 nm (Class II)
• Ozone
• Sulfur hexafluoride
• Implosion
• Explosion
• Electric shock
• Heavy equipment
• Hot surfaces
This section also describes the Patient Safety Zone, which is used to determine the boundaries
within which the patient must be positioned for safe treatment (see “The Patient Safety Zone” on
page 2-22).
In addition, instructions for performing a Contact Detection Sensor check are provided. This check
should be performed as part of daily Quality Assurance (QA) procedures (see “Contact Detection
Sensor Check” on page 2-32).
1075883-ENG A Safety Precautions | 2-9

It is unsafe for anyone other than trained personnel to operate the CyberKnife System. Anyone
working with the system must be aware of the hazards listed here. Only trained personnel should
perform user functions.
WARNING: Do NOT perform any maintenance not specifically listed as user functions.
Otherwise, the CyberKnife System may malfunction and could cause the permanent injury
or death of the user or patient.
X-ray Radiation
WARNING: If the equipment is not operated properly, you can receive a harmful, even
lethal, dose of radiation in a short time without knowing it is being received. Radiation
exposure can damage some types of cardiac pacemakers. Ensure that the safety
precautions described below are followed.
WARNING: For ALL CyberKnife System installations, when the CyberKnife System is
controlled manually, the LINAC radiation beam can be pointed in almost any direction,
including at locations outside the primary shielding.
• It is the operator’s responsibility to be aware of where the LINAC radiation beam is

pointing at all times when using these operational modes.
• Be familiar with the sequence of operations required to initiate and terminate the
radiation beam (turning on the MV BEAM ON light on the operator control panel
and turning off the light).
• Maintain visual contact with the CyberKnife System at all times during operation.
• Maintain control over access to the Treatment Room.
• Initiate the radiation beam (MV BEAM ON) only when it is directed at a location
and for a duration that you have determined is safe.
Failure to comply with the above guidelines can result in injury or death.
The CyberKnife System emits X-rays from both the LINAC for treatment and the X-ray imaging
system to determine the patient’s real-time location.
Protection from X-rays
The following safety precautions are required:
• Radiation hazard warnings must be posted in appropriate locations.
• Only qualified personnel may operate and service the equipment.
• Personnel radiation dosimeters should be worn when operating the CyberKnife System.
2-10 | Safety Precautions 1075883-ENG A

• When treatment or imaging is in progress, only the patient should be allowed inside the
room.
• Before entering the room, ensure the LINAC and X-ray imaging system are not emitting
radiation. Turn the high voltage interlock key switch to the OFF position. Verify that the
LINAC BEAM ON light and the HIGH VOLTAGE light on the operator control panel are
OFF. Verify that all other installed safety systems show that the Treatment Room is safe
to enter.
• Remove the safety interlock key from the operator control panel before leaving the
Control Room area to prevent unauthorized operation. Do NOT duplicate the safety
interlock key. Use a single key only to either enable the high voltage interlock on the
operator control panel, or to disable the Treatment Room door interlock.
• Monitor the Beam Data window during treatment and commence emergency shut-off
procedures if the system does not terminate when the dose at a node exceeds the
prescribed dose by 1% or 1 cGy.
• Pay attention to objects that may lie between the LINAC and the patient. Such objects
may attenuate and scatter radiation. Such objects may include shadow trays or blocks,
side rails, spinal attachments, various panels and filters. If possible, remove these objects
or make the necessary dose corrections.
Implanted or Body-Worn Electronic Medical

Devices
CAUTION: The CyberKnife Treatment Delivery System produces high energy X-rays. This
energy can damage sensitive electronic devices, such as pacemakers, defibrillators and
other implanted or body-worn electronic medical devices.
Implement the following precautions when patients or personnel have implanted or body-worn
electronic medical devices:
• Prominently display warnings regarding potential damage to these devices.
• If a patient or staff member has such a device, contact the device manufacturer about
possible operational damage from radiation. The frequency of the microwaves used by
the LINAC in the CyberKnife System is approximately 9 GHz.
• Even if the manufacturer indicates the device is safe to operate, monitor its operation
according to the manufacturer’s recommendations. particularly if pulse generators are
near ongoing CyberKnife System treatments.
• If possible, inhibit the operation of the device during CyberKnife System treatments.

Essential Performance
The CyberKnife Treatment Delivery System delivers a prescribed radiation dose to a patient for the
treatment of tumors. The system's robotic arm can move to deliver dose to the patient from multiple
positions. During treatment, the unit compensates for normal physiological movements of the
patient to ensure the dose is accurately delivered. The system automatically places the CyberKnife
System in an interlock protected state when any system parameters are out of specification.
The CyberKnife System meets the following essential performance specifications:
1. The deviation between the prescribed dose value and actual measured value does not
exceed ±5%.
2. The system does not permit unanticipated radiation delivery. All radiation delivered is
system controlled.
3. The kV imaging device does not produce artifacts that interrupt treatment.
4. Key components of the robot, treatment table, and collimators do not have unanticipated
motion. All motion of key components is system controlled.
5. The Target Locating System locates, monitors, and tracks the patient’s position.
6. The system cannot treat when a key component fails or a fault error occurs.
Electromagnetic Interference
WARNING: To avoid compromising equipment or device performance, do not use

Accuray equipment adjacent to or stacked with other equipment. If this is not possible,
verify that all equipment and devices are operating normally.
WARNING: Use of accessories and cables other than those specified or provided by
Accuray Incorporated may result in increased electromagnetic emissions or decreased
electromagnetic immunity that compromises the performance of Accuray equipment.
WARNING: To avoid compromising equipment or device performance, do not place

portable RF communications equipment (including peripherals such as antenna cables
and external antennas) closer than 30 cm (12 inches) to any part of the CyberKnife
Treatment Delivery System, including cables specified by Accuray Incorporated.

WARNING: Failure to use Accuray equipment in the specified shielded location may
compromise the performance of Accuray equipment and interfere with other equipment or
radio services.
This equipment has been tested and found to comply with the limits of the standard for medical
devices, IEC 60601-1-2. The limits are designed to provide reasonable protection against harmful
interference in a typical medical installation. This equipment generates, uses and can radiate radio
frequency energy, and, if not installed and used in accordance with the manufacturer's instructions
may cause harmful interference to other devices in the vicinity. Portable and mobile RF
communications equipment can affect medical electrical equipment. There is no guarantee that
interference will not occur in a particular installation. If this equipment causes interference with
other devices, which may be determined by turning the equipment off and on, the user is
encouraged to try and correct the interference by one or more of the following measures:
• Reorient or relocate the device receiving the interference.
• Increase the separation between the equipment.
• For more information or assistance, contact Accuray Customer Support.
The low levels of electromagnetic radiation from the LINAC may cause electromagnetic
interference (EMI) to surrounding equipment and to patients and technical personnel who have
cardiac pacemakers. In addition, EMI from other nearby equipment, such as microwave
hyperthermia and diathermy equipment, may interfere with the dose counter in the CyberKnife
System. Shielding by the walls of the Treatment Room may lessen this risk.
The following precautions further protect the CyberKnife System from electromagnetic interference
from other equipment and protect other equipment from interference from CyberKnife System
components.
• Keep all doors, panels, and covers in place while you are operating the CyberKnife
System.
• Stop any treatment if you detect fluctuations in outputs, inputs, and power, or if you notice
any obvious erroneous readings. These fluctuations indicate possible EMI between
CyberKnife System components or from other nearby equipment.
Follow the Pacemaker precautions in “Implanted or Body-Worn Electronic Medical Devices ” on
page 2-11.
Table 1
Emissions test Compliance Electromagnetic environment - guidance
The CyberKnife System is intended for use in the electromagnetic environment specified below. The customer
or the user of the system should assure that it is used in such an environment.

Table 1 (continued)
Emissions test Compliance Electromagnetic environment - guidance
RF emissions Group 1 The CyberKnife systems uses RF energy only for its
CISPR 11 internal function. Therefore, its RF emissions are
very low and are not likely to cause any interference
in nearby electronic equipment.
RF emissions CISPR 11 Class [A or B] Radiated Emissions:

Class A, Group 1 30-1000 MHz
Conducted Emissions:
Class A, Group 1, 150kHZ -30MHz
Harmonic emissions IEC [Class A, B, C, D, or Not Not applicable

61000-3-2 applicable]
Voltage fluctuations/flicker [Complies or Not applicable

emissions Not applicable]
IEC 61000-3-3
Table 2
Electromagnetic environment -
IMMUNITY test IEC 60601 test level Compliance guidance
The CyberKnife systems are intended for use in the electromagnetic environment specified below. The
customer or the user of the system should assure that it is used in such an environment.
Electrostatic discharge ± 8 kV contact ± 8 kV contact Floors should be wood, concrete, or

(ESD) IEC 61000-4-2 ceramic tile. If floors are covered
± 15 kV air ± 2, 4, 15 kV air
with synthetic material, the relative
humidity should be at least 30%.

Table 2 (continued)
Radiated RF Stepped ISM Band Stepped ISM Band See Table 3.

IEC 61000-4-3 3 V/m, 80 - 2700 MHz 3 V/m, 80 - 2700 MHz
80%, 1 kHz, AM 80%, 1 kHz, AM
Modulation Spot Modulation Spot
Frequencies 385 – 5750 Frequencies 385 – 5750
MHz MHz
Pulse Modulation Pulse Modulation
433.05 - 434.79 MHz

and 433.05 - 434.79 MHz
and
902 - 928 MHz
902 - 928 MHz
3 V/m 80% @ 1 kHz
3 V/m 80% @ 1 kHz
Portable 2-Way Radios
Portable 2-Way Radios
80-2700 MHz
151.625 MHz 151.625 MHz
151.995 MHz 151.995 MHz
464.500 MHz 464.500 MHz
464.550 MHz 464.550 MHz
Electrical fast ±2 kV AC mains ±2 kV AC mains* Mains power quality should be that

transient/burst of a typical hospital environment.
±1 kV input/output lines ±1 kV input/output lines
IEC 61000-4-4
*GSM Band tested in
situ spot frequencies
385.16MHz - 5.750
GHz. Specific test
frequencies available
upon request.
Surge ±1 kV line(s) to line(s) +/-1 kV Mains power quality should be that

IEC 61000-4-5 of a typical hospital environment.
±2 kV line(s) to earth
line to line
+/-2 kV lines to earth
Conducted RF 0.15 - 80 MHz 0.15 - 80 MHz See Table 3.

IEC 61000-4-6
3 Vrms 1 kHz 3 and 6 Vrms1 kHz
AC mains AC mains

Table 2 (continued)
Power frequency (50/ 30 A/m 30 A/m Power frequency magnetic fields

60 Hz) magnetic field 50/60 Hz 60 Hz should be at levels characteristic of
IEC 61000-4-8 a typical location in a typical
hospital environment.
Voltage dips, short >95% dip in UT >95% dip in UT Mains power quality should be that
interruptions and for 5 seconds for 5 second of a typical hospital environment. If
voltage variations on the user of the CyberKnife systems
power supply input require continued operation during
lines power mains interruptions, it is
IEC 61000-4-11 recommended that the system be
powered from an uninterruptible
power supply or a battery.
NOTE: UT is the AC mains voltage prior to application of the test level.
Table 3 Recommended Separation Distances between portable and mobile RF Communications

Equipment and the CyberKnife Systems
The CyberKnife systems are intended for use in an electromagnetic environment in which radiated RF
disturbances are not controlled. The user of the CyberKnife systems can help prevent electromagnetic
interference by maintaining a minimum distance between portable and mobile RF communications equipment
(transmitters) and the CyberKnife systems as recommended below, according to the maximum output power of
the communications equipment.
Rated maximum output Separation distance (m) according to frequency of transmitter

power (W) of transmitter
150 kHz to 80 MHz 80 MHz to 800 MHz 800 MHz to 2.5 GHz
d = 1.2 √P d = 1.2 √P d = 2.3 √P
0.01 0.12 0.12 0.23
0.1 0.38 0.38 0.73
1 1.20 1.20 2.30
10 3.80 3.80 7.30
100 12.00 12.00 23.00

Table 3 Recommended Separation Distances between portable and mobile RF Communications

Equipment and the CyberKnife Systems
For transmitters rated at a maximum output power not listed above, the recommended separation distance d in
meters (m) can be determined using the equation applicable to the frequency of the transmitter, where P is the
maximum output power rating of the transmitter in watts (W) according to the transmitter manufacturer.
NOTE: At 80 MHz and 800 MHz, the separation distance for the higher frequency range applies.
NOTE: These guidelines may not apply in all situations. Electromagnetic propagation is affected by absorption
and reflection from structures, objects and people.
Laser Radiation
The LINAC uses laser radiation, narrow beams of bright red light. These lasers are in the LINAC
X-ray head. These lasers aid alignment of the treatment robot for LINAC calibration. Each laser
consists of two components, the plasma tube and the power supply. The tubes used have a
maximum of 1 mW output power, thus a Class 2 rating.
WARNING: Use of controls, adjustments, or performance of procedures other than those

specified herein may result in hazardous laser radiation exposure and/or exposure to high
voltage, which may result in severe injury or death. For more information, see “Electric
Shock” on page 2-19.
WARNING: The light from a laser beam can damage the retinas of the eyes. Never look
directly into the laser beam. Advise patients not to look into the laser beam. Otherwise,
blindness can result.
WARNING: Replacement of the laser tube must be done only by Accuray Field Service.
Do not attempt to replace the laser tube. Otherwise, exposure to high voltage is possible
that may result in severe injury or death. For more information, see “Electric Shock” on
page 2-19.
Sulfur Hexafluoride
Sulfur hexafluoride (SF6) is a colorless, odorless gas used in the CyberKnife System as an
electrical insulator. It is stored in a metal container under high pressure. If the metal container
ruptures, the gas or liquid will escape rapidly. Sulfur hexafluoride is nonflammable and is
considered to be nontoxic, but it can act as a simple asphyxiate by displacing air. Contact with the
liquefied gas may cause frostbite. SF6 gas is denser than air and accumulates on the floor if
released.

If the CyberKnife System detects a loss of SF6 gas pressure when high voltage is on, it will
generate an E-Stop.
WARNING: You can be asphyxiated by sulfur hexafluoride in high concentrations, or be

injured by the escaping gas or liquid or by the container itself. Ensure proper handling of
the container.
WARNING: If the gas is inhaled or if contact with the liquefied gas occurs, follow
emergency response procedures as established in your facility’s hazardous substances
training program.
• Handle the sulfur hexafluoride container carefully.

• Do not allow the temperature of the sulfur hexafluoride container to exceed 125° F
(52° C).
• Store extra containers in a dry, well-ventilated location.
• Shut the valve on the gas bottle after filling the RF system.
Implosion
The windows that separate the vacuum in the LINAC and magnetron from the waveguide can
shatter inwardly if they are struck or jolted excessively. Damage may occur to the equipment
because of the casing. Shattering glass should not harm the operator or patient.
The thyratron tubes in the LINAC modulator could also implode.
WARNING: Only trained service personnel should service these or any part of the
CyberKnife System. Otherwise, injury or death of the user can result. If an implosion
occurs, contact Accuray Customer Support immediately.
Explosion
The system must never be operated in the presence of flammable anesthetics or other flammable
or explosive substances. Electrical arcs that can occur during the normal operation of switches,
circuit breakers, push-buttons, and other circuit components can ignite vapors and gases.
WARNING: Only trained service personnel should service any part of the CyberKnife
System. Otherwise, injury or death of the user or patient can result. If an explosion occurs,
contact Accuray Customer Support immediately.

• If flammable substances are present before the system is turned on, do not turn it on.
• If flammable substances are detected after the system has been turned on, pause the
system. Do not turn the system off.
• If flammable substances are detected during a treatment, open the Treatment Room door
to cause an E-Stop. An E-Stop must be generated to evacuate the patient, but no other
operations should be performed.
 If flammable substances are detected:
1. Evacuate all persons immediately.
2. Ventilate the room to clear the air of the flammable vapor or gas.
3. Remove any volatile liquids that are producing flammable vapors to a safe storage area.
Electric Shock
Some CyberKnife System components operate with voltages up to 40,000 volts. Be cautious at all
times during operation.
WARNING: As with any equipment that uses high voltage, the residual voltage in the
components can shock you after the equipment has been turned off, which may result in
severe injury or death. Only qualified service personnel should remove equipment covers.
The following equipment may have residual high voltage:

• Power from the facility circuit breaker.
• Power lines to each component.
• Treatment delivery computer monitors.
• Capacitors in various power supplies, several of which remain charged for long periods.
• When a laser is energized, the red wire from the laser power supply has a potential
greater than 1 kV.
Precautions to Avoid Electric Shock

Observe the following precautions to avoid electric shock:
• Keep all equipment doors and covers closed during operation.
• Do not bypass any safety interlocks.
• Never attempt to tamper with instrumentation circuitry or disconnect a CyberKnife System
cable at any time.
• Only authorized personnel shall service the high voltage components or any part of the
system.
• Conductive fluids should not be spilled onto any part of the equipment.

• Discharge all high voltage storage components prior to servicing or disconnecting from
the supply.
Heavy Equipment
Many components of the CyberKnife System are heavy, particularly the treatment robot, the
standard treatment couch, and the optional RoboCouch Patient Positioning System.
The motors that control the treatment robot, the standard treatment couch, and the RoboCouch
System are very powerful. When these components move, they have substantial inertia. Observe
utmost care to prevent moving components from hitting or crushing you, the patient, other
personnel, or other equipment.
WARNING: Collision with the treatment robot, the RoboCouch System, or any other heavy
component can result in serious injury or death to users or the patient.
WARNING: An operator or patient may be pinched when occupying a location between

moving components or between moving components and a fixed object in the room. An
operator should assess the risk before changing the position of components and be
vigilant when components are moving.
WARNING: During treatment, carefully watch while the treatment robot or RoboCouch
System is moving. If you see either component moving too close (within 2 inches or 5 cm)
to any object, press the nearest E-Stop button immediately to avoid serious injury or
death to the user or patient.
WARNING: When performing operations that involve movement of the treatment robot or
RoboCouch System, never stand within the robot workspace. Otherwise, serious injury or
death can occur.

WARNING: When the RoboCouch System is in motion and under control of either the
Hand Controller or the Teach Pendant, avoid all locations that could pose a potential
crushing hazard. Such locations include (see “Chapter 7: Treatment Room Operations”):
1. The region between the upper and lower arms of the RoboCouch manipulator.
2. The region between the upper arm and nearby walls.
3. The region between the RoboCouch table top and nearby walls.
4. The area beneath the RoboCouch table top.
5. The area between the RoboCouch table top and lower arm.
Pay attention to people and other objects in the room at all times to avoid serious injury or
death.
NOTE: For the RoboCouch with the wall-mounted hand

controller and freestanding column cover, the Teach Pendant
accessed through the door panel is for Field Service use only.
WARNING: Observe the treatment robot safe movement envelope when you are in the
Treatment Room and when adding objects to the Treatment Room. The safe movement
envelope is the set of configurations the treatment robot can assume without colliding
with objects defined at installation. These objects include the floor, ceiling, treatment
table/patient area, and camera stands (for the X-ray imaging detectors).
WARNING: Keep adequate clearance between you and the treatment couch during
treatment couch movements to avoid possible injury.
WARNING: If any equipment collides with the patient or another component, stop the
treatment, attend to the patient, record the accumulated dosage, and call Accuray
Customer Support to service the equipment before any further use.
WARNING: If the treatment robot collides with another object, if forced motion of the
treatment robot occurs, or if slippage of the LINAC head on the treatment robot faceplate
mount occurs, you must re-verify pointing accuracy of the LINAC. Use standard Quality
Assurance (QA) methodology, including Automatic QA (AQA) and/or End-to-End testing,
to verify targeting accuracy specifications. Failure to re-verify alignment can result in
patient mistreatment. For information on Physics QA procedures, see the Physics
Essentials Guide.
CAUTION: Use caution when components are moving. Collisions among components can
damage equipment.

WARNING: Each interchangeable secondary fixed collimator weighs more than 12 lb

(5 kg). When handling a collimator, use two hands and support it securely with your palm
underneath the front face. Be careful not to drop the collimator on your foot or any other
part of your body. Never replace a collimator where it could fall on any part of the patient.
Dropping a collimator can result in serious injury to users or the patient.
CAUTION: Be careful not to drop the collimator on the X-ray detectors of the imaging system.
Otherwise, damage to the X-ray detectors can occur.
For more information on interchangeable secondary collimators, see “Chapter 7: Treatment Room
Operations”.
WARNING: Personal injury may occur if you stick your fingers or other body part into the
path of a moving IRIS aperture. Do not stick your fingers or other part body part into a
moving IRIS aperture.
The Patient Safety Zone

This section describes the Proximity Detection Program (PDP), the Supplemental Proximity
Detection Program (SPDP), and the Patient Safety Zone. It covers the following topics:
• “Proximity Detection Program” on page 2-22
• “Supplemental Proximity Detection Program” on page 2-23
• “Patient Safety Zone Dimensions (Standard Treatment Couch and
RoboCouch Flat Table Top Configuration)” on page 2-24
• “Required Measurements Before Treatment Delivery” on page 2-28
• “” on page 2-28
Proximity Detection Program

The Proximity Detection Program (PDP) is active when the treatment robot is moved from the
treatment delivery computer in the following applications: Treatment, Phantom, Demonstration,
Plan QA, Physics/Collimator, and Physics/Laser Alignment.
The PDP monitors the position of the treatment robot to minimize the possibility of collisions with
the patient or known Treatment Room components.
To detect collision risk, the PDP uses fixed and dynamic models based on Treatment Room
geometry, Cyberknife system components, and patient size. The fixed and dynamic models
combine to define the Patient Safety Zone.
During treatment planning, beams are disabled if they are likely to cause a PDP error.

Before treatment, the Patient Safety Zone is used to determine the boundaries for positioning the
patient for safe treatment. For instructions on checking the Patient Safety Zone before treatment,
see Chapter 7, “Checking the Patient Safety Zone".
For the dimensions of the fixed and dynamic zones used to define the Patient Safety Zone and
detect collision risk, see “Patient Safety Zone Dimensions (Standard Treatment Couch and
RoboCouch Flat Table Top Configuration)” on page 2-24.
For instructions on responding to PDP errors, see “PDP Errors From the Treatment Delivery
Computer” on page 2-29.
Supplemental Proximity Detection Program

The Supplemental Proximity Detection Program (SPDP) is active outside of treatment when the
treatment robot is moved using the Teach Pendant with the mode selector switch set to either T2
or Automatic and when the RoboCouch is moved using the RoboCouch Hand Controller.
The SPDP monitors the position of the treatment robot and the patient positioning system, which
includes the Standard Treatment Table and the RoboCouch, to minimize the possibility of collisions
between Treatment Room components. The SPDP is intended primarily to avoid equipment
collisions when PDP is not active.
To detect collision risk, the SPDP uses dynamic zones similar to those of the small patient PDP
dynamic models.
For instructions on responding to SPDP errors, see “SPDP Errors from the Treatment Robot Teach
Pendant” on page 2-29 and “SPDP Errors From the RoboCouch Hand Controller” on page 2-30.
WARNING: The PDP and SPDP models are based on room geometry and CyberKnife
System components. Do not place temporary objects inside the treatment room, for
example, chairs, gurneys, or IV poles. Otherwise, collision with the treatment robot or
treatment couch and serious injury or death may occur.
WARNING: The PDP model is based on the Head First Supine (HFS) patient position.
Before treatment, ensure that the patient and all devices are within the Patient Safety Zone
defined by the PDP model, even if the patient is not in the HFS position. For information
on supported patient positions, see “Chapter 8: Treatment Delivery”.
WARNING: Carefully monitor motion of the treatment robot when using the treatment
robot Teach Pendant to avoid collisions. It is possible for the treatment robot to be moved
into the patient, overhead structures such as the X-ray sources, the optional Xchange
Robotic Collimator Changer, and other objects or walls in the Treatment Room, which can
result in serious injury or death, and damage to the equipment and surrounding facilities.

Patient Safety Zone Dimensions (Standard Treatment

Couch and RoboCouch Flat Table Top Configuration)
This section gives dimensions in centimeters of the fixed and dynamic safety zones for CyberKnife
Systems with the standard treatment couch or the optional RoboCouch Flat Table Top
configuration.
Fixed Safety Zone (PDP Only)

This section gives dimensions of the fixed safety zone for CyberKnife Systems with the standard
treatment couch or the optional RoboCouch Flat Table Top configuration.
The fixed safety zone is a volume of space from which the treatment robot is excluded. This safety
zone is fixed relative to the machine center. Its dimensions depend on the anatomy chosen during
treatment planning (head or body treatment), as shown in Figure 3 on page 2-24, and Figure 4 on
page 2-25.
Fixed Safety Zone for Head Treatment

Figure 3 on page 2-24 shows the dimensions of the fixed safety zone for head treatment.
B=
A=
= Machine center
Figure 3 Fixed safety zone dimensions for head treatment

(standard treatment couch and RoboCouch Flat Table Top)

Fixed Safety Zone for Body Treatment

Figure 4 on page 2-25 shows the dimensions of the fixed safety zone for body treatment.
E=
D=
C=
= Machine center
Figure 4 Fixed safety zone dimensions for body treatment

(standard treatment couch and RoboCouch Flat Table Top
configuration)
Dynamic Safety Zone

This section gives dimensions of the dynamic safety zone for CyberKnife Systems with the
standard treatment couch or the optional RoboCouch Flat Table Top configuration.
The dynamic safety zone is a volume of space from which the treatment robot is excluded. The
dynamic safety zone is used to ensure that the treatment robot does not collide with the treatment
couch or patient.
When the PDP is active during treatment, the size of the dynamic safety zone is based on the size
of the patient selected, as described below. For the SPDP, the dynamic safety zone is based on a
small patient.
The dynamic safety zone encompasses the patient, the table top of the treatment couch, and the
headrest.

When aligning the patient, position the patient so that the dynamic safety zone of the treatment
couch is within the fixed safety zone relative to the machine center.
The patient size sets the dimensions of the dynamic safety zone. You can select the following
patient sizes:
• Large: Based on size data for a 99 percentile male (Figure 5 on page 2-26).
• Medium: Based on size data for a 75 percentile male (Figure 6 on page 2-27).
• Small: Based on size data for a 50 percentile female (Figure 7 on page 2-27).
WARNING: Choose a size that is as large as or larger than the patient. Otherwise,
collision with the treatment robot is possible which can result in serious injury or death of
the patient.
Figure 5 Dimensions of dynamic safety zone for large

patient size (standard treatment couch and RoboCouch Flat
Table Top configuration)

Figure 6 Dimensions of dynamic safety zone for medium

Figure 7 Dimensions of dynamic safety zone for small


WARNING: Position the patient and all devices within the Patient Safety Zone defined by
the Proximity Detection Program (PDP) model. Anything extending outside the boundaries
of the PDP model increases the risk of collision with the robot and can cause serious
injury or death of the patient.
WARNING: Do NOT place pillows or other objects in an area that could cause Patient
Safety Zone violations. Do NOT position patient extremities so that safety zone violations
occur, or else the patient may be seriously injured or killed.
For example, actions that could cause Patient Safety Zone violations include:
• Placing pillows under the patient's head.
• Positioning the patient with arms raised above head; this can cause elbows to exceed the
111 cm height limit or the 108 cm superior limit.
• Using too large a wedge under the patient's knees; this can elevate the knees above the
111 cm height limit.
• Treating lesions below L-4 Head First Supine (HFS).
Required Measurements Before Treatment Delivery

The measurements below are required before treatment delivery to ensure that the patient is
located within the Patient Safety Zone.
1. For cranial treatments, two measurements must be made to ensure the patient is located
within the fixed safety zone:
• Measuring upward from the floor, verify that the entire patient is lower than 106 cm
(the height labeled “A” in Figure 3 on page 2-24 for the standard treatment couch or
the RoboCouch Flat Table Top configuration.
• Measuring the distance labeled “B” superior from the machine center in Figure 3 on
page 2-24, verify that the patient is within this 22.9 cm boundary.
2. For extracranial treatments, measure upward from the floor to verify that:
• The entire patient is lower than 111.3 cm (the height labeled “C” in Figure 4 on
page 2-25 for the standard treatment couch or the RoboCouch Flat Table Top
configuration).
3. If you are treating a lateral lesion, measure to verify that:
• The lateral borders of the entire patient do not exceed 34.3 cm (1/2 the distance
labeled “E” in Figure 4 on page 2-25 for the standard treatment couch or the
RoboCouch Flat Table Top configuration) either to the left or right of the machine
center.

Responding to PDP and SPDP Errors

This section describes how to respond when the PDP or SPDP detects a collision risk and stops
device motion. It covers PDP and SPDP errors that occur during movement under control of the
following:
• “PDP Errors From the Treatment Delivery Computer” on page 2-29
• “SPDP Errors from the Treatment Robot Teach Pendant” on page 2-29
• “SPDP Errors From the RoboCouch Hand Controller” on page 2-30
PDP Errors From the Treatment Delivery Computer

If the PDP detects a collision risk when the treatment robot is moved from the treatment delivery
computer in treatment mode (Treatment, Phantom, Demonstration, Plan QA, Physics
> Collimator, and Physics > Laser Alignment), a PDP error message is displayed.
The error message window gives you an option to continue moving the treatment robot with a
smaller safety zone. If the PDP detects a collision risk with the smaller safety zone, a second error
message is displayed. The error message again gives you an option to continue with a further
reduced safety zone. If you continue and the PDP detects another collision risk with the further
reduced safety zone, you cannot move the treatment robot any closer.
WARNING: Neither the PDP nor the SPDP detect a collision risk when the treatment
couch is moved from the treatment delivery computer in treatment mode (Treatment,
Phantom, Demonstration, Plan QA, Simulation, and Physics>Collimator, and
Physics>Laser Alignment modes). Use extreme caution when moving the treatment
couch from the treatment delivery computer. Visually observe all movement of the
treatment couch to prevent potential collisions. Manually driving the treatment couch or
patient into other room obstacles using the Hand Controller or Teach Pendant can result
in serious injury or death of users or the patient.
SPDP Errors from the Treatment Robot Teach Pendant

If the SPDP detects a collision risk when the treatment robot is moved using the Teach Pendant
with the mode selector switch set to either T1 or T2, an SPDP error message is displayed ("SPDP
Protection has been triggered" and "Ackn. general motion enable" or only
"Ackn. general motion enable"). If the error is an SPDP error, the POV icon (topright) on
the Teach Pendant is automatically set to 10% unless it is already lower, and the HOV icon (bottom
right) is set to 20% unless it is already lower (see Figure 8).

POV 10%
HOV 20%
Figure 8 SPDP error message with POV and HOV settings
 To respond to a Teach Pendant SPDP error message:

1. Release the Teach Pendant Enable switch to clear the SPDP message.
2. Move the treatment robot safely away from the collision risk.
The SPDP allows only slow speed movement using the Teach Pendant until there is no further
collision risk. You can then resume normal jogging speeds.
WARNING: It is possible to move the treatment robot closer to the collision risk and
potentially collide with it when you jog at slow speed using the Teach Pendant. Use
extreme caution when moving the treatment robot towards the collision risk. For
guidelines on what to do if a collision with a patient or room object occurs, triggering an
E-Stop, see "Error Handling" in “Chapter 8: Treatment Delivery”.
SPDP Errors From the RoboCouch Hand Controller

If the SPDP detects a collision risk when the RoboCouch System is moved using the RoboCouch
Hand Controller at medium or fast speeds, the Hand Controller automatically switches to slow
speed.
 To respond to a RoboCouch Hand Controller SPDP error:
1. Release the Enable button on the RoboCouch Hand Controller.
2. Move the RoboCouch System away from the collision risk.

The SPDP allows only slow speed movement using the Hand Controller until there is no further
collision risk. You can then resume normal jogging speeds.
WARNING: It is possible to move the RoboCouch System closer to the collision risk and
potentially collide with it when you jog at slow speed using the Hand Controller. Use
extreme caution when moving the RoboCouch System towards the collision risk. Visually
observe all movement of the treatment couch to prevent potential collisions. Manually
driving the treatment couch or patient into other room obstacles using the Hand
Controller or Teach Pendant can result in serious injury or death of users or the patient.

Contact Detection Sensor Check

Daily Quality Assurance (QA) procedures should include a Contact Detection Sensor check. This
check can be performed as frequently as you wish.
Two procedures are described below. The first applies to both fixed collimators and the Iris
Collimator. The second applies to fixed collimators only.
 To perform a Contact Detection Sensor check for fixed collimators or the Iris Collimator:
1. Log into Physics mode on the treatment delivery computer.
2. On the Physics screen, click the LINAC button.
3. On the LINAC screen, click either the Warmup button or the Calibration Check
button. The Warmup screen or Calibration Check screen is displayed.
4. With the safety interlock key Enable High Voltage key in the operator control panel, open
the Treatment Room door. If the E-Stop status icon at the bottom right of the screen
displays an orange exclamation point over a treatment door icon, the E-Stop circuitry is
operational. You can also click the Error Information button to display the Error
Handling System window to confirm the Treatment Room door E-Stop was triggered.
5. Close the Treatment Room door.
The Treatment Room door E-Stop is automatically cleared, the E-Stop status icon
changes to a green checkmark, and you are returned to the Warmup screen or the
Calibration Check screen.
6. Remove the safety interlock key from the operator control panel and use it to bypass the
Treatment Room door interlock.
7. Enter the Treatment Room. Squeeze firmly around the contact detection sensor.
8. Return to the treatment delivery computer. An error message will be displayed in the error
message window reporting that an E-Stop due to a contact detection sensor error has
occurred.
WARNING: If the Contact Detection Sensor malfunctions (no clicking sound), it is

possible for contact to occur between the treatment robot and/or other LINAC
components that are protected with a contact sensor and another object or person
without triggering a Contact Detection Sensor error, which can result in serious injury or
death of the person, or damage to equipment. If the Contact Detection Sensor
malfunctions, contact Accuray Customer Support.

 To perform a Contact Detection Sensor check for fixed collimators (alternative check):
1. Squeeze firmly around different areas of the sensor (Figure 9 on page 2-33).
Slot
Area opposite the slot

on fixed collimator
secondary housing
Figure 9 Contact Detection Sensor check
2. Verify that a clicking sound can be heard. The area opposite the slot is most sensitive
when squeezing the sensor for sound. It may be necessary to position your ear close to
the sensor (approximately 4 in or 10 cm from the sensor) to hear the clicking sound.
WARNING: If the Contact Detection Sensor malfunctions (no clicking sound), it is

possible for contact to occur between the treatment robot and/or other LINAC
components that are protected with a contact sensor and another object or person
without triggering a Contact Detection Sensor error, which can result in serious injury or
death of the person, or damage to equipment. If the Contact Detection Sensor
malfunctions, contact Accuray Customer Support.

Hot Surfaces
Many components of the CyberKnife System operate at high temperatures. When equipment
covers are removed, hot surfaces are accessible.
WARNING: Do not remove equipment covers. Otherwise, you can be seriously burned
from touching hot surfaces that are exposed. Only qualified service personnel should
remove any equipment covers.
During operation of the CyberKnife System and during a reasonable cool-down period after turning
off the equipment, be sure not to touch the following components when they are hot:
• Thyratron tubes
• Any light bulbs
• Transformers
• Resistors
• Magnetron
• Laser tubes
• Robot motors
WARNING: Avoid any bodily contact with the above components or any other
components that seem warm when approached. Otherwise, you can be seriously burned
from touching hot surfaces. Be aware that the thyratron, magnetron, and LINAC filaments
remain on while the equipment is in the stand-by mode.

Facility Responsibilities
This section describes your responsibilities for setting up emergency and safety procedures for
CyberKnife System operations.
General Use
Use the following guidelines for routine use of the CyberKnife System:
• Keep a logbook of regular Quality Assurance (QA) and maintenance activities and also
record all unusual events related to the system.
• Always observe the standard startup and shutdown procedures, being certain to disable
the equipment by the documented procedures only.
• Test Emergency Stop procedures monthly.
Disinfection Instructions
The only parts of the CyberKnife System that should come in contact with the patient are the
carbon fiber treatment couch table top and the cushions provided with the treatment couch. These
surfaces are not intended to be sterile. They can be cleaned with normal cleaning solutions.
Safety Operations
You must provide and train your technical, service, and support staff in the following safety
operations.
• Fire extinguishers should be present in the Treatment Room and near the operator
control panel, per local fire code.
• The Treatment Room and operator control panel area must have emergency lighting. In
addition, flashlights must be on-site as a back-up during emergencies.
• Hazard signs regarding radiation exposure, high voltage, laser light hazards, and
pacemaker hazards must be posted where appropriate, near the Treatment Room, near
the operator control panel, and on the system components.
• Radiation monitoring badges should be worn at all times while in the Treatment Room.
• Dangers to people with pacemakers must be ascertained by following the guidelines
described earlier in this chapter.
• Video and audio monitoring are mandatory whenever a patient is in the Treatment Room.
This monitoring equipment is required in addition to the radiation monitoring equipment
incorporated in the CyberKnife System.
1075883-ENG A Facility Responsibilities | 2-35

Emergency and Safety Training

All personnel who work with the CyberKnife System must have initial training and periodic refresher
courses for the following:
• Emergency Stop (E-Stop) procedures.
• Emergency Power Off (EPO) procedures.
• Location of the main circuit breaker as a backup for emergency power off.
• Evacuation procedures and egress routes in case of fire, fumes, or other threatening
situations.
• Emergency procedures in case of earthquake or other natural disasters likely at the
facility’s location.
• Emergency lighting system activation and the location of backup flashlights.
• How to assist a patient to get down from the treatment couch and out of the facility.
• List of people to contact in case of a fire, medical, or technical emergency.
• How to restart the CyberKnife System after an emergency shutdown.
Radiation Overdose
The CyberKnife System uses dual redundant dose monitoring systems, which stop treatment upon
reaching the prescribed dose.
If the treatment is stopped manually because of a failure in the automatic shut-off by the dose
monitoring system, the equipment must be checked and serviced by a qualified technician before
any further treatments are performed.
 In the case of a radiation overexposure:
1. Seek emergency treatment for the victim.
2. Contact the local radiation safety officer according to facility protocols.
3. Notify the local, state, and federal authorities in accordance with your institutional
procedures.
4. Consult with medical experts in radiation treatment.
5. Notify the Accuray radiation safety officer at RSO@accuray.com as quickly as possible.
2-36 | Facility Responsibilities 1075883-ENG A

Chapter 3: CyberKnife
Treatment Delivery System
Overview
Introduction
The CyberKnife Treatment Delivery System combines continuous image-guidance technology with
computer-controlled robotics to deliver a prescribed dose of radiation.
The CyberKnife System utilizes a compact linear accelerator attached to a computer-controlled
robotic arm, called the treatment robot, to target a number of beams of radiation at a lesion from
many different directions. The patented image-guidance technology correlates intra-operative X-
rays with previously acquired CT images of the lesion and surrounding tissue to target each beam
of radiation. This approach results in a high dose of radiation concentrated within and conforming
to the lesion, where the beams converge.

CyberKnife System Components

The main components and subsystems of the CyberKnife System are described in this section.
3
3
4
6
1
Figure 1 CyberKnife Treatment Delivery System
1. Treatment robot 2. Patient positioning system 3. Target Locating System (TLS) 4. Linear
accelerator (LINAC) 5. X-ray detector and floor panel 6. Synchrony Respiratory Camera Array
(option).
• “Target Locating System (TLS)” on page 3-3
• “Operator Control Systems” on page 3-6
• “Accuray Precision Treatment Planning System” on page 3-7
• “LINAC and Control Systems” on page 3-8
• “Treatment Robot” on page 3-10
• “Power Distribution Unit (PDU)” on page 3-11
• “E-Stop Control Chassis (ESCC)” on page 3-11
• “Uninterruptible Power Supply (UPS)” on page 3-11
• “Miscellaneous Equipment (Supplied by Customer)” on page 3-11
3-2 | CyberKnife System Components 1075883-ENG A

Treatment Delivery Manual Chapter 3: CyberKnife Treatment Delivery System Overview
• “Standard Treatment Couch” on page 3-14
Target Locating System (TLS)

The Target Locating System (TLS), also called the X-ray imaging system, provides information
about the location of the treatment target throughout the treatment process.
The TLS uses 2 X-ray sources mounted overhead on either side of the treatment couch. The X-ray
sources provide orthogonal pairs of X-ray images. The images are digitized and then compared to
reference Digitally Reconstructed Radiograph (DRR) images that have been synthesized from
patient CT images.
The TLS includes the following components:
• “X-ray Sources and Generators” on page 3-3
• “Digital X-ray Detectors” on page 3-4
• “Isopost Calibration Tool” on page 3-4
• “Detector Windows” on page 3-4
TLS components are aligned within the imaging plane and are symmetric about the isopost. These
components are described in the sections that follow.
X-ray
Sources
Isopost
Calibration
Tool
Digital X-ray
Detectors Localizing
Frame
Figure 2 Target Locating System (TLS) General Diagram
X-ray Sources and Generators

Two X-ray sources (see Figure 1) produce the X-ray beams for imaging the patient. They are
mounted to the ceiling of the Treatment Room on either side of the treatment couch.
1075883-ENG A CyberKnife System Components | 3-3

Two X-ray generators (not shown in Figure 1) supply power to each X-ray source. The maximum
symmetrical radiation field is approximately 24 x 17 cm at the treatment isocenter. Depending on
the room configuration, the distance between the source and the treatment center (isocrystal) is
2200 ± 100 mm, and the distance between the detector and treatment center is 1420 ± 5 mm.
The X-ray generators and X-ray generator control chassis may be located in either the Treatment
Room or the Equipment Room.
Digital X-ray Detectors

Two high sensitivity digital X-ray detectors (see Figure 1) are mounted within a localizing frame to
ensure a high degree of alignment and accuracy between all components of the X-ray imaging
system.
NOTE: The localizing frame is mounted either flush with the floor
(In-Floor Detectors) or slightly above the floor (On-Floor
Detectors) in the Treatment Room.
WARNING: The On-Floor Detectors are a possible trip hazard.
Isopost Calibration Tool

The isopost calibration tool (see Figure 2 on page 3-3) mounts directly into the localizing frame and
is the reference point for calibrating the treatment robot and the X-ray imaging system.
NOTE: The isopost calibration tool is used only for calibrating the
CyberKnife System and is then removed.
Detector Windows
The 2 detector windows are made of carbon fiber material to ensure X-ray translucency and high
strength. They are designed to support up to a 500 lb (227 kg) load and protect the detectors.
Protective material covers the detector windows. The protective window coverings can be replaced
if they become scratched or damaged.

CAUTION: Do not drop any heavy or sharp objects onto the detector windows. If a heavy object
is dropped on the detector windows, call Accuray to assess the structural damage.
• Do not change secondary collimators over the detector windows.

• Never jump onto the detector windows.
• Do not operate the CyberKnife System without the detector windows in place.
• Avoid walking on the detector windows when possible.
• Do not slide heavy objects across detector windows.
• Scratches on the detector windows can degrade X-ray images to the point where
CyberKnife System performance may be affected. If necessary, replace the
protective window covering at regular maintenance intervals.

Operator Control Systems

The operator control system controls the treatment delivery process according to the treatment
plan.
Treatment Delivery Computer

The treatment delivery computer is the main computer used for delivering and monitoring patient
treatment. It includes a flat panel monitor. The monitor, keyboard, and mouse are located in the
Control Room. The treatment delivery computer is usually located in the Equipment Room.
Synchrony Skull Tracking

Synchrony Skull Tracking enables tracking of intracranial targets without the need for stereotactic
frames. Skull Tracking works by computing the offset between Live X-ray images and reference
DRR images by identifying and matching skeletal features of the skull. Tracking the target relies
on the fixed relationship between the target volume and these skeletal features.
Synchrony Fiducial Tracking

Synchrony Fiducial Tracking enables tracking extracranial tumors by tracking implanted fiducials.
Fiducial tracking mode correlates fiducial locations in reference DRR images with Live X-ray
images to extract fiducial locations. Tracking the target relies on the fixed relationship between the
target volume and the configuration of fiducials. Fiducial tracking allows tracking and treating
tumors with submillimeter accuracy.
Synchrony Fiducial Tracking with Respiratory Modeling may be used to track the tumor due to
respiration. For more information, see “Chapter 12: Synchrony Respiratory Tracking System
(Option)”
iDMS Data Management System

The iDMS Data Management System provides the central database of the CyberKnife System,
where CyberKnife patient, user, and system data are stored. It provides data management
applications that allow the user to add, access, modify, export, delete, and validate CyberKnife
data. It includes Image Review and Import, Patient Archive and Restore, and Beam Data Import
applications. The iDMS Data Management System supports multiple CyberKnife Systems.
The iDMS Data Management System includes the following components:
• CyberKnife System data server: The data server hosts the CyberKnife System
database, DICOM server, and DRR Generation server. It is located in the Equipment
Room.
• iDMS Data Management System administrative applications for performing patient,
user, and treatment plan administration tasks are installed on every Accuray Precision
Treatment Planning System workstation.
For more information on the iDMS Data Management System, see the Data Management Manual.

User Control Console Equipment

The user control console equipment for the CyberKnife System includes the following components
located in the Control Room:
• Operator control panel to turn on the high voltage to the LINAC and monitor status of the
treatment radiation beam. The operator control panel includes an Emergency Stop (E-
Stop) button.
• Monitor, keyboard, and mouse for the treatment delivery computer.
• Monitoring equipment for the Treatment Room. See “Miscellaneous Equipment (Supplied
by Customer)” on page 3-11.
Accuray Precision Treatment Planning System

The Accuray Precision Treatment Planning System is a highly interactive, workflow-based
software application designed for radiosurgery and high precision radiation therapy planning. The
Accuray Precision System provides tools necessary to generate quality treatment plans for
delivery using the CyberKnife System. It allows you to load and fuse images, draw contours,
choose the appropriate tracking mode, and set dose constraints to create an optimized treatment
plan using forward or inverse planning techniques. A variety of tools are provided to perform quality
assurance (QA) and system commissioning tasks in line with common commissioning and QA
standards.
The Accuray Precision System enables the creation of treatment plans using Synchrony Skull
Tracking, Synchrony Fiducial Tracking, and the following tracking options if installed with the
CyberKnife System: Synchrony Spine Tracking, Synchrony Lung Tracking with Respiratory
Modeling, and Synchrony Fiducial Tracking with Respiratory Modeling. Treatment plans can be
evaluated and compared to determine the best plan possible for the patient.
Several Accuray Precision System workstations may be associated with one CyberKnife System.
For more information on the Accuray Precision System, see the Treatment Planning Manual.
NOTE: iDMS Data Management System administrative

applications for performing patient, user, and treatment plan
administration tasks are installed on every Accuray Precision
Treatment Planning System workstation.

LINAC and Control Systems

The LINAC is mounted in the X-ray head and delivers radiation treatment to the patient.
Figure 3 LINAC in X-ray head
LINAC
The X-band LINAC provides a collimated beam of 6 MV X-rays. The LINAC consists of an electron
gun and a series of microwave cavities under vacuum. Its compact size allows robotic manipulation
with 6 degrees of freedom.
The high efficiency design of the LINAC provides a dose rate of 800 monitor units (MU) per minute.
X-ray Head
The X-ray head contains the LINAC, magnetron, microwave waveguide components, the pulse
transformer, water-circulating connections and a gas pressurizing connection for the waveguide.
The X-ray head is attached to the treatment robot.
Secondary Collimators
12 interchangeable fixed collimators with apertures (in millimeters) of 5, 7.5, 10, 12.5, 15, 20, 25,
30, 35, 40, 50, 60 allow flexibility and conformability during the treatment planning process. Pinhole
and blank (no aperture) collimators are also included. The fixed collimators attach to a secondary
collimator housing which is mounted on the X-ray head.
The optional Iris™ Variable Aperture Collimator provides the same 12 apertures as the fixed
collimators. The aperture of the Iris Collimator is adjustable under computer control. For
information, see “Iris Variable Aperture Collimator (Option)” on page 3-16.

Laser Alignment Check Sensor

The Laser Alignment Check sensor is located on the Xchange table or on the base of the treatment
robot for systems without an Xchange table. CyberKnife Systems use this sensor during a Laser
Alignment Check procedure.
For more information on the Laser Alignment Check procedure performed during treatment
delivery, see “Chapter 8: Treatment Delivery”. For information on the Laser Alignment Check
application, see the Physics Essentials Guide.
Modulator Control Chassis (MCC)

The Modulator Control Chassis (MCC) contains the control circuits for the modulator and the
LINAC. It also contains the fault circuitry and an interface card allowing control by the CyberKnife
System. It is also used to route complex signals used by the LINAC. The MCC is located in the
Equipment Room.
Modulator (MOD)
The Modulator (MOD) contains high voltage pulse-generating circuits and provides a pulse to the
magnetron so the magnetron can produce radio frequency (RF) energy. The MOD is located in the
Equipment Room.
Chiller
The chiller is a closed-loop system that cools the LINAC. It consists of a water reservoir, a
recirculating pump, and a refrigeration unit. The chiller includes temperature-regulating control to
maintain a stable operating temperature, a water temperature indicator, and status lamps. The
chiller does not require external facility connections. The chiller is located in the Equipment Room.
Target Locating System (TLS) computer

The Target Locating System (TLS) computer is used primarily to control the Target Locating
System. The TLS computer provides an interface between the TLS and the treatment delivery
computer. The unit also conducts image correlation to determine patient displacement during
treatment. The TLS computer is located in the Equipment Room.
Target Locating System Control Console (TLSCC)

The Target Locating System Control Console (TLSCC) provides an interface between the TLS
computer and the X-ray imaging system. This unit controls the diagnostic X-ray sources and
imaging panels used for image acquisition. The TLSCC is located in the Equipment Room.

Interface Control Chassis (IFCC)

The Interface Control Chassis (IFCC) functions as an interface between the LINAC and other
components of the CyberKnife System. The IFCC provides near-real-time control of hardware
components and relays status information to the multi-processing treatment delivery computer.
The IFCC also handles most digital processing of dosimetry signals, generates a variety of fault
signals, and monitors the sense potentiometers for the collimator. The IFCC is located in the
Equipment Room.
Treatment Robot
The treatment robot is a 6-axis robot that carries the LINAC. The treatment robot provides
automated positioning of the LINAC for patient treatment with 6 degrees of freedom.
Figure 4 Treatment robot
Manual operation of the treatment robot is provided by the treatment robot Teach Pendant, located
in the Treatment Room.
A treatment robot controller controls positioning of the treatment robot and is located in the
Equipment Room.

Power Distribution Unit (PDU)

The PDU supplies power to all components of the CyberKnife System. The customer supplies the
power input to the PDU. The PDU is located in the Equipment Room.
CyberKnife System electrical ratings are as follows:
• 3 phase, 50/60 Hz, 25 kVA
• 200 - 240 VAC, 30 A
• 380 - 480 VAC, 16 A
(Not all input voltages are available on all models.)
E-Stop Control Chassis (ESCC)

The E-Stop Control Chassis (ESCC) performs a wide variety of hardware functions, as well as
functioning as a central point for E-Stop signals, The ESCC is located in the Equipment Room.

The Uninterruptible Power Supply (UPS) provides backup power to the treatment delivery
computer and CyberKnife System data server for 5 minutes. It is located in the Equipment Room.
Miscellaneous Equipment (Supplied by

Customer)
The following equipment for the CyberKnife System is supplied by the customer:
• Physics conduit port between the Control Room and the Treatment Room. The conduit
port can be used for cables required for equipment used during Physics procedures. It
can also be used for cables for the infrastructure necessary for two-way patient
monitoring and communication.
• Closed Circuit TV (CCTV) system for monitoring the patient. The CCTV system usually
consists of the following components:
Quad Multiplex Monitor: The monitor is used for viewing the patient in the Treatment
Room. The monitor is located in the Control Room.
CCTV cameras: 4 CCTV cameras are recommended in the Treatment Room, 2 mounted
high and 2 mounted low, with 2 of the cameras (one high and one low) capable of pan
and zoom.
• Intercom System for communication between the Control Room and Treatment Room.
• Phone.
• Medical gas lines, if desired.

CyberKnife System Options

This section describes options available with the CyberKnife System.
Synchrony Spine Tracking (Option)

Synchrony Spine Tracking (supine and prone) enables tracking of skeletal structures in the spine
for accurate patient positioning and radiation beam delivery using the CyberKnife System without
implanting fiducials.
Synchrony Spine Tracking is capable of accurately and automatically tracking all regions of the
spine, from the cervical through the sacral spine. It is capable of tracking non-rigid deformations
typically observed in multiple vertebral structures.
Synchrony Spine Tracking Prone with Respiratory Modeling may be used to track the tumor due
to respiration. For more information, see “Chapter 12: Synchrony Respiratory Tracking System
(Option)”
For more information, see “Chapter 10: Synchrony Spine Tracking (Option)”.
Synchrony Lung Tracking with Respiratory

Modeling (Option)
The Synchrony Lung Tracking with Respiratory Modeling enables tracking and delivering radiation
beams to lung tumors that meet the criteria described in “Chapter 11: Synchrony Lung Tracking
with Respiratory Modeling (Options)”. The Synchrony Lung Tracking with Respiratory Modeling
allows accurate patient positioning and radiation beam delivery without the need for implanting
fiducials.
The Synchrony Lung Tracking with Respiratory Modeling is used in combination with Synchrony
Spine Tracking for patient alignment and uses Respiratory Modeling to track movement of the
tumor due to respiration.
For more information, see “Chapter 11: Synchrony Lung Tracking with Respiratory Modeling
(Options)”.
Lung Optimized Treatment (Option)

The Lung Optimized Treatment workflow includes a Simulation Application and target tracking
modes (Lung 1 View with Respiratory and Spine Supine) designed to increase the number of
patients who can benefit from non-invasive CyberKnife treatment of lung cancer.
The Simulation Application provides a workflow for determining which lung tracking modes are
viable for a given patient prior to creating a deliverable treatment plan. For more information, see
“Chapter 14: Simulation Application Overview (Option)”.
3-12 | CyberKnife System Options 1075883-ENG A

The Lung 1 View with Respiratory tracking is used in cases in which the tumor is more clearly
visible or better identified in one X-ray projection than the other. The Spine Supine tracking mode
is used in cases in which the tumor is not clearly visible in either X-ray projection. For more
information on Lung Optimized Treatment, see “Chapter 15: Lung Optimized Treatment (Option)”.
Synchrony Respiratory Tracking System (Option)

The Synchrony Respiratory Tracking System is used to monitor patient breathing and adjust the
position of the LINAC to match respiratory motion of the target. The Synchrony Respiratory
Tracking System includes the following components:
• Synchrony Respiratory interface module, mounted underneath the headrest of the
treatment couch. in the Treatment Room.
• Synchrony Respiratory Camera Array, mounted to the ceiling near the foot of the
treatment couch in the Treatment Room.
• Synchrony Respiratory Vest, a single-use patient vest with 3 single-use Synchrony
Respiratory External LED Markers – light-emitting diodes (LEDs) – attached. The patient
wears the vest during pretreatment scanning and during treatment.
The Synchrony Respiratory System can be set up in manual or automatic modes. Manual Setup
allows a correlation model between target motion and respiratory motion of the patient to be
established image by image. The Automatic Setup option allows a complete Respiratory
correlation model to be established automatically.
With the Automatic Setup option, the Synchrony Respiratory tracking system can use Image Burst
to rapidly take a set of images at an adjustable time interval during treatment delivery automation.
The burst of images reduces the image age used in the Respiratory Model, which improves the
model quality and reduces treatment interruptions.
For more information, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
Synchrony Tracking™ with InTempo Imaging

(Option)
Synchrony® Tracking™ with InTempo Imaging is a time-based motion tracking technology used
to compensate for intrafraction motion of the target. It can be used with Synchrony Skull Tracking,
Synchrony Spine Tracking, and Synchrony Fiducial Tracking.
For more information, see “Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging
(Option)”.
1075883-ENG A CyberKnife System Options | 3-13

Standard Treatment Couch

The standard treatment couch is used to position the patient for treatment. It is capable of moving
the patient under computer control in 3 translation directions (Inferior/Superior, Left/Right, Anterior/
Posterior) and 2 rotation directions (roll and pitch).
Figure 5 Standard treatment couch
The maximum load supported by the standard treatment couch is 350 lb (159 kg). Patient weight
includes any pads, restraints, and devices that are loaded on the table top.
The standard treatment couch includes the following components:
• Standard treatment couch table top
• Standard treatment couch head base plate
• Hand Controller and readout display for manual operation of the treatment couch

RoboCouch Patient Positioning System (Option)

The RoboCouch Patient Positioning System is a computer-controlled system for positioning
patients using a robot with 6 degrees of freedom. The RoboCouch System is capable of moving
the patient under computer control in 3 translation directions (Inferior/Superior, Left/Right, Anterior/
Posterior) and 3 rotation directions (roll, pitch, and yaw). The maximum load supported by the
RoboCouch System is 500 lb (227 kg). Patient weight includes any pads, restraints, and devices
that are loaded on the table top.
The RoboCouch System has four major components:
• RoboCouch Manipulator: Includes a 6-axis robot capable of positioning the patient in
six degrees of freedom.
• RoboCouch Controller: Controls the manipulator and interfaces with other components
of the CyberKnife System, including E-Stop signals.
• RoboCouch Table Top: Provides patient support.
• RoboCouch Hand Controller: Allows you to input movement commands to the
RoboCouch controller in the same way a conventional treatment couch operates.
During treatment, the RoboCouch manipulator together with the table top move based on the
positioning commands issued by the CyberKnife System.
RoboCouch Flat Table Top Configuration

The RoboCouch Flat Table Top configuration is shown in Figure 6. This configuration is standard
with the RoboCouch System. The flat table top is fabricated from carbon fiber and designed to
provide uniform radiolucency for the Target Locating System. It is attached to the end effector of
the manipulator.
Figure 6 RoboCouch Flat Table Top configuration
1075883-ENG A CyberKnife System Options | 3-15

Iris Variable Aperture Collimator (Option)

The Iris Variable Aperture Collimator is a secondary collimator whose aperture is adjustable under
computer control (see Figure 7). The Iris Collimator reduces treatment time by consolidating
multiple path sets with multiple collimators into a single path set. It removes the need to exchange
fixed collimators during treatment, making multiple collimator treatments practical for routine daily
use.
Using tungsten segments to rapidly adjust the aperture, the Iris Collimator can deliver multiple-
sized beams from each LINAC position.
Figure 7 Iris Variable Aperture Collimator
The Iris Collimator nominally provides the same 12 apertures as the fixed collimators (in
millimeters): 5, 7.5, 10, 12.5, 15, 20, 25, 30, 35, 40, 50, 60. It contains 2 stacked hexagonal banks
of tungsten segments that together produce a 12-sided aperture (a regular dodecagon).
The Iris Collimator mounts on the X-ray head and requires the Xchange Robotic Collimator
Changer (see “Xchange Robotic Collimator Changer (Option Model B)” on page 3-17).

Xchange Robotic Collimator Changer (Option

Model B)
The Xchange Robotic Collimator Changer is a computer-controlled system for automatically
exchanging collimators on the treatment robot, both before and during treatment. The Xchange
collimator table (Model B) supports both fixed collimators and the Iris Collimator. It includes 12
collimator cups for holding the fixed collimators, a receptacle for the secondary housing for fixed
collimators, and a receptacle for the Iris Collimator. If your Xchange System configuration includes
only fixed collimators, both receptacles are covered.
Figure 8 Xchange Robotic Collimator Changer (Model B)
The Xchange System includes the following components:

• Xchange collimator table (Model B)
• Xchange calibration isoposts (not shown) for calibrating the Xchange System
• 12 interchangeable fixed secondary collimators
• Retaining nut to secure a fixed collimator on the X-ray head
• Optional Iris Variable Aperture Collimator
Equipment Locations
The location of components of the CyberKnife System are listed below.
1075883-ENG A Equipment Locations | 3-17

Control Room
The Control Room for the CyberKnife System contains the following equipment:
• Operator control panel
• Monitors, keyboard, and mouse for the treatment delivery computer
• Quad Multiplex Monitor of CCTV system
• Intercom System
• Phone
• Physics conduit port
Treatment Room
The Treatment Room of the CyberKnife System contains the following equipment:
• LINAC
• Treatment robot
• Standard treatment couch or optional RoboCouch System
• Target Locating System (TLS). X-ray generators and X-ray generator control chassis may
be located in the Treatment Room or the Equipment Room
• Xchange table with fixed collimators and, if installed, the Iris Collimator
• Respiratory Camera Array and Respiratory interface module (if the Respiratory Modeling
System is installed)
• CCTV cameras
• Intercom System
• Phone
• Medical gas lines, if desired
3-18 | Equipment Locations 1075883-ENG A

Equipment Room
The Equipment Room is typically located adjacent to the shielded walls of the Treatment Room
and is intended to hold the bulk of the support equipment needed for treatment. This equipment
includes the facility power interface. The room is cooled with a customer-supplied A/C unit.
The Equipment Room contains the following equipment:
• Treatment delivery computer
• CyberKnife System data server
• Modulator (MOD)
• Modulator Control Chassis (MCC)
• Chiller in mechanical rack
• Target Locating System Control Chassis (TLSCC)
• Target Locating System (TLS) Computer
• X-ray generators and X-ray generator control chassis (if not located in the Treatment
Room)
• Interface Control Chassis (IFCC)
• Treatment robot controller
• RoboCouch controller (if the RoboCouch System is installed)
• Power Distribution Unit (PDU)
• E-Stop Control Chassis (ESCC)
• Uninterruptible Power Supply (UPS)
• Monitor, keyboard and mouse
• Firewall
• Compressor (with optional Iris Collimator)
• Automatic Temperature Control (ATC) unit (with optional Iris Collimator)
For more information on components in the Equipment Room, see the Physics Essentials Guide.
1075883-ENG A Equipment Locations | 3-19

3-20 | Equipment Locations 1075883-ENG A

Chapter 4: System Startup and
Shutdown
Introduction
This chapter describes procedures for taking the CyberKnife Treatment Delivery System from a
shutdown state to a powered-on condition where it is ready to deliver a treatment or be operated
in Physics mode. It also describes procedures for shutting down the CyberKnife System.
This chapter also provides equipment instructions including using the Collimator controls in
Physics mode, the Target Locating System (TLS) components, and the treatment robot Teach
Pendant.
It includes the following topics:
• “Pre-startup Checklist” on page 4-2
• “Powering On the CyberKnife System” on page 4-6
• “Error Handling” on page 4-10
• “Post-startup Checklist” on page 4-12
• “Logging into the CyberKnife System” on page 4-13
• “X-ray System Warmup” on page 4-14
• “Powering Off Equipment” on page 4-18
• “System Shutdown Checklist” on page 4-19
• “Power-on After Power Interruption” on page 4-19
• “Equipment Operating Instructions” on page 4-22

Pre-startup Checklist
It is recommended that each site develop a checklist that includes, at a minimum, the tasks below.
As each task is performed, you check it off. When all tasks are completed, initial the completed
checklist and file it with the treatment records.
NOTE: Only a qualified person operating the CyberKnife System

should perform the items on the pre-startup checklist each time
the system is to be used. Correct any discrepancy prior to
powering up the equipment (see “Powering On the CyberKnife
System” on page 4-6).
1. Check that the treatment robot Teach Pendant is in the proper mode.
• Check that the Teach Pendant is in External mode.
• The display of the treatment robot Teach Pendant should be dark indicating that the
treatment robot is powered down.
2. Check the pressure (30 ± 2 psi) (2.1 Kg/cm) of SF6 gas (on the pressure gauge in the
mechanical rack in the Equipment Room) and recharge if needed.
3. Verify that the key switch on the E-Stop Control Chassis (ESCC) is not turned to
SERVICE MODE (see Figure 1).
WARNING: Do not deliver treatment using SERVICE MODE. SERVICE MODE bypasses
some safety features. Using SERVICE MODE during treatment delivery can produce
hazardous conditions that can result in injury or death to the user or patient.
The user should only use SERVICE MODE when performing an E-Stop circuit check after
a power interruption (see “Step 2: Hardware Power On” on page 4-21). Otherwise, only
Accuray Field Service should use LOCAL MODE.
4-2 | Pre-startup Checklist 1075883-ENG A

Treatment Delivery Manual Chapter 4: System Startup and Shutdown
Service Mode Switch
Figure 1 E-Stop Control Chassis (ESCC)
4. Check the Uninterruptible Power Supply (UPS) battery charge level and verify that the
Battery disconnected/Replace battery indicator is not lit (see “Uninterruptible Power
Supply (UPS)” on page 4-35) If the battery charge indicators show less than full charge,
wait for the UPS to fully recharge before powering up the system.
1075883-ENG A Pre-startup Checklist | 4-3

UPS Power Switch Battery Charge Level
Figure 2 Uninterruptible Power Supply (UPS)
5. Check the water level of the cooling system.

6. Verify that the Modulator Control Chassis (MCC) manual POWER key is in the OFF
position (see Figure 3, left key switch).
4-4 | Pre-startup Checklist 1075883-ENG A

Steering Magnetron
Power Control Tuning Controls Dose Rate Fault and Status
Coil Current Meter
Lock Meters and Position Indicators
Meter
Manual Pulse Manual X-ray Emergency Fault Summary

Rate Control Lock and Stop Button Indicator/Reset
Controls
Figure 3 Modulator Control Chassis (MCC)
7. Turn on the Treatment Room Closed Circuit TV (CCTV) cameras and intercom system.
8. Turn on the monitors for the treatment delivery computer.
You are now ready to power up the CyberKnife System using the treatment delivery system
software on the treatment delivery computer, as described in the next section.
1075883-ENG A Pre-startup Checklist | 4-5

Powering On the CyberKnife System

This section describes how to power on CyberKnife System equipment remotely from the
treatment delivery computer and how to use the Power Scheduler.
NOTE: This procedure should only be performed after the pre-

startup checklist is completed (see “Pre-startup Checklist” on
page 4-2).
For instructions on powering on the CyberKnife System after a power interruption, see “Power-on
After Power Interruption” on page 4-19.
 To power up CyberKnife System equipment remotely:
1. Initially, the Equipment Status screen shows that the electrical power for each equipment
subsystem is OFF and the subsystem control status is Not Ready (see Figure 4).
Figure 4 Equipment Status screen "Not Ready"
4-6 | Powering On the CyberKnife System 1075883-ENG A

2. Click the Power On button.

The power for all equipment subsystems is turned on. In the Equipment Status screen,
the power and control status change for the treatment robot, ESCC, LINAC, secondary
collimator system, TLS computer, X-ray image detectors (Camera A and Camera B),
Synchrony tracking System, and treatment couch.
The power-up process usually takes approximately 20 – 25 minutes. When the electrical
power for each subsystem is ON and its control status is On Standby, the CyberKnife
System is powered up (see Figure 5).
Figure 5 Equipment Status screen "On Standby"
The task and delivery mode buttons are now enabled.

For more information on the Equipment Status screen, see “Chapter 5: Treatment Delivery System
Overview”.
You are now ready to log into a task or delivery mode on the treatment delivery computer, as
described in “Logging into the CyberKnife System” on page 4-13.
1075883-ENG A Powering On the CyberKnife System | 4-7

Power Scheduler
Use the Power Scheduler to schedule automatic power-on dates for the treatment delivery system.
You can schedule automatic power-on for days of the week, select specific days to always include
or exclude, and can change or cancel the time for the next scheduled power-on. You can also set
the number of hours of inactivity after an automatic power-on before the treatment delivery system
is automatically powered off to ensure the system is not left on overnight. When an automatic
power-on is complete, a user must click OK in the message that indicates the time remaining
before the system is automatically powered off.
 To open the Power Scheduler dialog box:
• On the Cyberknife System Menu screen, click Computer, and then click Power
Schedule. The Power Schedule dialog box appears.
Figure 6 Power Schedule dialog box
The dialog box has the following areas:
Next scheduled power-on

The Next scheduled power-on area displays the next scheduled power-on time and gives
you the following options:
4-8 | Power Scheduler 1075883-ENG A

• To cancel power-on for the next scheduled day, click to clear the Power on at check
box. Or, to activate power-on for the next scheduled day, select the Power on at check
box.
• To change the currently scheduled power-on hour, minute, or PM/AM setting, type or
select values in the appropriate boxes.
Weekly power-on policy

In the Weekly power on policy area, do any of the following:
• Select the check boxes for the days you want to automatically power on the treatment
delivery system. Or, click a check box to clear a day.
• Click Select All to select all the days of the week. Or, click Clear to clear all the days of
the week.
Date exceptions
The Date Exceptions area displays a calendar with the following status indicators:
• Cyan highlight box for the selected date
• Red font for today’s date
• Gray-blue highlight box for scheduled dates
• A red square for "never try to power on"
• A green square for "always try to power on"
Figure 7 Power-on calendar
To modify scheduling for specific dates, double click the calendar, and then do any of the following:
• To move to the month of interest, click the right or left arrows in the calendar title bar,
• To return to today’s date, click the Return to today’s date button .
1075883-ENG A Power Scheduler | 4-9

• To change a date to "never try to power on," double click it. Double click it again to
change it to “always try to power on." Double click it again to clear the date’s exception
status.
After automatic power-on

In the After automatic power on area, type or select the number of hours (1-4) of inactivity
before the treatment delivery computer is powered off. The value here is used for the countdown
to power-off that appears in the message after automatic power-on is complete to ensure the
system is not left on over night. If the user does not click OK in the message before the countdown
reaches 0, the treatment delivery system is automatically powered off.
Figure 8 Countdown to power-off message
 To save changes made in the Power Schedule dialog box:

• Click Save or click Close to close the dialog box without saving changes.
Error Handling
Power-on Errors
If an error in a subsystem is encountered during the power-on sequence, a dialog box is displayed
reporting the error. When you click the OK button in the dialog box, a full power-down sequence
begins.
4-10 | Error Handling 1075883-ENG A

Errors Occurring After Power-on

If an unrecoverable error occurs after power-on, the Error Handling System screen is displayed
with information about the error. The Continue button is disabled. In this case, it is necessary to
exit Treatment mode and return to the CyberKnife System Menu by clicking the Exit icon. Other
modes or applications within the Treatment Delivery System may display an Abort button instead
of the Exit icon.
A power-down sequence then begins and the system powers back up automatically. On the
Equipment Status screen, the Control Status of all subsystems switches to Not Ready (red).
The Power remains ON (green) for all subsystems except the Imaging Computer, XRS A
and XRS B, CAM A and CAM B, and Respiratory. These subsystems switch to OFF (red)
and then are powered back ON (green).
For some errors, a power-down sequence occurs and then the Power On button is no longer
available.
Errors may also occur for which no power-down sequence is performed, all the icons on the
CyberKnife System Menu become unavailable, and only the Power Off button is available. If this
occurs, contact Accuray Customer Support.
For information on the Error Handling System and the Equipment Status screen, see “Chapter 5:
1075883-ENG A Error Handling | 4-11

Post-startup Checklist
WARNING: When the CyberKnife System power-up procedure is complete, perform each
item on the post-startup checklist. Correct any discrepancy before proceeding. If
necessary, power off the equipment as described in “Powering Off Equipment” on
page 4-18. Then make the necessary corrections and restart the power-up procedure.
Failure to perform these procedures can result in damage to equipment and increased
risk of injury or death of the patient.
It is recommended that each site develop a checklist that should include, at minimum, the following
tasks:
• Check that on the ESCC no mechanical interlock LED is illuminated. If illuminated, safety
features are disabled and should be reset.
• Check that none of the bypass buttons on the ESCC are illuminated.
• Check the chiller water temperature (19 ± 1° C) on the LINAC chiller.
• Verify that the treatment robot is positioned at its perch position. Move the treatment robot
back to the perch position using the Teach Pendant as necessary. (For information on
moving the treatment robot to the perch position, see “Treatment Robot Operation” on
page 4-27.)
• Verify door interlocks and E-Stops are enabled. To do this:
 Open the Treatment Room door and verify that the E-Stop status icon on the
treatment delivery computer shows that an E-Stop occurred.
 Press the E-Stop button on the operator control panel and verify that the E-Stop
status icon on the treatment delivery computer shows that an E-Stop occurred.
After each daily task is performed, it should be checked off, initialed, and dated by the user.
4-12 | Post-startup Checklist 1075883-ENG A

Logging into the CyberKnife System

After equipment power is turned on, you can log in as the primary user to access a specific task or
delivery mode on the CyberKnife System Menu:
• Physics mode
• Demonstration mode
• Plan QA mode
• Phantom mode
• Simulation mode (option)
• Treatment mode
You must log in whenever you switch between a task or delivery mode on the CyberKnife System
Menu. Depending on your user access level, you may not have access to all tasks or delivery
modes.
 To log into a task or delivery mode:
1. On the CyberKnife System Menu, click the button for the task or delivery mode you want
to access. The Primary User Login window is displayed (see Figure 9).
Figure 9 Primary User Login window
2. Enter your username in the Username textbox. Then press the <Tab> key or move the
cursor to the next textbox.
3. Enter your password in the Password textbox.
4. Click the OK button or press the <Enter> key. Or, press the Cancel button to return to
the CyberKnife System Menu.
• When your username and password are authenticated successfully, press the
Continue button to proceed to the task or delivery mode.
• If you enter an incorrect username or password, a message asks you to try again.
Press the Continue button to return to the primary user login window and repeat
the login procedure.
As the primary user, you can add participants to your CyberKnife session. For more information on
adding participants, see “Chapter 5: Treatment Delivery System Overview”.
1075883-ENG A Logging into the CyberKnife System | 4-13

 To log out of a task or delivery mode:

• From within a task or delivery mode, click the Exit button to return to the previous
screen, until you return to the CyberKnife System Menu.
You are now logged out of the task or delivery mode. You also use this procedure to log off the
treatment delivery computer. You do not need to shut down the treatment delivery computer when
you log off.
X-ray System Warmup

After the CyberKnife System is powered up, perform the X-ray tube warmup procedure to ensure
that the X-ray tubes of the imaging system are adequately warmed up prior to being used for
treatment. If the CyberKnife System is powered up but is idle for 8 hours or more, repeat the X-ray
tube warmup procedure.
WARNING: During the X-ray tube warmup procedure, X-rays are produced. Make sure no
one is in the Treatment Room during this procedure to prevent unnecessary exposures.
CAUTION: Failure to perform the X-ray tube warmup procedure could damage the X-ray tubes
of the X-ray imaging system.
NOTE: X-ray tube warmup takes less than 5 minutes.
 To perform the X-ray tube warmup procedure:

1. From the CyberKnife System Menu, click the Physics button and log in. The Physics
menu appears (Figure 10). If the system is fully powered up, the X-Ray Warmup
button is enabled
4-14 | X-ray System Warmup 1075883-ENG A

Figure 10 Physics menu
2. Click the X-Ray Warmup button. The X-ray Tube Warmup screen appears (see
Figure 11). The text located in the X-ray Tube Warmup section of the screen
displays the date and time that the most recent X-ray tube warmup was performed.
Figure 11 X-ray Tube Warmup screen "Not Started"
1075883-ENG A X-ray System Warmup | 4-15

3. Click the Start button. The text IN PROGRESS is displayed below the yellow progress
bar, and the upper left display box flashes red, displaying the text WARMUP ON. As
images are acquired, the X-ray settings for the X-ray image detectors (Camera A and
Camera B) are displayed in the 6 text fields located in the X-Ray Tube Warmup
section (see Figure 12).
When X-ray tube warmup is complete, the upper left display box changes from red to
green again and displays the text WARMUP OFF. The progress bar displays 100%,
and the text below it displays COMPLETED. The Last Successful Warmup date
and time display is updated.
Figure 12 X-ray Tube Warmup screen "In Progress"
4. Click the Exit button to exit the X-ray Tube Warmup screen.
NOTE: If the X-ray imaging system has not been used for 8 or
more hours, it is recommended that you perform the X-ray tube
warmup procedure again.
If the Interlock button is pressed while X-ray tube warmup is in progress, the warmup
procedure is aborted and the Error Handling System window is displayed indicating that
the warmup procedure was interrupted (see Figure 13). Clicking the Continue button in
the Error Handling System window resets the system and allows you to restart the X-ray
tube warmup procedure by clicking the Start button in the X-Ray Tube Warmup
section.
4-16 | X-ray System Warmup 1075883-ENG A

Figure 13 Error Handling System window
After performing the X-ray tube warmup procedure, you are ready to perform the LINAC warmup
procedure. For more information, see the Physics Essentials Guide.
1075883-ENG A X-ray System Warmup | 4-17

Powering Off Equipment

 To power off the CyberKnife System, follow these steps:
1. From a task or delivery mode, click the Interlock button to display the CyberKnife
System Menu.
2. Click the Power Off button on the Equipment Status screen.
A message window (Figure 14) asks you to confirm that you want to shut off electrical
power to CyberKnife System components.
Figure 14 Power shutdown message
3. Click Yes to power off equipment. Or, click No to return to the Equipment Status screen
without powering off equipment.
• If you click Yes, the Power Off button on the Equipment Status screen becomes
inactive. After a few seconds equipment status changes to the powered-off state.
When power is off, the Power On button becomes active.
If you click No, the Power Off button in the Equipment Status screen remains active.
4-18 | Powering Off Equipment 1075883-ENG A

System Shutdown Checklist

1. DO NOT turn off power to the treatment delivery computer or any other computers using
the computer power off button.
2. Turn off the Treatment Room CCTV cameras and intercom.
3. Turn off the lights in the Treatment Room.
4. Leave the Treatment Room door open.
5. Turn off the monitors for the treatment delivery computer.
6. Remove the Enable High Voltage key from the operator control panel and store it in a
secure location.
The chiller and cooling fan on the LINAC will keep running up to 60 minutes after electrical power
is off.
The Gun Heater Voltage (standby) and High Voltage applied to the Vacuum Pump for the LINAC
waveguide and magnetron are always on.
The TLS computer, data server, UPS, treatment delivery computer, standard treatment couch,
PDU, network switch, Firewall, IFCC and ESCC, X-ray detectors, Treatment Room backlight, and
RC J-box are always on.
Power-on After Power Interruption

The procedure described in this section is most often used when a power interruption or some
other disruptive event has occurred, usually when the system was unattended (during the night or
over a weekend).
This section covers the following topics:
• “Step 1: Establish "Normal" Power-off Status” on page 4-20
• “Step 2: Hardware Power On” on page 4-21
The procedure ensures all subsystems and computers are in the proper condition for power-on and
that communication between various subsystems is working correctly.
CAUTION: In the event of a power interruption, shutdown all computers from their desktop
menus. Do not turn off or reset power to the treatment delivery computer or other computers
using the power button on the computer. Doing so may cause the computer to become corrupted
and unable to reboot.
NOTE: If any problems occur while following this procedure,

contact Accuray Customer Support.
1075883-ENG A System Shutdown Checklist | 4-19

Step 1: Establish "Normal" Power-off Status

The Uninterruptible Power Supply provides temporary backup power to enable shutdown
procedures in the event of a planned or unexpected power outage of extended duration. If the
CyberKnife System is unattended during a power interruption and the UPS has exhausted its
battery, the Power Distribution Unit (PDU) will "latch off" and will not automatically reset.
This step ensures that the CyberKnife System is powered off properly and in the correct standby
state, thereby establishing a dependable starting point.
 To achieve normal power-off status:
Make sure that the power to the CyberKnife System is off on the Equipment Status screen
on the treatment delivery computer and that there are no subsystems on local power.
1. On the treatment delivery computer, the treatment delivery system software should be at
the CyberKnife System Menu. Select the Shutdown Computer menu item from the
Computer menu and confirm that you want to shut down the treatment delivery
computer.
2. Shut down the TLS computer (the imaging computer).
3. Shutdown all planning computers from their desktops. This includes the Accuray
Precision Treatment Planning System and the iDMS Data Management System.
4. The treatment robot should be in the perch position and powered off.
5. On the Power Distribution Unit (PDU):
• Turn off all the small 1, 2, and 3-prong circuit breakers except for the ones labeled
EPO.
• Turn off the breakers for Generator A and Generator B.
• Turn off the Main breaker.
4-20 | Power-on After Power Interruption 1075883-ENG A

Step 2: Hardware Power On

 To power up the CyberKnife System:
1. On the Power Distribution Unit (PDU):
• Turn on the Main breaker.
• Turn on the breakers for Generator A and Generator B.
• Turn on all the small 1, 2, and 3-prong breakers.
2. Power on the Uninterruptible Power Supply (UPS):
• Verify that the Battery disconnected/Replace battery indicator is not lit (see
“Uninterruptible Power Supply (UPS)” on page 4-35). If the battery charge indicators
show less than full charge, wait for the UPS to fully recharge before powering up the
system.
3. Power on the CyberKnife System data server.
4. Power on the treatment delivery computer.
5. Power on the TLS computer and wait about four minutes for the computer to initialize.
6. Power on all planning computers. This includes the Accuray Precision Treatment
Planning System and the iDMS Data Management System.
7. If the CyberKnife System was shut down for an extended period of time, let the system sit
for 10 minutes before clicking the Equipment Power button on the CyberKnife
System Menu on the treatment delivery computer.
8. In the Equipment Status screen, click the Power On button.
If at any time an error message appears, troubleshoot using the error message as a
guide or contact Accuray Customer Support.
9. When the Equipment Status screen indicates electrical power status ON and control
status On Standby for all equipment subsystems, the task and delivery mode buttons
are enabled on the CyberKnife System Menu.
The CyberKnife System should now be fully powered up.
1075883-ENG A Power-on After Power Interruption | 4-21

Equipment Operating Instructions

• “Collimator Controls in Physics Mode” on page 4-22
• “Operator Control Panel” on page 4-25
• “Target Locating System (TLS) Imaging System Components” on page 4-26
• “Treatment Robot Operation” on page 4-27
• “Uninterruptible Power Supply (UPS)” on page 4-35
Collimator Controls in Physics Mode

This section describes the Collimator screen available in Physics mode (see Figure 5). To access
this screen, you must have login access to Physics mode from the CyberKnife System Menu.
NOTE: Controls in the Collimator screen are enabled only if your

configuration includes the optional Xchange Robotic Collimator
Changer.
Controls in the Collimator screen are described in Table 1 on page 4-23. This screen allows you
to perform the following tasks outside of a treatment plan:
• Exchange fixed collimators.
• Change from a fixed collimator to the optional Iris Variable Aperture Collimator.
• Change the fixed aperture size or the aperture size of the Iris Collimator.
• Initialize or reset the Iris Collimator.
For more information on the Xchange System, see “Chapter 7: Treatment Room Operations”.
Chapter 6 describes how to use the Xchange System to exchange collimators automatically within
a treatment plan, in Demonstration, Plan QA, Phantom, or Treatment mode.
4-22 | Equipment Operating Instructions 1075883-ENG A

Figure 15 Collimator screen
Table 1 Controls in the Collimator screen
Control Function
E-STOPS CLEAR/E-STOP Displays the status of CyberKnife System E-Stops.

ENGAGED indicator
Current Activity text field Displays current activity of the treatment robot and the Xchange
System, as well as the elapsed time.
Status section Displays information about the currently installed collimator and
the treatment robot position.
Collimator Type text field: Displays the currently installed
collimator type: Fixed or Iris.
Collimator Aperture text field: Displays the aperture (in
millimeters) of the currently installed collimator.
Robot Position text field: Indicates whether the treatment
robot is at or away from the perch position.
1075883-ENG A Equipment Operating Instructions | 4-23

Control Function
Collimator Selection Allows you to switch between the housing for fixed collimators
section and the Iris Collimator.
Pick Up Iris button: Instructs the treatment robot to pick up the
Iris Collimator. If a fixed collimator is currently installed, the
treatment robot first drops off the fixed collimator housing (with
fixed collimator attached) in its receptacle on the Xchange table.
Pick Up Fixed button: Instructs the treatment robot to pick up
the fixed collimator housing (with previous fixed collimator
attached). If the Iris Collimator is currently installed, the treatment
robot first drops it off in its receptacle on the Xchange table.
Collimator Aperture Allows you to specify the desired collimator aperture (fixed or Iris).
Selection section
Desired Aperture drop-down list: Specifies the desired
aperture (in millimeters). In addition, allows you to select the
following options:
• Full Open: Fully opens the aperture (to approximately
68 mm) to allow attachment of the Iris pinhole collimator. For
more information, see the Physics Essentials Guide.
• Full Close: Fully closes the aperture (to just above 0 mm). If
the aperture is fully open and the Iris pinhole collimator has
just been attached, this option closes the aperture. The Iris
Collimator stalls when it contacts the pinhole collimator, thus
holding it securely. For more information, see the Physics
Essentials Guide.
Apply button: Changes the collimator aperture. If a fixed
collimator is currently installed, the treatment robot exchanges it
for the desired collimator. If the Iris Collimator is currently
installed, the Iris aperture is automatically adjusted.
Collimator Control Performs an initialization check of the Iris aperture calibration.

section The initialization process checks the aperture calibration and
warms up the Iris motors to verify the aperture’s open and closed
limits.
Initialize button: Performs the initialization process. This button
is enabled if the Iris Collimator has not yet been initialized. Always
initialize the Iris Collimator after picking it up using the Xchange
System. You should also initialize the Iris Collimator before
changing the aperture.
Reset button: This button is for Accuray Service use only.
E-STOP button Triggers an Emergency Stop (E-Stop).
Exit button Returns you to the Physics menu.

Operator Control Panel

One of the functions of the operator control panel (Figure 16) is to enable the user to turn on or off
the high voltage to the LINAC. After the high voltage is on, radiation can be generated and
delivered.
High Voltage Control

and Status Laser Status
Emergency Stop
Button
Emergency Stop
Indicator Lamp
High Voltage Treatment Radiation

Interlock (Key LINAC Status
Switch)
Figure 16 Operator control panel
High Voltage Interlock (Key Switch)

 To enable the high voltage to the LINAC to be turned on:
1. Insert the safety interlock key into the high voltage interlock (key switch) on the operator
control panel.
2. Turn the interlock key clockwise to the ON position. This releases the safety interlock and
allows the high voltage to the LINAC to be turned on.
The safety interlock key should be stored in a safe location at the end of use each day.
Turning High Voltage On or Off

When the interlock key is in the ON position and the "Turn on HIGH VOLTAGE to continue."
message is displayed on the treatment delivery computer, pressing the high voltage ON button on
the operator control panel turns on the high voltage to the LINAC.

Pressing the high voltage OFF button on the operator control panel turns off the high voltage to the
LINAC. When radiation is being generated, the BEAM ON light on the operator control panel is on.
When no radiation is being generated, this light will be off.
WARNING: If you suspect a problem, depress the E-Stop button to terminate radiation
delivery and cease treatment robot motion.
Target Locating System (TLS) Imaging System

Components
The Target Locating System (TLS) consists of the imaging software and the associated imaging
device hardware. The Target Locating System controls the X-ray sources and X-ray imaging
panels to acquire real-time X-ray images, as well as to correlate images to determine patient
displacements during treatment. The TLS software runs automatically upon startup of the TLS
computer. After the software is operational, it communicates with the treatment delivery computer.
X-ray Image Detector AC Power Switches

The X-ray image detector A-C PWR switches turn the AC power on or off to the TLS X-ray image
detectors (Camera A and Camera B of the X-ray imaging system).
NOTE: For best imaging system performance, the imaging

detector power should be kept turned on (A-C PWR switches up)
at all times.
You may need to turn off power to the imaging detectors for maintenance or to recover from an
imaging detector device fault. If the imaging detectors have not been powered on for 4 or more
hours, they should be turned on and allowed to warm up for at least 30 minutes before resuming
system operation.
Turning on the TLS computer starts the TLS system software. After the TLS computer has been
booted and before patient treatment, the TLS computer should remain at the Windows Login
screen to ensure that only the TLS system software is operating.
CAUTION: Using TLS software tools or other programs can interfere with the performance and
proper functioning of the Target Locating System. For this reason, the TLS software tools should
only be run by Accuray personnel for maintenance or calibration.
Reboot the system if you experience problems with the TLS system software such as:
• TLS communication failures that are reported on the treatment delivery computer.
• Imaging hardware fails to power on successfully (as indicated on the Equipment Status
window on the treatment delivery computer).
• Other TLS-related errors.

 To reboot the system:

1. Navigate to the Equipment Status screen on the treatment delivery computer.
2. Press the Power Off button within the Equipment Status screen.
3. Go to the Equipment Room and reboot the TLS computer as follows:
• On the TLS computer, press Start > Shut Down > Shut down. Wait for the
TLS computer to shut down completely.
• Press and release the power button on the front of the TLS PC.
• Wait for the Windows XP login prompt to appear.
4. From the treatment delivery computer, Equipment Status screen, press the Power On
button and wait for the TLS computer’s Control status to transition from “Not Ready” to
“Ready.”
If you encounter further problems, contact Accuray Customer Support.
Treatment Robot Operation

This section is a quick reference for operating the KUKA Robot, also called the treatment robot.
For more detailed information, see the KUKA Robot operations manual.
Controller Power-up
The main disconnect switch is on the treatment robot controller cabinet. When this handle is in the
Up position, the switch is closed. If power is supplied to the cabinet, the controller will start. It takes
2 to 3 minutes for the treatment robot to boot up.
To power off the controller, put the handle in the Down position. It takes about 30 to 60 seconds
for the controller to shut down. Wait at least 60 seconds after the treatment robot controller has
been powered off before powering it up again.
Using the Teach Pendant

This section is a quick reference for operating the treatment robot using the Teach Pendant (see
Figure 17 and Figure 18 on page 4-29). It covers the following topics:
• “Jog Modes and Coordinates” on page 4-30
• “Moving the Treatment Robot Manually” on page 4-31
• “Moving to the Perch Position” on page 4-32
• “Using the MoveUp Program” on page 4-33

WARNING: Maintain at least a 3 ft (1 m) distance from the treatment robot when operating
the treatment robot manually. When moving the treatment robot, focus on the treatment
robot rather than looking at the Teach Pendant to avoid collision. Collision with the
treatment robot can result in serious injury or death of the user or patient.
WARNING: Do not remove the treatment robot Teach Pendant from the Treatment Room
during treatment delivery. The Teach Pendant should only be used in the Treatment Room
in order to safely monitor operation of the treatment robot.
Mode E-Stop
Escape Selector
Start
Toggle
Program
Stop
Program
Start
Enter
Figure 17 Teach Pendant for treatment robot (front

view)

Enable Switch
Enable Switch
Space Mouse
Enable Switch
Program Start
Figure 18 Teach Pendant for treatment robot (rear

view)
The enable switches on the Teach Pendant (also called KCP) are three-position switches (see
Figure 18). If the switches are released, the drives are disabled. If they are held too tightly, the
drives are also disabled. The switches should be held in the middle position (depressed halfway)
for the drives to be enabled. If the treatment robot Teach Pendant does not respond, check to see
if the E-Stop button is depressed halfway.
The mode selector switch is used to select the operating mode (see Table 2).
Table 2 Operating modes on mode selector switch
T1 Low speed teach mode
T2 High speed teach mode
Automatic Runs programs
External Runs programs from treatment delivery computer

Jog Modes and Coordinates

Jogging can only be performed in T1 or T2 mode. The Jog mode soft key is located on the upper
left of the Teach Pendant screen. Pressing it repeatedly changes the Jog mode (see Table 3).
Table 3 Jog modes available using Jog mode soft key
No Jogging allowed
Jog with space mouse
Jog using soft keys (right side of display)
Jogging can be performed in one of the coordinate frames shown in Table 4. Pressing the soft key
on the left side of the Teach Pendant screen changes the frame. All coordinate frames, except the
first one (Individual axes), are Cartesian coordinate systems.
Table 4 Coordinate frames used in Jog mode
Individual axes
Base coordinate frame
World coordinate
frame
Tool coordinate frame

Moving the Treatment Robot Manually

 To move the treatment robot manually using the Teach Pendant:
1. Move the mode selector switch from External mode to one of the manual teach modes
(select either T1 or T2 mode).
2. Press the button for the Ackn. or Ackn. All soft key located at the bottom right corner
of the Teach Pendant screen.
3. Press the button for the top left soft key repeatedly until the Jog mode icon appears.
4. Change the speed of the treatment robot by pressing the button for the soft key located at
the lower right (second button from the bottom) of the Teach Pendant screen.
WARNING: Select 50% or less for the speed of treatment robot travel to provide enough
time to avoid collision.
5. Depress and hold one of the enable switches halfway to enable the treatment robot
drives. On the status indicator located at the bottom left of the Teach Pendant screen, the
middle indicator changes from red
to green.
When the enable switch is depressed halfway, soft keys along the right side of the Teach
Pendant screen will change to +/- corresponding to various possible motions of each of
the 6 robot joints of the treatment robot.
6. Move the treatment robot as desired using the +/- buttons for each individual joint.
WARNING: Keep your eyes on the treatment robot at all times, not the Teach Pendant,
when robot joints are in motion, to avoid collision.
NOTE: With the mode selector switch set to T2, if an SPDP

proximity error occurs, release the Teach Pendant enable switch
to clear the message. While the treatment robot is within the
proximity safety zone, you can continue to move the treatment
robot, but only at reduced speed. When the treatment robot is
moved outside the proximity safety zone, it can be moved again
in T2 mode at faster speeds.

Moving to the Perch Position

When the Teach Pendant is used to move the treatment robot to the perch position using the prch
program, the treatment robot takes the most efficient route based on joint motion.
WARNING: Keep your eyes on the treatment robot at all times, not the Teach Pendant,
when using the prch program to avoid collision.
CAUTION: If your system includes the optional Xchange System and the treatment robot stops
when it is in contact with or close to the Xchange collimator table, do not use the prch program
to move the treatment robot away from the Xchange collimator table. To avoid possible collision
with the Xchange table, use the MoveUp program on the Teach Pendant to move the treatment
robot safely above the table. See “Using the MoveUp Program” on page 4-33.
 To move the treatment robot to the perch position using the Teach Pendant:
1. Move the mode selector switch from External mode to manual teach mode T2.
3. Press the blue Toggle button to highlight the top of the Teach Pendant screen.
4. Use the arrow buttons at the bottom right of the Teach Pendant to select the CKMAIN
program folder in the left panel of the Teach Pendant screen. The selected folder will be
highlighted in blue.
5. Press the Enter button (yellow button) to open the folder.
CAUTION: Do not press the Enter button (yellow button) when a program is running. Damage to
CyberKnife System program files could result.
6.
7. Use the arrow buttons at the bottom right of the Teach Pendant to highlight the prch
program in the right panel of the Teach Pendant screen.
8. Launch the prch program by pressing the button for the Select soft key displayed at the
bottom of the Teach Pendant screen.
NOTE: If the Deselect soft key is displayed instead, another

program is active. Press the button for the Deselect soft key to
toggle the display to the Select soft key. Then press the button
for the Select soft key to launch the prch program.
middle indicator changes from red to green.

10. Press the green Program Start button once and then release the button when the
message "programmed path reached (BCO)" is displayed in the message window in
the bottom panel of the Teach Pendant screen.
11. Press and hold the green Program Start button a second time. The prch program checks
the current position of the treatment robot to see if it can safely be moved to the perch
position.
If the treatment robot can safely be moved to the perch position, it begins moving. All
three status indicators will be green.
Keep the green Program Start button depressed until the treatment robot returns to the
perch position, as indicated by the black indicator.
12. Reset the mode selector switch to External mode by moving the switch from manual
teach mode T2 to External mode.
Using the MoveUp Program

For systems that include the optional Xchange System, if the treatment robot stops when it is in
contact with or close to the Xchange collimator table, the MoveUp program on the Teach Pendant
should be used to move the treatment robot safely away from the Xchange table.
CAUTION: Do not use the prch program to move the treatment robot away from the Xchange
collimator table. To avoid possible collision with the Xchange table, use the MoveUp program
on the Teach Pendant to move the treatment robot safely above the table.
 To use the MoveUp program on the Teach Pendant:

3. Press the blue Toggle button to highlight the top of the Teach Pendant screen.
4. Use the arrow buttons at the bottom right of the Teach Pendant to select the CKtool
program folder in the left panel of the Teach Pendant screen. The selected folder will be
highlighted in blue.
5. Press the Enter button (yellow button) to open the folder.

6. Use the arrow buttons at the bottom right of the Teach Pendant to highlight the MoveUp
program in the right panel of the Teach Pendant screen.
7. Launch the MoveUp program by pressing the button for the Select soft key displayed
at the bottom of the Teach Pendant screen.
NOTE: If the Deselect soft key is displayed instead, another

program is active. Press the button for the Deselect soft key to
toggle the display to the Select soft key. Then press the button
for the Select soft key to launch the prch program.
middle indicator changes from red
to green.
9. Press the green Program Start button once and then release the button when the
message "programmed path reached (BCO)" is displayed in the message window in
the bottom panel of the Teach Pendant screen.
10. Press and hold the green Program Start button a second time.
Keep the button depressed until the treatment robot moves vertically up and comes to a
stop, as indicated by the black indicator.
When the treatment robot has come to a stop, you can use the prch program to move to
the perch position as needed (see “Moving to the Perch Position” on page 4-32).

Turning the LINAC Laser On and Off

 To turn the LINAC laser on and off using the Teach Pendant:
2. Press the button for the Monitor soft key at the top of the Teach Pendant screen.
3. Use the arrow buttons at the bottom right of the Teach Pendant to select the I/O menu
item.
4. Press the Enter button (yellow button).
5. Use the arrow buttons at the bottom right of the Teach Pendant to select the Digital
Outputs menu item. Ensure that Output number 1 is selected.
6. Press the Enter button (yellow button).
7.
8. Depress and hold one of the enable switches halfway until the middle status indicator
changes from red
to green.
9. Press the yellow Enter button.
10. Wait a few seconds to verify that the LINAC laser has turned on.
Repeat the procedure above to turn the LINAC laser off.

The Uninterruptible Power Supply (UPS) provides backup power to the treatment delivery
computer and CyberKnife System data server for 5 minutes (see Figure 19). The UPS is located
in the Equipment Room.

Figure 19 UPS front display panel
The following table lists the icons displayed on the UPS and describes the function of each.
Table 5 UPS Icons
Feature Function Description
Power on Press to turn on the UPS / Press to silence alarm.
Power off Press to turn off the UPS.
Indicator Function Description
Online The UPS is supplying utility power to the connected equipment.
AVR trim The UPS is compensating for a high utility voltage.
AVR boost The UPS is compensating for a low utility voltage.
On battery The UPS is supplying battery power to the connected

equipment.
Overload The connected loads are drawing more than the UPS power
rating.
Battery The battery is disconnected or must be replaced.

disconnected /
Replace battery

Chapter 5: Treatment Delivery
System Overview
Introduction
The Treatment Delivery System allows you to align the patient and deliver treatment. This chapter
gives an overview of the Treatment Delivery System user interface, starting from the CyberKnife
System Menu. This chapter covers the following topics:
• “CyberKnife System Menu” on page 5-2
• “Error Handling System” on page 5-10
• “Function Keys” on page 5-21
• “Equipment Power Status” on page 5-23
• “Physics Mode” on page 5-30
• “Treatment Mode” on page 5-39
• “Demonstration Mode” on page 5-60
• “Phantom Mode” on page 5-64
• “Plan QA Mode” on page 5-65
To log into the Treatment Delivery System, follow the instructions in “Chapter 4: System Startup
and Shutdown”
To perform data management and system administration tasks, use the iDMS Data Management
System.The iDMS Data Management System allows you to perform user, patient, treatment plan,
and DICOM administration tasks for the CyberKnife System. It also includes a DRR generation
server for generating Digitally Reconstructed Radiographs (DRR images) and applications for
Image Review and Import, Patient Record Archive and Restore, and Beam Data Import. For
information on using the iDMS Data Management System, see the Data Management Manual.

CyberKnife System Menu

This section describes the CyberKnife System Menu of the Treatment Delivery System user
interface which is displayed on the left screen of the treatment delivery computer (see Figure 1).
Figure 1 CyberKnife System Menu
The CyberKnife System Menu includes the following user interface controls:
• “CyberKnife System Menu Buttons” on page 5-3
• “Computer Menu” on page 5-7
• “Help Menu” on page 5-9
NOTE: The Physics, Demonstration, Plan QA,

Phantom, and Treatment buttons on the CyberKnife
System Menu are disabled until equipment power is turned on
using the Equipment Status screen on the right. See “Equipment
Power Status” on page 5-23.
5-2 | CyberKnife System Menu 1075883-ENG A

Treatment Delivery Manual Chapter 5: Treatment Delivery System Overview
CyberKnife System Menu Buttons

Table 1describes the buttons on the CyberKnife System Menu.
This section also covers the following topics:
• “Logging into a Delivery Mode” on page 5-4
• “Adding Participants to Your CyberKnife Session” on page 5-4
• “Changing Your Login Password” on page 5-6
Table 1 CyberKnife System Menu buttons
Button Function
Physics Enters Physics mode, where you perform the X-ray tube warmup
procedure, operate the LINAC manually and view current LINAC
calibration parameters, operate the Xchange Robotic Collimator
Changer outside of a treatment plan, and perform a Laser Alignment
check.
You must log in to access this mode. For more information, see
“Physics Mode” on page 5-30
Enters Demonstration mode, where you can demonstrate
Demonstration
operation of the CyberKnife System by performing a BB test. In this
mode, no treatment radiation is delivered. X-ray images can be taken
before path traversal begins, but not during the demonstration. The
treatment robot is operated manually using the Teach Pendant.
Controls are the same as those in Treatment mode, except for the
following:
Bypass X-ray imaging: You have the option of bypassing the X-ray
imaging system, allowing you to start and run the demonstration
without acquiring Live X-ray images.
Bypass collimator control: You have the option of bypassing some
controls and checks of the Secondary Collimator System. This option
allows you to operate the CyberKnife System with any secondary
collimator, regardless of the collimator type and aperture specified in
the treatment plan.
“Demonstration Mode” on page 5-60.
Plan QA Enters Plan QA mode, which provides a method to perform quality
assurance (QA) for patient-specific treatment plans. In this mode, you
can deliver a treatment plan for a specific patient to a phantom.
1075883-ENG A CyberKnife System Menu | 5-3

Table 1 CyberKnife System Menu buttons
Button Function
Phantom Enters Phantom mode, where you simulate treatment using a

phantom treatment plan. Controls are the same as those in
Treatment mode.
In this mode, when the last fraction in the treatment plan is delivered,
a new fraction is automatically created. In this way, you can continue
treatment delivery to the phantom without the need to create a new
treatment plan.
“Phantom Mode” on page 5-64.
Simulation Enters Simulation mode, where you use the Simulation

Application, which provides a workflow for determining which lung
tracking mode(s) are viable for a given patient prior to creating a
deliverable treatment plan.
“Chapter 14: Simulation Application Overview (Option)”, and “Chapter
15: Lung Optimized Treatment (Option)”.
Treatment Enters Treatment mode, where you load patient data, align the
patient, start treatment delivery, and monitor treatment.
“Treatment Mode” on page 5-39.
Logging into a Delivery Mode

You must log into the CyberKnife System to access Physics, Demonstration, Plan QA,
Phantom, Simulation, or Treatment modes on the CyberKnife System Menu. You must
also log in each time you switch between modes. Depending on your user profile, you may not have
access to all modes.
NOTE: Equipment power must be turned on before you can log

into the CyberKnife System.
For instructions on logging into the CyberKnife System, see “Chapter 4: System Startup and
Shutdown”.
Adding Participants to Your CyberKnife Session

When you log into the CyberKnife System, you become the primary user for that session. You can
also add participants to your CyberKnife session in Demonstration, Plan QA, Phantom,
Simulation, and Treatment modes.
Participants log in separately. The CyberKnife System keeps a log of your activity as the primary
user and records the names of participants during your session.

 To add participants to your CyberKnife session:

1. Turn on equipment power as described in “Chapter 4: System Startup and Shutdown”.
2. On the CyberKnife System Menu, click the button of the mode you want to access. The
Primary User Login window is displayed (see Figure 2).
Figure 2 Primary User Login screen
3. Enter your username in the Username textbox. Then press the <Tab> key or move the
cursor to the next textbox.
4. Enter your password in the Password textbox. Then click the OK button or press the
<Enter> key. When your username and password are authenticated successfully, the
Add Participants window is displayed (see Figure 3).
Figure 3 Add Participants window
5. Press the Add Participants button. The Additional Authenticated Participants window
is displayed (see Figure 4).

Figure 4 Additional Authenticated Participants window
6. To add a participant, click the Add button. The Participant Login window is displayed.
7. Ask the participant to log in. They should enter their username in the Participant
Name textbox and their password in the Password textbox, and then press the OK
button.
When the participant is authenticated successfully, their username is displayed in the
Username list (see Figure 4). Continue adding participants as needed.
8. To remove a participant from the list, select a name to highlight it. Then click the
Remove button. You are asked to confirm the removal. Click the OK button to remove
the name from the list. Or, click the Cancel button to return to the previous screen
without removing the name.
9. When you are finished adding or removing participants, click the Done button to proceed
to the mode. Or, click the Exit button to log out all users and return to the CyberKnife
System Menu.
Changing Your Login Password

When you log into the CyberKnife System, you can change your login password.
 To change your login password:
1. Turn on equipment power as described in “Chapter 4: System Startup and Shutdown”.
2. On the CyberKnife System Menu, click the button of the mode you want to access. The
Primary User Login window is displayed (see Figure 2 on page 5-5).
3. Click the Change Password button. The Password window opens.
4. Enter your username in the Username textbox. Then press the <Tab> key.
5. Enter your old password in the Old Password textbox. Then press the <Tab> key.

6. Enter your new password in the New Password textbox. Then press the <Tab> key.
7. Enter your new password in the Repeat Password textbox to confirm it. Then click the
OK button.
Or, click the Cancel button to return to the Primary User Login window without changing
your password.
8. When your new password is accepted, the screen for the mode you selected is displayed.
You must use the new password the next time you log in.
Computer Menu
The Computer menu on the CyberKnife System Menu screen (see Figure 5) allows you to
perform the tasks described in Table 2.
Figure 5 Computer menu
Access to these tasks depends on your user profile.
Table 2 Computer menu
Menu Item Function
Service Login This menu item is for Accuray Service use only. It allows qualified Service
personnel to log into service applications.
Power Use to schedule dates to automatically power on the treatment delivery

Schedule system. For more information on using the Power Schedule, see “Error
Handling” on page 4-9.
Restart Restarts the Treatment Delivery System software, then returns you to the
Software CyberKnife System Menu.
Reboot Reboots the treatment delivery computer. All computer processes are shut
Computer down and restarted. Then you are returned to the CyberKnife System Menu.

Menu Item Function
Shutdown Shuts down the treatment delivery computer for computer maintenance.
Computer
Shut Down Use to remotely shut down the treatment delivery system computers, the
Remote iDMS System computer, and the storage vault that are preset by Accuray
Computers service personnel according to your system configuration. This menu option
does not shut down the treatment delivery computer. To shut down the
treatment delivery computer, use the Shutdown Computer menu
option. For more information on the system computers that comprise the
CyberKnife network environment, see the Physics Essentials Guide.
 To log in to service applications:

1. Select the Service Login menu item in the Computer menu. The Primary User Login
window is displayed (see Figure 2 on page 5-5).
2. Log in using your username and password, and then click the OK button. The operating
system desktop is displayed, with icons representing service applications.
3. To return to the Treatment Delivery System user interface, in the Computer menu, click
Switch to CyberKnife User Mode.
 To restart the Treatment Delivery System software:
You can restart the Treatment Delivery System software, for example, if an application error
occurs.
1. Select the Restart Software menu item in the Computer menu. You are asked to
confirm that you want to restart the software.
2. Click the OK button to restart the software. Or, click the Cancel button to return to the
CyberKnife System Menu without restarting the software.
After the Treatment Delivery System software is restarted, you are returned to the
CyberKnife System Menu.
 To reboot the treatment delivery computer:
1. Select the Reboot Computer menu item in the Computer menu. You are asked to
confirm that you want to reboot the treatment delivery computer.
2. Click the OK button to reboot the computer. Or, click the Cancel button to return to the
CyberKnife System Menu without rebooting the computer.
Rebooting the computer takes a few minutes. Then you are returned to the CyberKnife
System Menu.
 To shut down the treatment delivery computer for computer maintenance:
1. Select the Shutdown Computer menu item in the Computer menu. You are asked
to confirm that you want to shut down the treatment delivery computer.
2. Click the OK button to shut down the computer. Or, click the Cancel button to return to
the CyberKnife System Menu without shutting down the computer.

3. To restart the computer, press the computer power-on switch on the computer front
panel. The treatment delivery computer is located in the Equipment Room.
NOTE: Under normal circumstances, you do not need to shut

down the treatment delivery computer. It should remain on.
 To remotely shut down treatment delivery system computers:

1. Select the Shut Down Remote Computers menu item in the Computer menu.
You are asked to confirm that you want to remotely shut down the preset treatment
delivery computers.
NOTE: Before remotely shutting down the preset treatment

delivery computers and iDMS System data management server,
ensure that Accuray Precision System or other treatment
delivery systems do not require access to the iDMS System.
2. Click the OK button to remotely shut down the computers. Or, click the Cancel button to
return to the CyberKnife System Menu without shutting down the remote computers.
NOTE: Shut Down Remote Computers does not shut

down the treatment delivery computer. To shut down the
treatment delivery computer, use Shut Down Computer.
Help Menu
The Help menu displays information about the CyberKnife System, including the software version
and installed options.

Error Handling System

• “Error Handling System Controls” on page 5-10
• “Error Handling System Screen” on page 5-15
The Error Handling System for treatment mode applications includes Device Status and E-Stop/
Interlock controls that appear at the bottom right of all screens and the Error Handling System
screen that is displayed when an E-Stop occurs, showing detailed error information and E-Stop
status.
Error Handling System Controls

Device Status and E-Stop/Interlock controls are displayed on the bottom right corner of the left
screen of the treatment delivery computer. The controls are arranged in two groups (see Figure 6).
Device status icons E-Stop/Interlock controls
Figure 6 Device status and E-Stop/Interlock controls dis-

played at the bottom right corner of the left screen
Device Status Icons

The Device Status icons displayed at the bottom of the screen show the current state of the four
main hardware devices: treatment robot, treatment couch, X-ray sources, and LINAC.
Table 3 describes the Device Status icons
5-10 | Error Handling System 1075883-ENG A

Table 3 Operational status of CyberKnife System components
Device Icon Status
Treatment Treatment robot is idle and will not move unless the user
Robot initiates an action.
Treatment robot is ready and may begin moving at any

time.
Treatment robot is currently moving. (Icon is not displayed

when treatment robot is moved using the Teach Pendant
when the mode selector switch is set to Automatic, T1, or
T2.)
Treatment Treatment couch is idle and will not move unless the user
Couch initiates an action.
Treatment couch is ready and may begin moving at any

time.
Treatment couch is currently moving.
1075883-ENG A Error Handling System | 5-11

Table 3 Operational status of CyberKnife System components (continued)
Device Icon Status
X-ray X-ray sources are idle and will not generate X-rays unless
Sources image acquisition is initiated by the user.
X-ray sources are ready and may begin generating X-rays

at any time under automatic control of the Treatment
Delivery System.
X-ray sources are currently generating X-rays. X-ray

imaging system is currently acquiring Live X-ray images.
LINAC LINAC is idle and will not deliver treatment radiation unless
the user initiates an action.
LINAC is ready and may begin delivering treatment

radiation at any time.
LINAC is currently delivering treatment radiation.

E-Stop/Interlock Controls
There are three E-Stop/Interlock controls displayed at the bottom right corner of the left screen: an
Error Information button, an E-Stop status icon, and an Interlock button. Table 4 describes
these controls.
Table 4 E-Stop Controls
Tool Tip Control Description
Error Toggles between the current screen and the Error

Information Handling System window which displays E-Stop status and
describes any errors and notifications.
A green exclamation point indicates there are no error
messages or notifications displayed on the Error Handling
System window that require user action.
An orange exclamation point indicates that an error

message or notification is displayed on the Error Handling
System window that may require user action.

Table 4 E-Stop Controls (continued)
E-Stop Displays the E-Stop status.

Status
A green checkmark indicates that all E-Stops are clear and
no user action is required, such as a button release, key
turn, or door close. In some cases, a device may have a
green checkmark and also an E-Stop if it is an E-Stop that
does not require user action.
A grey exclamation point indicates that the E-Stop state is

unknown. This is the normal state when equipment power
is off.
A purple exclamation point indicates that the System E-

Stop status is unexpectedly clear. Unexpected means that
it was not commanded by the Error Handling System,
which occurs when the software E-Stop bypass button is
pressed on the ESCC and no other E-Stop is engaged.
Purple may also mean that only the software E-Stop
interlock is unexpectedly clear, yet the System E-Stop
interlock is engaged. This may happen when the software
bypass button was pressed on the ESCC and at the same
time some other E-Stop interlock is engaged which
prevents clearing of the System E-Stop (even though the
software E-Stop is clear).
A orange exclamation point superimposed on a device

icon indicates an E-Stop has occurred and the device
displayed is the source of the E-Stop. The computer icon is
shown if the only E-Stop is a software E-Stop.
A orange exclamation point superimposed on a slideshow

of icons indicates more than one component has triggered
an E-Stop. A device is only shown as an E-Stop in the
slideshow if user action, such as releasing a button, turning
a key or closing the door, is required to clear the E-Stop. If
a device has an E-Stop that does not require user action, it
is an unrecoverable error. An E-Stop, other than the
computer icon, is not shown as a device if a contact
detection error occurs.

Table 4 E-Stop Controls (continued)
Interlock The Interlock button triggers a recoverable software E-

button Stop interlock and displays the Error Handling System
window. During treatment, stops movement of the
treatment robot and treatment couch, image acquisition,
treatment radiation delivery, and turns off high voltage to
the LINAC.
You can click this button to pause treatment at any time.
For more information on pausing treatment, see “Chapter
8: Treatment Delivery”.
Error Handling System Screen

When an E-Stop or interlock occurs or when the Error Information button is clicked, the Error
Handling System window is displayed (see Figure 7).
NOTE: If iDMS System related messages are displayed on the

Error Handling System screen, you may need to go to the iDMS
System to resolve them.
NOTE: If an automation sequence is not in progress and the

treatment room door is the only E-Stop, the Error Handling
System window is not displayed and the E-Stop is automatically
cleared when the treatment room door is closed.

Figure 7 Error Handling System screen
The Error Handling System window has 3 main sections: a table with information about the error
event, a section that displays the complete text for the error and its resolution, and a section that
displays icons representing the overall status of E-Stops and the E-Stop status of individual
components, including the treatment robot, the treatment couch, LINAC, treatment room door,
operator console, wall E-Stop switches and the software E-Stop state. Table 5 describes the Error
Handling System window controls:
Table 5 Error Handling System window controls
Control Description
Show All (radio When selected, shows up to 1000 acknowledged event entries for
button) every twenty-four hour period. There is no limit to the number of
unacknowledged events displayed.

Table 5 Error Handling System window controls (continued)
Control Description
(Table) The left column displays an icon representing the type of error
event.
Indicates a notification that requires user action.
Indicates a recoverable E-Stop is engaged.
Indicates an unrecoverable E-Stop is engaged.
Number Displays the number of the error event.
Time Displays the time of the error event.
Source Displays the subsystem that triggered the E-Stop.
Reason Displays the reason the E-Stop occurred.
Resolution Displays the possible options for resolving the E-Stop.
Reason/ Displays the same text that may be truncated in the error table
Resolution (section) and lists the reason the selected error occurred and the options
for resolving it.
Overall Status of Displays icon representing overall E-Stop status.

Device E-Stops (icon)
A green checkmark indicates that all E-Stops that
require user action (such as a button release, key
turn, or door close) are cleared.
A grey exclamation point indicates that the E-Stop
state is unknown. This is the normal state when
equipment power is off.
An orange exclamation point indicates one or more

uncleared recoverable E-Stops.
A purple exclamation point indicates that the either

the software E-Stop is unexpectedly clear or the
overall system E-Stop is clear, which happens when
the software E-Stop is bypassed on the ESCC.

Control Description
Status of Individual The icons used to indicate the status of individual devices have
Devices and Software essentially the same meaning as the icons used for overall status.
Interlocks (icons)
A green checkmark indicates that all E-Stops that
require user action (such as a button release, key
turn, or door close) are cleared.
Treatment LINAC Operator Software

robot control E-Stop
console
Treatment Treatment Wall E-Stop
couch room door button(s)
A grey exclamation point indicates that the E-Stop

state for the device is unknown. This is the normal
state when equipment power is off.

console

Control Description
An orange exclamation point indicates one or more

uncleared E-Stops for the device. In the following
example, the treatment room door, operator control
console, and software have recoverable E-Stops that
must be cleared.

console
A purple exclamation point indicates that either the

software E-Stop is unexpectedly clear or the overall
system E-Stop is clear, which happens when the
software E-Stop is bypassed on the ESCC.

console
Continue (button) Signals to the Error Handling System that you have
acknowledged any listed errors. Depending on the error, user
action may be required to resolve the error in addition to
acknowledging the error.
Exit Treatment Also called Exit Application. Ends all current task
activities.

Control Description
Abort (button) Displayed in Physics mode and when loading patient data, in
which cases it ends all current task activities.
 To display or hide the Error Handling System window:

• Click the Error Information button in the E-Stop/Interlock controls area at the bottom
right of the screen.
 To trigger a recoverable E-Stop:
• Click the Interlock button in the E-Stop/Interlock controls area at the bottom right of the
screen.
 To recover from a recoverable E-Stop:
1. Resolve all E-Stops.
2. Click the Continue button to acknowledge listed errors.
All E-Stops are resolved when all device icons display a green checkmark. When the
overall device status icon is a green checkmark, you can proceed normally even though
an E-Stop may be engaged, for example, if the Treatment Room door is open before the
Delivery phases starts.
 If an unrecoverable error occurs, in the Error Handling System window:
1. Click the Exit button to end all current task activities.
For more information about responding to unrecoverable errors, see “Chapter 8:
Treatment Delivery”.

Function Keys
Function keys (keyboard shortcuts) on the keyboard allow you to perform the tasks described in
Table 6. The function keys are the top row of keys on the keyboard.
CAUTION: Do not press the function keys ALT+F5 through ALT+F8 on the keyboard while
treating a patient. The normal treatment process may be interrupted by the data collection
process.
Table 6 Function keys on the keyboard
Function key Function Description
ALT+F5 Transfer Logs Invokes a log file transfer utility to transfer a core subset of
CyberKnife System log files for the current day to the
Accuray FTP site. The subset includes the log files that are
most likely to reveal the system problem.
ALT+F6 Transfer All Logs Invokes a log file transfer utility to transfer all CyberKnife
System log files for the current day to the Accuray FTP site.
ALT+F7 Transfer Takes a screenshot of the currently displayed screen to give

Screenshot an Accuray Service Engineer a view of the particular local
problem. Then invokes a log file transfer utility to transfer the
screenshot to the Accuray FTP site.
ALT+F8 Transfer Active Invokes a log file transfer utility to transfer current patient
Patient Record fraction files to the Accuray FTP site. These files contain all
information needed for an Accuray Service Engineer to
reproduce the current imaging environment, including the
patient DRR images and the last pair of Live X-ray images
captured. This function is enabled only after a patient
treatment plan has been loaded in the Alignment,
Readiness, or Delivery phases.
SHIFT+ALT+ Open Shell Opens a Linux command shell.

F10
ALT+F11 Save Logs Creates a compressed package of current log files and
saves it in the following location: /var/tmp/
log<timestamp>.tar.gz.
F12 Save Screenshot Takes a screenshot of the current screen and saves it on the
to File treatment delivery computer in the following location:
/accuray/printscreen. Does not send the screenshot
to the printer.
1075883-ENG A Function Keys | 5-21

Function key Function Description
Print Screen Print Screen Takes a screenshot of the current screen and saves it on the
treatment delivery computer in the following location:
/accuray/PrintScreen, in a sub-directory labeled with
the date. Simultaneously sends the screenshot to the
printer.
Transferring System Data for Remote Diagnostics

Function keys ALT+F5 through ALT+F8 on the keyboard provide four options to transfer system
data to Accuray (see Table 6). The purpose of collecting and transferring system data is to help an
Accuray Service Engineer analyze a particular problem and provide a solution. These four function
keys must be used while still in Treatment mode in the Alignment, Readiness, or
Delivery phases.
CAUTION: Do not press the function keys ALT+F5 through ALT+F8 on the keyboard while
treating a patient. The normal treatment process may be interrupted by the data collection
process.
An Accuray Service Engineer or Applications Support Specialist might also be given permission to
remotely log into your system. When this occurs, you will see a message on the upper right corner
of your left monitor (see Figure 8) that a remote user has connected. It will be displayed for
approximately 10 seconds and will appear on any screen that you are viewing when the login
occurs.
Figure 8 Remote user notification example on home screen
Obtaining Screen Captures

Obtaining screen captures allows you to take a screenshot of the currently displayed screen and
save it as a file and/or print it using your default printer.
NOTE: Consult your system administrator to set up your default

printer.
5-22 | Function Keys 1075883-ENG A

A screen capture of the currently displayed screen can be obtained as follows:

• Press the <Print Screen> key on your keyboard (see Table 6). A screenshot of the
currently displayed screen will be taken and saved in the /accuray/PrintScreen
directory on the treatment delivery computer, in a sub-directory labeled with the date. The
sub-directories are kept for 10 days. The screenshot is also automatically sent to the
default printer.
When printed using the <Print Screen> key, screen captures of the left and right screens
of the UI will include patient information at the top. This only affects the screenshots sent
to the printer. Screenshots saved to a file do not include patient information.
When the Alignment, Readiness, or Delivery phases are displayed for a particular
treatment plan, the screenshot is also saved in the iDMS Data Management System in
the Plan Administration application for that treatment plan after treatment delivery.
• Press the F12 function key on the keyboard (see Table 6). A screenshot of the currently
displayed screen will be taken and saved in the /accuray/PrintScreen directory on
the treatment delivery computer, in a sub-directory labeled with the date. The sub-
directories are kept for 10 days. The screenshot is not sent to the default printer.
When the Alignment, Readiness, or Delivery phases are displayed for a particular
treatment plan, the screenshot is also saved in the iDMS Data Management System in
the Plan Administration application for that treatment plan after treatment delivery.
• A screenshot of the final Delivery phase screen at the end of each treatment path is
automatically saved in the iDMS Data Management System in the Plan Administration
application for that treatment plan.
Equipment Power Status

The Equipment Status panel (right screen) allows you to turn on power to CyberKnife System
equipment. The screen also displays the power and control status of equipment subsystems. You
do not need to log in to turn on equipment power.
1075883-ENG A Equipment Power Status | 5-23

Figure 9 CyberKnife System Menu before

equipment powered on
NOTE: Delivery mode buttons on the CyberKnife System Menu

are disabled until equipment power is turned on.
5-24 | Equipment Power Status 1075883-ENG A

Figure 10 Equipment Status screen "Not Ready"

The Equipment Status screen shows the status of the following subsystems (see Figure 10):
• Manipulator: Treatment robot (also called the treatment manipulator)
• E-Stop: E-Stop Control Chassis (ESCC)
• LINAC: Linear accelerator
• Power Schedule: If scheduled, the date and time of the next scheduled automatic
power-on is displayed to the right of the Equipment Status panel.
Figure 11 Next scheduled power-on
• Collimator: Secondary Collimator System. If the optional Xchange System is installed,

a table to the right of the Equipment Status panel displays the Calibration Status of
the Xchange System and the available collimators (see Figure 16). The following entries
are displayed:
 Xchange, for the Xchange System.
 Iris, for the optional Iris Variable Aperture Collimator.
Figure 12 Calibration status of the Xchange System

and collimators
NOTE: The Equipment Status screen is updated as the

calibration status of the Secondary Collimator System changes.

NOTE: When a pinhole collimator is inserted into the Fixed

collimator housing, the Fixed calibration status is "Calibrate
Fixed." When the pinhole collimator is removed, the status is
updated to the actual calibrated state of the Fixed collimator. If a
Fixed collimator other than the pinhole collimator is installed and
the status is "Calibrate Fixed," please contact Accuray Customer
Support.
• Imaging Computer: Target Locating System (TLS) computer
• XRS A: Imaging X-ray Source A
• XRS B: Imaging X-ray Source B
• CAM A: Camera A of X-ray imaging system
• CAM B: Camera B of X-ray imaging system
• Respiratory: Synchrony Fiducial Tracking with Respiratory Modeling (Option)
• Couch: Standard treatment couch or optional RoboCouch Patient Positioning System
Control buttons in the Equipment Status screen are described Table 7.
Table 7 Controls in the Equipment Status screen
Button Function
Power On Turns on electrical power for all equipment subsystems of the CyberKnife
System.
Power Off After you confirm your intent to shutdown power, turns off electrical power to
all equipment subsystems.
Reset Resets communication between the treatment delivery computer and

equipment subsystems. Clicking the Reset button avoids a full power-down
and power-up of the treatment robot and treatment couch. Under normal
conditions, you do not need to press Reset.
Power to all equipment subsystems is generally controlled remotely via the Treatment Delivery
System software. When power is controlled remotely, you turn on equipment power by clicking the
Power On button in the Equipment Status screen, as described in “Chapter 4: System Startup
and Shutdown”.
The Manipulator, ESCC, LINAC, Secondary Collimator System, and RoboCouch System may also
be powered locally via the Power Distribution Unit (PDU), or both locally and remotely via the PDU
and software. Depending on how these equipment subsystems are powered on, the Equipment
Status screen indicates one of the following power states:
• Local power only: When the subsystems listed above are powered locally via the PDU
but not powered on via the software, the Power indicator color is green and displays
ON for the Manipulator, E-Stop, LINAC, Collimator, and Couch subsystems. In addition,
the text Local Power is displayed under these subsystem names in the Equipment
Status screen.

• Remote power only: The Power indicator color is green and displays ON. The
Control Status indicator is green.
• Local and remote power: The Power indicator color is green and displays ON. In
addition, the text Local & Remote Power is displayed under the Manipulator, E-Stop,
LINAC, Collimator, and Couch subsystem names in the Equipment Status screen. The
Control Status indicator is green.
For more information on powering up and powering down the CyberKnife System, see “Chapter 4:
System Startup and Shutdown”.
During the power-up sequence, indicators in the Equipment Status screen display the power and
control states described in Table 8. Control Status indicates the status of processes needed by
the treatment application.
Table 8 Equipment status indicators
Power Control Status Indicator Description
OFF Not Ready Indicator colors are red. The default state when an
equipment subsystem is powered off.
OFF/FAULT FAULT/Not Ready Indicator colors are red. Indicates that a fault
occurred while attempting to power up an
equipment subsystem, and the power up sequence
was not successful.
ON Not Ready Power indicator color is green, and Control

Status indicator is red. For the Manipulator, E-
Stop, LINAC, Collimator, and Couch subsystems,
indicates equipment is powered on but
communication with these subsystems is not yet
fully established.
ON Warming Up/ Power indicator color is green, and Control

Communications Status indicator color is light green. These states
Up/Connected occur during the power up sequence. When the
power up sequence is complete, the Control
Status switches to On Standby.
ON On Standby Indicator colors are green. Indicates that the power

up sequence for the equipment subsystem is
complete.
COOLDOWN Not Ready Power indicator color is blue, and Control

Status indicator is red. For the Manipulator and
Couch subsystems, indicates equipment is cooling
down.

Power Control Status Indicator Description
Not Available Not Available (Respiratory only) Indicator colors are gray.
Indicates that the Synchrony tracking System is not
enabled (licensed) in the current configuration of the
CyberKnife System.
Disabled Disabled (Respiratory only) Indicator colors are gray.

Indicates that the Synchrony Respiratory Tracking
System did not power up correctly. You can deliver
treatments that do not use Respiratory Modeling in
this state.
For more information, see “Chapter 12: Synchrony
Respiratory Tracking System (Option)”.
Table 9 describes the device calibration status for the Xchange System and the Iris Collimator.
Table 9 Device calibration status
Control Status Indicator Description
Xchange Disabled Indicator colors are gray. When the Xchange System is installed,
indicates that the Xchange table has lost power or is disconnected
from the network.
For more information, see “Chapter 7: Treatment Room Operations”.
Calibrate Xchange Indicator colors are orange. When the Xchange System is installed,
indicates that the quick-check sensor on the Xchange table is unable
to confirm alignment. If this occurs, the treatment robot returns to the
perch position.
Iris Disabled Indicator colors are gray. When the Iris Collimator is installed,
indicates that the collimator is disabled.
Calibrate Iris Indicator colors are orange. When the Iris Collimator is installed,
indicates that the Iris Collimator needs to be calibrated.

Physics Mode
The Physics screen in Physics mode allows Physics Quality Assurance (QA) and Calibration of
the CyberKnife System (see Figure 13). Depending on your user profile, you may not have access
to all buttons on the Physics screen.
NOTE: For information on Physics Quality Assurance (QA) and

Calibration procedures, see the Physics Essentials Guide.
To display this screen, click the Physics button on the CyberKnife System Menu and then log in.
The Physics button is enabled only when equipment power is on.
Figure 13 Physics menu
The Physics menu contains the controls described in Table 10.
Table 10 Controls in the Physics screen
Button Function
LINAC Allows you to operate the LINAC manually for LINAC warmup, dosimetry
verification, and dose calibration.
For information on performing LINAC tasks, see the Physics Essentials
Guide.
5-30 | Physics Mode 1075883-ENG A

Button Function
X-Ray Warmup Allows you to perform the X-ray tube warmup procedure for the imaging
X-ray sources.
For information on this procedure, see “Chapter 4: System Startup and
Shutdown”.
Collimator Allows you to exchange collimators, including the fixed collimator housing
and the Iris Variable Aperture Collimator. Controls allow you to adjust the
aperture of the Iris Collimator, outside of a treatment plan. Controls also
allow initialization of the Iris Collimator. This button is enabled only if your
configuration includes the Xchange System.
For information on collimator tasks in Physics mode, see “Chapter 4:
System Startup and Shutdown”.
Laser Alignment Allows you to perform a quick verification of robot pointing accuracy. In the
event that the laser intensity changes over time, this application allows you
to reset the baseline. It gives you options to perform the check, display the
current and calibrated values for laser intensity and position, and adjust the
baseline for intensity values when the current position offset is within
tolerance (~0.3 mm at 800 mm SAD).
For information on laser alignment tasks in Physics mode, see C“Chapter
4: System Startup and Shutdown”.
Exit Returns you to the CyberKnife System Menu.
1075883-ENG A Physics Mode | 5-31

LINAC Menu
You use the LINAC menu to manually operate the LINAC for warmup, dosimetry verification, and
calibration. When you click the LINAC button, the LINAC menu is displayed as shown in
Figure 14.
NOTE: For more information on procedures performed using the

LINAC menu, see the Physics Essentials Guide.
Figure 14 LINAC menu
The LINAC menu contains the buttons described in Table 11.
Table 11 LINAC menu
Button Function
Warmup Allows you to warm up the LINAC.
Calibration Check Allows you to verify LINAC dosimetry calibration.
Calibration Adjustment Allows you to adjust the dose calibration in cGy

or Gy depending on the setting in iDMS System.
Exit Allows you to exit the LINAC menu.

Warmup Screen
Clicking the Warmup button in the LINAC menu displays the Warmup window shown in
Figure 15. The Warmup window allows you to enable the high voltage to the LINAC and specify a
desired dose to be delivered to warm up the LINAC. This window contains the controls described
inTable 12.
NOTE: For more information on the LINAC warmup procedure,

see the Physics Essentials Guide.
Figure 15 Warmup screen

Table 12 Controls in the Warmup screen
Control Function
LINAC Status section Allows you to enable the high voltage to the LINAC.
HV WAIT/HV ON/HV OFF indicator: Displays the status of the
LINAC high voltage. When the high voltage is enabled but not
turned on, the red HV WAIT indicator is displayed. When the
high voltage is turned on, the yellow HV ON indicator is displayed.
When the high voltage is disabled and turned off, the green HV
OFF indicator is displayed.
BEAM ON/BEAM OFF indicator: Displays the status of the
LINAC X-ray beam. When the yellow BEAM ON indicator is
displayed, dose is being delivered.
Enable button: This button is active when the high voltage is
turned off. Clicking this button enables the high voltage.
Disable button: This button is active when the high voltage is
turned on. Clicking this button turns off the high voltage.
Beam Control section Allows you to specify a time interval for beam delivery to warm up
the LINAC.
Desired Time textbox: Allows you to enter the desired warmup
time with a value between 1 second and 10 hours.
Start button: Allows you to start beam delivery to warm up the
LINAC.
Status bar: Displays the percentage of the specified warmup time
(0 to 100%) that has elapsed.
Delivered MU: Displays the delivered dose (in monitor units)
measured for dose channels A and B.
Dose Rate (MU/min): Displays the dose rate in MU/min for
dose channels A and B. Note that during warmup calibration
factors are not applied to the dose rate.
E-STOP button Triggers an Emergency Stop (E-Stop). The high voltage is turned
off when an E-Stop is triggered.
Exit button Returns you to the LINAC menu.

Calibration Check Screen

Clicking the Calibration Check button in the LINAC menu displays the Calibration Check
screen shown in Figure 16. The LINAC calibration check verifies the dosimetry calibration of the
LINAC. It allows you to verify that the desired dose is the same as the measured dose.
NOTE: For information on the daily LINAC calibration check

procedure, see the Physics Essentials Guide.
Figure 16 Calibration Check screen

The Calibration Check screen contains the controls described in Table 13, in addition to the
controls displayed on the Warmup screen.
Table 13 Controls in the Calibration Check screen
Control Function
Beam Control section Automatically displays the delivered dose and dose rate for dose
channel A and B.
Delivered MU fields: Display the delivered dose (in monitor
units) measured for dose channel A and B.
Dose Rate (MU/min) fields: Display the dose rate in MU/min
for dose channel A and B.
Last Calibration display Displays the date and time of the last LINAC dosimetry calibration
area procedure.
Calibration Adjustment Screen

Clicking the Calibration Adjustment button in the LINAC menu displays the Calibration
Adjustment screen shown in Figure 17. The LINAC calibration adjustment procedure allows you to
calibrate the LINAC dosimetry system.
WARNING: Do not adjust the LINAC calibration unless you are the qualified Medical
Physicist. Incorrect dose delivery can result which could cause serious injury or death of
the patient.
NOTE: For information on the LINAC calibration adjustment

procedure, see the Physics Essentials Guide.

Figure 17 Calibration Adjustment screen
The Calibration Adjustment screen contains the controls described in Table 14.
Table 14 Controls in the Calibration Adjustment screen
Control Function
LINAC Status section Allows you to enable the high voltage to the LINAC.
HV WAIT/HV ON/HV OFF indicator: Displays the status of the
LINAC high voltage. When the high voltage is enabled but not
turned on, HV WAIT is displayed. When the high voltage is
turned on, HV ON is displayed. When the high voltage is
disabled and turned off, HV OFF is displayed.
BEAM ON/BEAM OFF indicator: Displays the status of the
LINAC X-ray beam. When the red BEAM ON indicator is
displayed, dose is being delivered.
Enable button: This button is active when the high voltage is
turned off. Clicking this button enables the high voltage.
Disable button: This button is active when the high voltage is
turned on. Clicking this button turns off the high voltage.

Control Function
Calibration section Displays nominal dose values to be delivered for each calibration
data point, and allows you to enter the corresponding measured
dose value.
Nominal MUs fields: Display 5 preset nominal dose values (in
monitor units) to be delivered.
Measured (cGy/Gy) text boxes: Allows you to enter the
measured dose (in centigray or gray depending on the iDMS
System setting) corresponding to each nominal dose.
Start/Reset button: Allows you to start dose delivery for one of
the nominal doses, or reset a data point already obtained.
LINAC Model Displays dosimetry calibration parameters obtained from a linear

Information section best fit to the 5 measured data points.
Gain fields: Displays the gain value (slope of the linear best fit to
the data points) for dose channel A and B.
The following fields display information on calibration modeling
errors:
Relative (%) fields: Displays the largest relative error as a
percentage for dose channel A and B.
Absolute (cGy/Gy) fields: Displays the largest absolute error
(in centigray or gray depending on the iDMS System setting) for
dose channel A and B.
Calibration Status field: Displays the status of the LINAC
calibration adjustment procedure (Complete, Not Complete, or
Error).
Accept & Save button: This button is enabled when all 5
measured data points have been entered. Allows you to accept
and save the new dosimetry calibration parameters.
Last Calibration display area: Displays the date and time of
the last LINAC dosimetry calibration procedure.
Exit button Returns you to the LINAC menu.

Treatment Mode
This section provides additional details on the user interface screens in Treatment mode that
are not described in later chapters. It covers the following topics:
• “Load Patient Data Screen” on page 5-39
• “Overview Phase” on page 5-43
• “Left and Right Screens of the Delivery Phase” on page 5-46
For information on the workflow for patient alignment and treatment delivery, and for details on the
user interface workflow for Synchrony Skull Tracking, see “Chapter 8: Treatment Delivery”. For
details on the user interface workflow for other tracking modes, see also the following chapters:
• “Chapter 9: Synchrony Fiducial Tracking”
• “Chapter 10: Synchrony Spine Tracking (Option)”
• “Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”
• “Chapter 12: Synchrony Respiratory Tracking System (Option)”
• “Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging (Option)”
• “Chapter 15: Lung Optimized Treatment (Option)”
Load Patient Data Screen

When you click the Treatment button on the CyberKnife System Menu and log in, the Load
Patient Data screen is displayed (see Figure 18).
NOTE: If an Oncology Information System (OIS) is licensed,

patient data is displayed in the following way, depending on the
OIS: If one or more patients are scheduled for treatment, the
Load Patient Data screen displays only scheduled OIS patients
and the Show only OIS scheduled patients and plans
checkbox is selected. If no OIS patient is scheduled or the
checkbox is cleared, all patients are displayed and you are
prompted to select a patient from the list.
1075883-ENG A Treatment Mode | 5-39

Figure 18 Load Patient Data screen for Treatment

mode
The Load Patient Data screen displays a list of patients with treatment plans that are approved for
delivery and allows you to select the patient to be treated. A list of approved treatment plans for
the patient is then displayed, allowing you to select a treatment plan to be delivered. Then a list of
fractions is displayed. Treatment plans are not listed until they have been approved for delivery and
DRR images have been generated on the iDMS Data Management System.
As you select the patient, treatment plan, and fraction, additional patient and treatment information
is displayed. A text message at the bottom left of the screen reports status as data is retrieved from
the database.
The screen includes the checkbox Show only OIS scheduled patients and plans (if licensed) and
the Load and Refresh buttons listed in Table 15.
5-40 | Treatment Mode 1075883-ENG A

Table 15 Controls in the Load Patient Data screen
Button Function
Show only OIS Select if you want to display only OIS scheduled patients and plans. Clear if
scheduled you want to display all treatable patients and plans.
patients and
plans (licensed
option)
Load After you have selected a patient, plan, and fraction, begins downloading
patient and treatment data from the iDMS Data Management System to the
treatment delivery computer.
Refresh Refreshes the Patient and Plan lists with the latest data from the iDMS
Data Management System. New patients and treatment plans are added to
the list only after the treatment plans have been approved for delivery and
DRR images have been generated on the iDMS Data Management System.
Click this button if a treatment plan has been approved for delivery but is not
yet displayed in the list.
The Patient section of the Load Patient Data screen displays the following information:
• Last Name: Last name of the patient.
• First Name: First name of the patient.
• Medical ID: Medical ID of the patient.
• Date of Birth: Date of birth of the patient
• Gender: Gender of the patient
The Plan section displays the following information:
• Name: Name of the treatment plan.
• Synchrony Method: Tracking mode specified in the treatment plan.
• Respiratory: The status of Synchrony Respiratory Tracking (yes if Synchrony
Respiratory Tracking is enabled in the treatment plan, or no if Synchrony Respiratory
Tracking is not enabled). For more information on the Synchrony tracking System, see
“Chapter 12: Synchrony Respiratory Tracking System (Option)”.

• InTempo: The status of InTempo imaging (yes if the InTempo imaging is enabled in
the treatment plan, or no if InTempo imaging is not enabled). For more information on the
Synchrony Fiducial Tracking with InTempo Imaging, see “Chapter 13: Synchrony Fiducial
Tracking with InTempo Imaging (Option)”.
• Anatomy: Anatomy to be treated.
• Orientation: Patient position as specified in the treatment plan.
• Fractions: The total number of fractions in the treatment plan.
• Delivered: The number of full fractions already delivered for the treatment plan.
• Remaining: The number of fractions that remain to be delivered for the treatment plan.
• Delivered / Prescribed (MU): Cumulative radiation amount already delivered for
the treatment plan (in monitor units) / Total prescribed radiation amount for the treatment
plan (in monitor units).
• Percentage progress bar: A bar graph displaying the percentage of the total prescribed
radiation amount for the treatment plan that has already been delivered.
The Fraction section displays the following information:
• Number: The selected fraction number to be delivered (an integer value).
If a full fraction was not completed, a makeup fraction is created that includes the
remaining radiation amount needed to complete the fraction. The makeup fraction has the
same number as the original fraction, with the text makeup displayed next to it.
the fraction (in monitor units) / Total prescribed radiation amount for the fraction (in
monitor units).
If the radiation amount delivered is zero, the fraction is a full fraction. The number of full
fractions multiplied by the prescribed radiation amount for each fraction equals the total
prescribed radiation amount for the treatment plan.
If the radiation amount already delivered is non-zero, the fraction is a makeup fraction.
radiation amount for the fraction that has already been delivered. If the percentage is non-
zero, the fraction is a makeup fraction.
The Notifications section displays the following information:
• Message panel: Notification message about the treatment or QA plan that is displayed
if an OIS is licensed and there is an inconsistency between OIS information and the iDMS
Data Management System.
• Acknowledge checkbox: Indicates that you have read and acknowledged the
notification message. The checkbox must be selected before treatment can proceed.

Overview Phase
The left screen of the Overview phase allows you to verify that the patient is in fact the one to
be treated and the treatment plan is the correct one to use (see Figure 19). If a photo of the patient
is available, it is displayed at the left of the screen.
WARNING: Carefully verify that this patient is in fact the one to be treated and the
treatment plan is the correct one to use. Otherwise, patient mistreatment can result.
WARNING: When the safety interlock key is used to bypass the Treatment Room door
interlock and the Treatment Room door is open, potentially harmful LINAC radiation
exposure to operators can occur outside the Treatment Room. Ensure that no LINAC
radiation is delivered while the Treatment Room door interlock is bypassed and the
Treatment Room door is open.
Figure 19 Overview phase (left screen)
The left screen includes the controls listed in Table 16.

Table 16 Controls on the left screen of the Overview phase
Control Function
Data Verified Indicate that you have verified patient information, treatment plan
checkboxes information, and then treatment fraction information by selecting each
checkbox in turn. Each checkbox is enabled only after you have selected the
previous checkbox.
The patient information section of this screen displays the following information:
• Gender: Gender of the patient.
• Date of Birth: Date of birth of the patient.
The treatment plan information section displays the following information:
• Plan Name: Name of the treatment plan to be delivered.
• Treatment Site: Anatomy to be treated.
• Orientation: Patient position specified in the treatment plan.
• Path Set: Name of the path set.
• Respiratory: The status of Respiratory Tracking (Yes if Synchrony Respiratory
Tracking is enabled in the treatment plan, or No if Synchrony Respiratory Tracking is not
enabled). For more information on the Synchrony tracking System, see “Chapter 12:
Synchrony Respiratory Tracking System (Option)”.
• Total Prescribed MU: Total prescribed radiation amount for the treatment plan (in
monitor units).
• Total Delivered MU: Cumulative radiation amount delivered for the treatment plan.
• Total Prescribed Dose (cGy/Gy): Total prescribed radiation dose for the
treatment plan (in centigray or gray depending on iDMS System setting).
• Total Fractions: Total number of fractions for the treatment plan.
• Plan Collimator: The type of collimator specified in the treatment plan (Fixed for
fixed collimators, or Iris for the optional Iris Collimator, followed by the aperture (in
millimeters) for fixed collimators.
The treatment fraction information section displays the following information:
• Fraction: The number of the current fraction to be delivered.

• Prescribed MU: Prescribed radiation amount per fraction (in monitor units).
Delivered MU: The radiation amount already delivered for the current treatment fraction (in
monitor units). The top of the right screen of the Overview phase summarizes current patient
and treatment data (see Figure 20).
Figure 20 Overview phase (right screen)
The following data is displayed:

• Plan Name: Name of the treatment plan.
• MU: Cumulative radiation amount delivered for the treatment plan (updated in real time
as dose is delivered) and the total prescribed radiation amount for the treatment plan,
given in the following form:
(Delivered MU) / (Prescribed MU)
where
MU is the number of monitor units.
• Treatment Site: Anatomy to be treated.
• Orientation: Patient position as specified in the treatment plan.
• Mode: The mode button selected on the CyberKnife System Menu.
For information on the right screen of the Overview phase for treatments using the Synchrony
tracking System, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.

Left and Right Screens of the Delivery Phase

The Delivery phase for Synchrony Skull Tracking mode is shown in Figure 21 (left screen) and
Figure 22 (right screen). This section describes some of the user interface displays and controls
on these screens. For more information on the Delivery phase, see “Chapter 8: Treatment
Delivery”.
Figure 21 Delivery phase (left screen) for Synchrony

Skull Tracking mode

Figure 22 Delivery phase (right screen) for Syn-

chrony Skull Tracking mode

• “Image Display Area” on page 5-48
• “Start Button” on page 5-48
• “Resume Button” on page 5-49
• “Pause Button” on page 5-50
• “Acquire Button” on page 5-51
• “Current Robot Position Indicator” on page 5-51
• “Mark Image as Blocked Button” on page 5-52
• “Move to Imaging Node Button” on page 5-53
• “Treatment Monitoring Graphs” on page 5-53
• “Image Interval Slider Bar” on page 5-56
• “Max Image Age Slider Bar” on page 5-56
• “Images Counter” on page 5-58
• “Estimated Imaging Dose (cGy/Gy) Display” on page 5-58
• “Beam Delivery and Delivery Progress Panels” on page 5-59
• “,” on page 5-60

Image Display Area

The Image display area on the left screen of the Delivery phase contains two image panels
displaying overlays of the Digitally Reconstructed Radiograph (DRR) image and Live X-ray image
that correspond to the orientation of Camera B (left) and Camera A (right) of the X-ray imaging
system. The bottom row contains the DRR image and Live X-ray image that correspond to the
orientation of Camera B of the X-ray imaging system. The following images are displayed:
• The reference DRR images that correspond to Camera A and B, respectively, of the X-
ray imaging system in a gray color scale.
• The Live X-ray images captured by Camera A and B, respectively, of the X-ray imaging
system in a teal color scale.
A text field between the Treatment Monitoring graphs below the images indicates the position of
the treatment robot (also called the treatment manipulator) at the time the images were acquired.
During treatment delivery, the node number at which the images were acquired is displayed. The
text is updated when the next images are acquired.
Start Button
The Start button allows delivery of a treatment fraction or makeup fraction (see Figure 23).
Figure 23 Start button on left screen of Delivery phase
Depending on the status of patient alignment, the Start button may be disabled. For more
information, see “Chapter 8: Treatment Delivery”.
When treatment is interrupted, the Start button is replaced by the Resume button. Controls are
displayed for acquiring new Live X-ray images to confirm patient alignment or to perform patient
realignment. Controls allow you to respond to treatment interruptions such as:
• Treatment is interrupted at a node that is blocked. A blocked node occurs when the
treatment robot or some other obstruction blocks the X-ray imaging system and prevents
the successful acquisition of new images.
• Treatment is interrupted when the treatment robot is at a beam position. A beam position
is a treatment robot position where the LINAC is located at a node and is pointed at the
treatment target. The beam position includes the offset of the LINAC required for
targeting corrections.

• Treatment is interrupted and treatment robot motion stops between nodes or between a
node position and a beam position. A node position is a treatment robot position where
the LINAC is located at a node and is pointed at the machine center.
NOTE: Where no targeting corrections are required, the beam

position is the same as the node position.
Resume Button
The Resume button allows you to resume automated treatment delivery after a Soft Stop, Pause,
or recoverable E-Stop occurs. (see Figure 24).
Figure 24 Resume button on left screen of Delivery phase
When you click the Resume button, the Treatment Delivery System checks many factors to
determine if new Live X-ray images are required. If new images are not required, the treatment
robot moves automatically to the next node in the treatment path and treatment proceeds.
If new images are required, they are acquired automatically and image correlation is performed
prior to delivery of the next beam. If the treatment robot is not at an unblocked node position, it
moves to one for image acquisition. The treatment robot then moves to the next node in the
treatment path and treatment proceeds.
NOTE: The treatment robot may move forward (in the forward
direction of the treatment path) or backward to reach the closest
unblocked node for imaging. The closest unblocked node may
be outside the treatment path.
If it is determined by visual inspection that the new images are blocked, you can mark the images
as blocked. See “Mark Image as Blocked Button” on page 5-52.
NOTE: It is the user’s responsibility to identify by visual

inspection of the X-ray images whether image correlation has
been performed successfully and the target has been correctly
identified.
Depending on the status of patient realignment, the Resume button may be disabled. For more

Pause Button
Clicking the Pause button requests a Soft Stop, which is a non-emergency treatment interruption
(see Figure 25).
Figure 25 Pause button on left screen of Delivery phase
A Soft Stop pauses treatment without triggering an E-Stop/interlock. Imaging errors such as an
image algorithm error or a patient out-of-bounds error also trigger a Soft Stop.
NOTE: A Soft Stop is not the same as an Emergency Stop

(E-Stop). In an emergency, you should press the nearest E-Stop
button. An E-Stop immediately stops movement of the treatment
couch and treatment robot, stops acquisition of X-ray images,
and terminates high voltage and treatment radiation. For more
information on E-Stops, see “Chapter 2: Safety”.
When you request a Soft Stop during treatment delivery, the following actions are performed:
• The treatment robot completes any in-progress motion, such as movement between node
positions or between node and beam positions.
• The X-ray imaging system completes any in progress image acquisition.
• If beam delivery is in progress, delivery of the current beam is completed.
• The LINAC high voltage remains ON for 180 seconds.
• When the Soft Stop is actually engaged, the elapsed time displayed in the Beam Data
window stops incrementing until treatment is resumed.
For more information on resuming treatment after a Soft Stop, see “Chapter 8: Treatment Delivery”.

Acquire Button
When you click the Acquire button in the Delivery Phase, the X-ray imaging system acquires a
pair of Live X-ray images. The Treatment Delivery System correlates the Live X-ray images with
the DRR images to determine target offsets.
The Acquire button is inactive when the treatment robot is stopped at a known blocked node. In
this case, text at the bottom of the left screen of the Delivery phase indicates that the current
position is blocked (see “Current Robot Position Indicator” on page 5-51). The Move Robot to
Imaging Node button then becomes active.
In the above case, you can click the Move Robot to Imaging Node button to automatically
move the treatment robot to the closest unblocked node for imaging, click the Acquire button to
obtain new images, and then click the Resume button to resume treatment.
NOTE: You can click the Acquire button to take images when
the treatment robot is stopped and is not at a node position.
Automatic image acquisition, however, only occurs at node
positions.
For information on acquiring images in other phases such as Couch, Technique, and Alignment,
see “Chapter 5: Treatment Delivery System Overview”.
Current Robot Position Indicator

When delivery automation begins, text between the Treatment Monitoring graphs on the left screen
of the Delivery phase indicates the current position of the treatment robot (also called the
treatment manipulator). Examples follow:
• "Robot at: Node 1": The treatment robot is at node number 1.
• "Robot at: Node 8": (Node number in yellow text) The treatment robot is at node
number 8, which is identified as a blocked node in the treatment path template or which
has previously been marked as blocked by the user for the current treatment plan.
• "Robot at: Node 10": (Node number in blue text) The treatment robot is currently
moving to node number 10.
NOTE: Robot node numbers may not be sequential.

Mark Image as Blocked Button

The Mark Image as Blocked button allows you to mark the currently displayed Live X-ray
images as blocked and the node position where those images were acquired as a user-designated
blocked node. A user-designated blocked node is a node that is marked as unblocked in the
treatment planning template but which is actually blocked. For example, a user-designated blocked
node can occur due to the particular placement of CyberKnife equipment at your site.
NOTE: User-designated blocked nodes must be identified by the

user during treatment by visual inspection of the Live X-ray
images.
When you click this button, the following actions occur:

• The Live X-ray images are crossed-out on the screen. The offset values determined
using these images will be discarded when you click the Resume button.
• The node position where the blocked images were acquired is marked as blocked for the
remainder of the treatment plan, including the remainder of the current fraction and all
future fractions.
NOTE: The node will not be permanently marked as blocked. It

will be identified as unblocked for other treatment plans.
For the remainder of the treatment plan, text at the bottom of the left screen of the
Delivery phase will indicate that the marked node is blocked (see “Current Robot
Position Indicator” on page 5-51).
Handling User-Designated Blocked Nodes With the InTempo

System
(Synchrony Fiducial Tracking with InTempo Imaging only) The optional Synchrony Fiducial
Tracking with InTempo Imaging enables the use of specific pathsets that are designed not to have
any blocked nodes. However, there may be certain cases in which you observe a particular node
to be blocked and wish to designate it as blocked as described above.
In this case, the Treatment Delivery System will fulfill both the requirements of the Synchrony
Fiducial Tracking with InTempo Imaging and those of the user. The Treatment Delivery System
achieves this by moving the treatment robot to an unblocked position for the purpose of imaging
from the node marked as blocked. Treatment beams will be delivered from the original node in the
pathset (now marked as blocked by the user). This movement of the treatment robot to an
unblocked position may be unexpected by the user. However, it is normal behavior and the system
is functioning as designed. This behavior is similar to that observed when the Move to Imaging
Node button is clicked (see “Move to Imaging Node Button” on page 5-53).

Move to Imaging Node Button

Clicking the Move to Imaging Node button moves the treatment robot to the closest
unblocked node to acquire Live X-ray images.
NOTE: The location where the currently displayed images were

acquired may be different from the current position of the
treatment robot.
The Move to Imaging Node button is active only when the treatment robot is not stopped at
an unblocked node position.
When the treatment robot reaches the imaging position, the Move to Imaging Node button
becomes inactive and the Acquire button becomes active, allowing you to acquire a pair of
images manually.
Treatment Monitoring Graphs

In the Delivery phase, Treatment Monitoring graphs are displayed and include treatment data
graphs and treatment controls (see Figure 26).
Click Tabs To View Graph

Other Graphs Legend
Toggle Legend Pause/Play

On/Off Graph
Figure 26 Treatment Monitoring graph for Position

The Treatment Monitoring graphs available depend on the tracking mode specified in the treatment
plan. Three Treatment Monitoring graphs can be displayed at a time. All graphs are plotted as a
function of time and display 300 seconds of data at a time. Each graph includes a legend.
The graphs includes the following controls:
• To select a set of graphs for display, click a tab.
• To view a legend for the graphs, click the Toggle Legend button at the bottom left of the
graph. To hide the legend, click the Toggle Legend button again.
• To view or hide individual data graphs on a tab, click the graph legend for that data graph.
• To view coordinate values for a data point on a graph, click the data point. The coordinate
values for that data point are displayed.
• To pan the horizontal display, click and drag the mouse over the graph.
• To expand or reduce the time scale, rotate the mouse scroll wheel over the graph.
• To pause the graph, click the Pause icon.
• To resume monitoring in real-time, click the Play icon. The graph jumps to the current
time.
The available treatment graphs are described in the sections that follow.
Orientation Graph
Displays the aggregate and individual rotational displacements as a function of time (see
Figure 27):
Figure 27 Orientation graph
• Aggregate (deg): Aggregate rotational displacement. The sum of the absolute values of
the rotational displacements as a function of time. This value is updated each time an X-
ray image is acquired.
• Roll (deg), Pitch (deg), Yaw (deg): Three lines, each corresponding to an individual
rotational displacement (Right/Left roll, Head Up/Head Down pitch, or CCW/CW yaw) as
a function of time.

Position Graph
Displays the distance between the actual and nominal alignment position as a function of time over
the course of the treatment path (see Figure 44). This graph indicates how much the patient is
moving over time as a function of distance from the nominal aligned position:
• Position Delta (mm): Delta translational displacement. The square root of the sum of the
squares of the three displacements along the translational axes as a function of time. This
value is updated each time an X-ray image is acquired.
• Inf/Sup (mm), Left/Right (mm), Ant/Pos (mm) translational displacements: Three
lines, each corresponding to a translational displacement in the Left/Right, Inferior/
Superior, and Anterior/Posterior directions.
Skull Graph
(Synchrony Skull Tracking mode only) Displays the value of image algorithm parameters for
Synchrony Skull Tracking mode. For more information, see “Chapter 8: Treatment Delivery”.
Fiducial Graph
(Synchrony Fiducial tracking mode only) Displays the value of algorithm parameters for Synchrony
Fiducial Tracking mode as a function of time. For more information, see “Chapter 9: Synchrony
Fiducial Tracking”.
Spine Graph
(Synchrony Spine Tracking) Displays the value of algorithm parameters for Synchrony Spine
Tracking as a function of time. For more information, see “Chapter 10: Synchrony Spine Tracking
(Option)”.
Lung Graph
(Synchrony Lung Tracking with Respiratory Modeling and Lung 1 View with Respiratory Tracking
only) Displays the value of image algorithm parameters for Synchrony Lung Tracking with
Respiratory Modeling. For more information, see “Chapter 11: Synchrony Lung Tracking with
Respiratory Modeling (Options)” and “Chapter 15: Lung Optimized Treatment (Option)”.
Respiratory Model Standard Error Graph

(Synchrony Respiratory Tracking treatments only) This graph displays the Average Standard Error
(mm) and the Maximum Standard Error (mm) for the Respiratory Model as a function of time. The
Average Standard Error (mm) and Maximum Standard Error (mm) for the current Respiratory
Model are also displayed In the Model Information area. For more information, see “Chapter 12:

Image Interval Slider Bar

(Synchrony Fiducial Tracking with InTempo Imaging not in use) The Image Interval (sec)
slider bar displays the current value of the Image Interval parameter (in seconds) for X-ray images.
The slider bar allows you to adjust the Image Interval in real-time during treatment. The default
value is 15 seconds.
The Image Interval parameter sets the minimum time interval between images, or conversely the
maximum imaging frequency, during treatment delivery. The Treatment Delivery System acquires
images as frequently as possible, but never more frequently than the value set by this parameter.
The goal of adjusting the interval slider is to correct for shifts in the tumor target and to minimize
patient exposure to imaging X-rays. If a patient, and therefore tumor target, moves more, decrease
the imaging interval to image more often. If a patient, and therefore tumor target, moves less,
increase the imaging interval because images are not required as often.
The Image Interval includes treatment interruptions, for example, due to a Soft Stop or a Pause.
When treatment is resumed, image acquisition and image correlation are performed automatically
if required before the next beam delivery. Some reasons image acquisition and correlation may be
required include:
• The previous imaging position was blocked or the previous images were discarded by the
user (see “Mark Image as Blocked Button” on page 5-52).
• There are no current offset values displayed in the Offsets panel. Offset values are
required before beam delivery can begin.
• The amount of time since the last image acquisition exceeds the Image Interval.
Max Image Age Slider Bar

(Synchrony Fiducial Tracking with InTempo Imaging only) The Max Image Age (sec) slider
bar displays the current value of the Max Image Age parameter (in seconds) for X-ray images. The
slider bar allows you to adjust the Max Image Age in real-time during treatment. A checkbox allows
you to enable or disable adaptive imaging for the Synchrony Fiducial Tracking with InTempo
Imaging.
NOTE: The Max Image Age parameter is not the same as the
Image Interval parameter. The Max Image Age parameter
applies only to treatment plans that use the Synchrony Fiducial
Tracking with InTempo Imaging.
For more information on the Synchrony Fiducial Tracking with InTempo Imaging, see “Chapter 13:
Synchrony Fiducial Tracking with InTempo Imaging (Option)”.

Image Burst Interval Slider Bar

(Synchrony Fiducial Tracking with Respiratory Modeling with Image Burst option enabled only) The
Image Burst Interval (sec) slider bar displays the current value of the Image Burst Interval
parameter (in seconds) for X-ray images. The slider bar allows you to adjust the Image Burst
Interval in real-time during treatment. The default value is 60 seconds.
An image burst is a rapid burst of 3 Live X-ray images taken 1 second apart. The new images
replace the 3 oldest images in the Respiratory Model. When the Image Burst option is enabled, the
Image Burst Interval parameter sets the approximate time interval between image bursts during
treatment delivery automation.
The Image Burst Enabled checkbox in the Readiness phase allows you to enable or
disable the Image Burst option for the Synchrony tracking System (see Figure 28).
Figure 28 Image Burst Enabled checkbox in Readiness

phase (left screen) with the Synchrony Respiratory Tracking
System
The Image Burst option cannot be enabled in the following cases:

• If the Synchrony tracking System is disabled in the Alignment > Respiratory phase
(the Skip Respiratory checkbox is selected).
• If imaging is disabled in the Readiness phase (the Disable Imaging checkbox is
selected).
If the Image Burst option is disabled in the Readiness phase (the Image Burst Enabled
checkbox is deselected), the slider bar is replaced by the Image Interval (sec) slider bar (see
“Image Interval Slider Bar” on page 5-56).
For more information on the Image Burst option with the Synchrony tracking System, see “Chapter
12: Synchrony Respiratory Tracking System (Option)”.

Images Counter
The Images counter displays a count of the acquired and expected X-ray images for the entire
treatment plan:
• Acquired: The number of X-ray images taken so far for the treatment plan, including
images taken manually during patient alignment and automatically during treatment
delivery. Images taken by Camera A and Camera B of the X-ray imaging system are
counted separately (that is, a pair of images from Camera A and Camera B are counted
as 2 images). The number of images acquired increases by 2 for each image pair
acquired.
• Expected: The estimated total number of X-ray images for all fractions in the treatment
plan. The estimate is updated prior to each beam delivery and depends on the following:
 (Synchrony Fiducial Tracking with InTempo Imaging not in use) The value of the
Image Interval parameter. The estimated total changes when this value is changed.
 (Synchrony Fiducial Tracking with InTempo Imaging only) The value of the Max
Image Age parameter. The estimated total changes when this value is changed.
 A fixed number of X-ray images is added for each expected patient alignment
procedure (one patient alignment procedure per treatment fraction): For a treatment
plan that does not use Respiratory Modeling, 10 X-ray images (5 image pairs) are
added. For a treatment plan that uses Respiratory Modeling, 20 X-ray images (10
image pairs) are added. The fixed number is added to the estimated total only for
fractions that have not yet been delivered. For the fraction currently being delivered,
the fixed number added to the estimated total is 0.
 The estimated total increases by 2 for each image pair acquired during patient
alignment or realignment, because the system cannot know how many images will be
acquired during these procedures.
Estimated Imaging Dose (cGy/Gy) Display

The Estimated Imaging Dose (cGy or Gy depending on the iDMS System setting) display
gives the estimated imaging X-ray dose to the patient based on the number of X-ray images taken
so far for the entire treatment plan:
• Exposed: Estimated imaging X-ray dose based on the number of acquired X-ray images
and their technique taken so far for the treatment plan, including images taken manually
during patient alignment and automatically during treatment delivery.
• Expected: Estimated total X-ray dose based on the current X-ray technique and the
number of expected images for this and all remaining fractions.
For information on approximate entrance dose per image produced by one of the CyberKnife
System X-ray sources for a range of X-ray techniques, see the Physics Essentials Guide.

Beam Delivery and Delivery Progress Panels

The Beam Delivery and Delivery Progress of the Beam Data window panels display
information about beam status and radiation dose during treatment delivery.
Figure 29 Beam Delivery and Delivery Progress

panels of the Beam Data window
• Beam Delivery panel:

 BEAM is OFF / BEAM is ON / HV is ON / HV is OFF / HV WAIT: Status of
the beam. When the beam is off, the beam status indicator is gray and displays
BEAM is OFF. When beam is being delivered, the beam status indicator is yellow
and displays BEAM is ON.
 Beam MU progress bar: Cumulative radiation amount delivered for the current
beam. This value (in monitor units) is displayed to the right of the progress bar. When
the beam is on, the value increases. Desired radiation dose (in monitor units) for the
current beam is displayed at the right of the progress bar.

 Fraction MU progress bar: Cumulative radiation amount (in monitor units)

delivered for the current fraction. This value (in monitor units) is displayed to the right
of the progress bar. When the beam is on, the value increases. Desired radiation
dose (in monitor units) for the entire fraction is displayed at the right of the progress
bar.
 Dose Rate A (MU/min) and Dose Rate B (MU/min): The nominal dose
rate for channels A and B during beam delivery.
 Counts (A/B): The number of counts read from Dosimeter A and Dosimeter B.
 Beam Time Limit (sec): The beam time limit (in seconds) that the beam has
been on. The beam time limit is 5 seconds or 150% of the beam delivery time,
whichever is greater.
 Beam Elapsed Time (sec): The elapsed time (in seconds) that the beam has
been on. If the elapsed time exceeds the beam time limit, an E-Stop occurs and the
beam is terminated.
• Delivery Progress panel:
 Beam ID: The number of the current beam at the current node, corresponding to
the order of beam delivery. There can be more than one beam per node.
 Fraction Duration progress bar: Elapsed time that treatment fraction has been in
progress. The elapsed time starts when the user clicks the Start button, stops when
a Soft Stop, Pause, or E-Stop occurs, and restarts when the user resumes treatment
delivery. During treatment delivery, the value increases.
 Total Fraction Duration (est): Estimated total treatment time for the current
fraction. The estimated total time is updated prior to each beam delivery and
becomes increasingly accurate as the end of a fraction is approached.
 Final Beam ID: Beam ID of the final beam in the fraction.
 Current Fraction: Current fraction number.
,
Demonstration Mode
Demonstration mode allows you to demonstrate operation of the CyberKnife System by
performing a BB test. To access this mode, click the Demonstration button on the CyberKnife
System Menu and then log in. This button is enabled only when equipment power is on.
In Demonstration mode in the delivery automation phase, no treatment radiation is delivered.
The laser turns on and off to indicate radiation beam on/off behavior.
Live X-ray images can be acquired in the patient alignment phase using a phantom. However, no
live X-ray images are acquired during the robot motion phase. You have the option of bypassing
the X-ray imaging system in the patient alignment phase, allowing you to start the demonstration
without acquiring initial Live X-rays.
5-60 | Demonstration Mode 1075883-ENG A

The demonstration is performed using the Teach Pendant to manually move the treatment robot.
Controls are the same as those in Treatment mode (see “Treatment Mode” on page 4-48),
except as described below. In Demonstration mode, the treatment delivery computer prompts
you when it is necessary to use the Teach Pendant. When the message shown in Figure 49 is
displayed on the treatment delivery computer, you remove the safety interlock key from the
operator control panel and use it to bypass the Treatment Room door interlock. Bypassing the
Treatment Room door interlock allows you to open the Treatment Room door without producing an
E-Stop.
Figure 30 Use Teach Pendant message
interlock, X-ray exposure to users and observers in the Treatment Room can occur.
Ensure that no X-ray images are taken while the Treatment Room door interlock is
bypassed. In Demonstration mode, when the Teach Pendant is used to initiate the robot
motion phase of the demonstration, no further X-ray images are taken.
WARNING: Make sure no one is in the Treatment Room when Live X-ray images are
acquired to prevent unnecessary exposures.
WARNING: Always hold the Teach Pendant while performing a treatment simulation in
Demonstration mode, so that the Emergency Stop (E-Stop) button is readily available.
1075883-ENG A Demonstration Mode | 5-61

WARNING: WARNING: When the safety interlock key is used to bypass the Treatment
Room door interlock and the Treatment Room door is open, potentially harmful LINAC
radiation exposure to operators can occur outside the Treatment Room. Ensure that no
LINAC radiation is delivered while the Treatment Room door interlock is bypassed and the
Bypassing the X-ray Imaging System

You have the option of bypassing the X-ray imaging system, allowing you to start the robot motion
phase of the demonstration without acquiring initial Live X-ray images in the patient alignment
phase.
WARNING: Make sure no one is in the Treatment Room when Live X-ray images are
acquired to prevent unnecessary exposures.
NOTE: During the patient alignment phase, if you click the

Acquire button when the Bypass Imaging checkbox is
disabled, a message is displayed warning that X-ray images will
be acquired. To continue and acquire images, click OK. To
cancel image acquisition, click Cancel.
 To bypass the X-ray imaging system:

• Select the Bypass Imaging checkbox under the Acquire button in any of the
workflow steps of the Alignment phase (see Figure 31).
Figure 31 Bypass Imaging checkbox in

Demonstration mode
Bypassing the Secondary Collimator System

You have the option of bypassing some controls and checks of the Secondary Collimator System.
This option allows you to operate the CyberKnife System with any secondary collimator, regardless
of the collimator specified in the treatment plan.
 To bypass the Secondary Collimator System:

• Select the Bypass Collimator checkbox in the Collimator and Laser

Alignment Check panel of the Alignment > Couch phase or the Readiness
phase (see Figure 32).
Figure 32 Bypass Collimator checkbox in

Demonstration mode
For more information on performing a BB test in Demonstration mode, see “Chapter 8:


Phantom Mode
Phantom mode allows you to simulate patient treatment using a phantom to check the accuracy
and safe delivery of a patient treatment plan. To access this mode, click the Phantom button on
the CyberKnife System Menu and then log in. This button is enabled only when equipment power
is on.
Controls are the same as those in Treatment mode.
Phantom Treatment Plans

You can only select treatment plans created for phantoms. Patient treatment plans are not
displayed in the Load Patient Data screen (see “Load Patient Data Screen” on page 5-39).
For information on specifying whether a treatment plan applies to a patient or phantom, see the
Data Management Manual.
Unlimited Deliverable Fractions

When the last fraction in a phantom treatment plan is completed, a new fraction is automatically
created. In this way, you can continue treatment delivery to the phantom without the need to create
a new treatment plan.
For more information on performing treatment simulation, see “Chapter 8: Treatment Delivery”.
5-64 | Phantom Mode 1075883-ENG A

Plan QA Mode
Plan QA mode allows you to select a quality assurance (QA) plan associated with a specific
patient and patient treatment plan and deliver the QA plan to a phantom. This mode provides a
method to perform quality assurance for patient-specific treatment plans. To access this mode,
click the Plan QA button on the CyberKnife System Menu and then log in. This button is enabled
only when equipment power is on.
WARNING: Plan QA should be performed prior to patient treatment delivery to verify that
the planned dose is consistent with the measured dose. Failure to perform plan QA can
result in patient mistreatment. For more information on the plan QA procedure, see the
Physics Essentials Guide.
Controls are the same as those in Treatment mode (see “Treatment Mode” on page 5-39),
except as described below.
NOTE: In Plan QA mode, a QA plan is associated with a

specific patient and patient treatment plan. In comparison, in
Phantom mode, a treatment plan is associated with a specific
phantom, not a patient. For more information on Phantom
mode, see “Phantom Mode” on page 5-64.
QA Plans
A QA plan is a special type of treatment plan that is intended to be delivered to a phantom, not a
patient. Each QA plan is associated with a specific patient and patient treatment plan. A QA plan
is derived from the patient treatment plan that it is associated with.
In Plan QA mode, you can only select QA plans for delivery. Only a single fraction is created for
a QA plan. If the fraction is partially delivered and treatment is aborted, a makeup fraction is created
that can be immediately delivered.
For information on creating a QA plan, see the Treatment Planning Manual. For information on
authorizing a QA plan and recording analysis results, see the Data Management Manual.
1075883-ENG A Plan QA Mode | 5-65

Load Patient Data Screen

When you click the Plan QA button on the CyberKnife System Menu and log in, the Load Patient
Data screen is displayed. In Plan QA mode, the Load Patient Data screen contains the sections
described below.approved

Load Patient Data screen displays only scheduled patients. If no
patient is scheduled, all patients are displayed and you are
The Load Patient Data screen displays a list of patients with approved QA plans and allows you to
select the patient that a QA plan is associated with. After you select the patient, a list of patient
treatment plans with approved QA plans is displayed. After you select a patient treatment plan, a
list of QA plans for that treatment plan is displayed. Patient treatment plans and QA plans are not
listed until they have been approved for delivery and DRR images have been generated on the
iDMS Data Management System.
As you select the patient, patient treatment plan, and QA plan, additional patient and treatment
information is displayed. A text message at the bottom left of the screen reports status as data is
retrieved from the database.
The screen includes the buttons listed in Table 17.
Table 17 Controls in the Load Patient Data screen
Button Function
Load After you have selected a patient, patient treatment plan, and QA plan,
begins downloading patient and treatment data from the iDMS Data
Management System to the treatment delivery computer.
Refresh Refreshes the Patient, Plan, and QA Plan lists with the latest data from
the iDMS Data Management System. New patients, patient treatment plans,
and QA plans are added to the list only after the plans have been approved
for delivery and DRR images have been generated on the iDMS Data
Management System.
The Patient section of the Load Patient Data screen displays the following information:
• Date of Birth: Date of birth of the patient
5-66 | Plan QA Mode 1075883-ENG A

• Gender: Gender of the patient

The Plan section displays the following information for the patient treatment plan:
• Name: Name of the patient treatment plan.
• Synchrony Method: Tracking mode specified in the patient treatment plan.
• Respiratory: The status of Synchrony Respiratory Tracking (yes if
SynchronyRespiratory Tracking is enabled in the patient treatment plan, or no if
SynchronyRespiratory Tracking is not enabled). For more information on the Synchrony
the patient treatment plan, or no if InTempo imaging is not enabled). For more
information on the Synchrony Fiducial Tracking with InTempo Imaging, see “Chapter 13:
• Anatomy: Patient anatomy to be treated as specified in the patient treatment plan.
• Orientation: Patient position as specified in the patient treatment plan.
• Fractions: The total number of fractions in the patient treatment plan.
• Delivered: The number of full fractions already delivered for the patient treatment plan.
NOTE: It is possible that some fractions of the patient treatment

plan have already been delivered before the plan QA procedure
is performed.
• Remaining: The number of fractions that remain to be delivered for the patient
treatment plan.
the treatment plan (in monitor units) / Total prescribed radiation amount for the treatment
plan (in monitor units).
radiation amount for the treatment plan that has already been delivered.
The QA Plan section displays the following information:
• Name: The name of the QA plan.
• Phantom Last Name: The last name of the phantom to which the QA plan will be
delivered.
• Phantom First Name: The first name of the phantom to which the QA plan will be
delivered.
• Phantom Medical ID: The Medical ID of the phantom to which the QA plan will be
delivered.
• Message panel: Notification message about the [treatment or QA] plan that is
displayed if an OIS is licensed and there is an inconsistency between OIS information
and the iDMS Data Management System

Overview Phase
The left screen of the Overview phase allows you to verify that the phantom is in fact the one
specified in the QA plan and that the QA plan is the correct one to use. If a photo of the phantom
is available, it is displayed at the right of the screen.
NOTE: Carefully verify that this phantom is in fact the one

specified in the QA plan and that the QA plan is the correct one
to use. Otherwise, the plan QA procedure will not yield accurate
results.
The screen includes the controls listed in Table 18.

Table 18 Controls in the Patient and Treatment Verification screen for Plan QA
Control Function
Data Verified Indicate that you have verified patient information, treatment and QA plan
checkboxes information, and then fraction information by selecting each checkbox in
turn. Each checkbox is enabled only after you have selected the previous
checkbox.
This screen displays the same information as in Treatment mode (see “Overview Phase” on
page 5-43) for the Patient section. The Plan section displays the following information:
• Plan Name: Name of the patient treatment plan that the QA plan is associated with.
• Treatment Site: Phantom anatomy to be treated, as specified in the QA plan.
• Orientation: Phantom position specified in the QA plan.
• Path Set: Name of the path set specified in the QA plan.
• Synchrony Method: Tracking mode specified in the QA plan.
• Respiratory: The status of Synchrony Respiratory Tracking (Yes if Synchrony
Respiratory Tracking is enabled in the QA plan, or No if Synchrony Respiratory Tracking
is not enabled). For more information on the Synchrony tracking System, see “Chapter
• Total Prescribed MU: Total prescribed radiation amount for the QA plan (in monitor
units).
• Total Delivered MU: Cumulative radiation amount delivered for the QA plan.
• Prescribed Dose (cGy/Gy): Prescribed radiation dose for the QA plan (in centigray
or gray depending on the iDMS System setting).

• Total Fractions: The number of fractions to be delivered in the QA plan. The total
number of fractions is always 1 for a QA plan.
• Plan Collimator: The type of collimator specified in the QA plan (Fixed for fixed
collimators or Iris for the optional Iris Collimator), followed by the aperture (in
millimeters) for fixed collimators.
• QA Phantom Name: The name of the phantom to which the QA plan will be
delivered.
• QA Phantom Medical ID: The Medical ID of the phantom to which the QA plan will
be delivered.
• QA Plan Name: Name of the QA plan to be delivered.
The Fraction section displays the following information:
• Fraction Number: The selected fraction number to be delivered.
• Prescribed MU: Prescribed radiation amount for the QA plan fraction (in monitor
units).
• Delivered MU: Cumulative radiation amount delivered for the QA plan fraction.
• Prescribed Dose (cGy/Gy): Prescribed radiation dose for the QA plan fraction (in
centigray or gray depending on the iDMS System setting).
The top of the right screen of the Overview phase summarizes current patient and QA plan data.
• First Name: First name of the patient (not the phantom name).
• Last Name: Last name of the patient (not the phantom name).
• Medical ID: Medical ID of the patient (not the phantom).
• Plan Name: Name of the QA plan (not the patient treatment plan).
• MU: Cumulative radiation amount delivered for the QA plan (updated in real time as
dose is delivered) and the total prescribed radiation amount for the QA plan, given in the
following form:
(Delivered MU) / (Prescribed MU)
where
MU is the number of monitor units.
• Treatment Site: Phantom anatomy to be treated, as specified in the QA plan.
• Orientation: Phantom position, as specified in the QA plan.
• Synchrony Method: Tracking mode specified in the QA plan.
• Mode: The mode button selected on the CyberKnife System Menu.

Left and Right Screens of Delivery Phase

Delivery phase screen controls are the same as those in Treatment mode. See “Treatment
Mode” on page 5-39.
For information on delivering a QA plan to a phantom, see “Chapter 8: Treatment Delivery”.

Chapter 6: Patient Preparation
Introduction
This chapter describes patient preparation procedures that should occur prior to treatment using
the CyberKnife Treatment Delivery System. During pretreatment scanning, image studies are
acquired that will be used for treatment planning.
• “Patient Immobilization Devices” on page 6-2
• “Pretreatment Scanning Guidelines” on page 6-7
• “Fiducial Placement” on page 6-18

Patient Immobilization Devices

WARNING: Ensure that the patient is properly immobilized to minimize patient movement
during treatment. Choose an appropriate immobilization device and ensure it is used as
intended following the instructions provided by the vendor. Otherwise, there is increased
risk of collision with the treatment robot due to violation of the Patient Safety Zone (see
“Chapter 2: Safety”). Collision with the treatment robot can result in serious injury or
death of the patient.
If the patient immobilization device is created on the treatment couch of the CyberKnife System, it
is important to ensure that the pitch and roll of the treatment couch are at zero degrees (0°) during
the immobilization process.
Head and Neck Immobilization

Head and neck treatments require that the neck of the patient be immobilized. This section gives
instructions for preparing devices for head and neck immobilization for the following types of
treatment:
• Treatment without fiducials
• Treatment using Synchrony Fiducial Tracking
• Treatment using Synchrony Spine Tracking
Treatments Without Fiducials

For head and neck immobilization for treatment without fiducials, follow the instructions below to
prepare a thermoplastic mask, also called an Aquaplast mask (see Figure 1 on page 6-3).
 To provide head and neck immobilization for treatments without fiducials:
• The thermoplastic mask should fit snugly to minimize movement.
• Mask thickness of 2.4 mm is recommended.
• The mask should extend below the patient’s chin.
• Mold the bridge of the nose to reduce lateral movement.
• Mark laser lines to assist in reproducing the setup position.
6-2 | Patient Immobilization Devices 1075883-ENG A

Treatment Delivery Manual Chapter 6: Patient Preparation
Figure 1 Thermoplastic mask
Treatment with Synchrony Fiducial Tracking

 For head and neck immobilization:
1. Prepare a thermoplastic mask (refer to “Treatments Without Fiducials” on page 6-2).
2. For better immobilization of the neck, use A C-Spine collar with a mask.
Make sure that the C-Spine collar does not contain metal or radiopaque material. These
materials can obscure the fiducials or the spine.
3. Do an imaging test to make sure that you can see the fiducials before CT scanning.
Treatment with Synchrony Spine Tracking

For head and neck immobilization for treatment using Synchrony Spine Tracking, follow the
instructions below.
 To provide head and neck immobilization for treatments using Synchrony Spine Tracking:
1. For C-Spine treatment, make an aquaplast mask as described above (see “Treatments
Without Fiducials” on page 6-2).
2. Conduct an imaging test to evaluate visualization of the spine prior to CT scanning.
1075883-ENG A Patient Immobilization Devices | 6-3

Body Immobilization
This section gives instructions for preparing a body immobilization device.
NOTE: For patients with fiducials, evaluate the patient position

and fiducial visualization in the immobilization device by
acquiring a Live X-ray image as described below.
NOTE: For treatment using the Synchrony Fiducial Tracking with

Respiratory Modeling, patients must wear the Synchrony
Respiratory Vest when the body immobilization device is made.
For information on using the Synchrony Respiratory Vest, see
 To make a body immobilization device:

1. Set up the patient for treatment on the treatment couch of the CyberKnife System.
• Use knee sponge, bolster, or other means to stabilize legs and feet. Reevaluate
position for patient comfort and safety and check the Patient Safety Zone.
For information on the Patient Safety Zone, see “Chapter 2: Safety”.
• Consider placement of arms:
Upper body treatment site: placed at sides
Lower body treatment site: holding sternum ring, crossed at chest
• Position the patient Feet First Supine (FFS) if needed.
WARNING: Verify that placement of patient extremities does not violate the Patient Safety
Zone (see “Chapter 2: Safety”). Otherwise, contact can occur between the treatment robot
and the patient.
2. Make an immobilization device (an alpha cradle or vacuum bag can be used).
Upper body immobilization (bottom of sternum and superior):
• Include patient head and shoulders extending inferior toward pelvis.
• Include arm position and imprint of fingers when possible.
An example of an alpha cradle for upper body immobilization is shown in Figure 2 on
page 6-5.

Figure 2 Alpha cradle for upper body
Lower body immobilization (bottom of sternum and inferior):

• Extend device below patient knees and include heel imprint.
• Place knee sponge or bolster under immobilization device for patient.
An example of an alpha cradle for lower body immobilization is shown in Figure 3 on
page 6-5.
Figure 3 Alpha cradle for lower body

 To evaluate patient position and fiducial visualization for patients with fiducials:
For patients with fiducials, evaluate patient position and fiducial visualization by acquiring a Live X-
ray image using the CyberKnife System as described below.
1. Set patient in the treatment position using the newly created immobilization device.
2. Position the patient's treatment area into the imaging field of the X-ray imaging system.
3. On the treatment delivery computer, open a phantom treatment plan designed using the
Synchrony Fiducial Tracking mode.
4. Acquire Live X-ray image.
• Ignore fiducial errors. These errors occur due to the difference between patient and
phantom fiducials.
5. Verify the number and location of fiducials against details from physician operative notes
and films.
• Reposition the patient as needed to bring fiducials into the X-ray imaging field.
• Check for obscured, overlapping, or unusable fiducials.
6. Repeat steps 2 and 3 as necessary to determine the quality of fiducial placement and
patient setup.
7. Using Treatment Room lasers for reference, mark the patient position on the
immobilization device.

Pretreatment Scanning Guidelines

• “Patient Positioning for Pretreatment Scanning” on page 6-7
• “Supported Image Types” on page 6-8
• “CT Imaging Guidelines” on page 6-8
• “MRI Imaging Guidelines” on page 6-15
• “PET Imaging Guidelines” on page 6-16
• “Angiography Imaging Guidelines” on page 6-17
• “Key Identifiers for DICOM Images” on page 6-18
Patient Positioning for Pretreatment Scanning
WARNING: Some scanners may orient patient data differently when the patient position is
other than Head First Supine (HFS). Image studies from scanners should not be used
unless the correct orientation of the patient in the Accuray Precision System has been
verified. Treatments based on incorrectly oriented patient data can lead to mistreatment of
the patient.
It is essential to have the patient in the same position for treatment as they were during
pretreatment CT scanning. A reproducible patient position is the primary requirement during
patient preparation for the CT scan.
For the standard treatment couch, if the patient will be treated using a knee bolster, the bolster
should be used during pretreatment scanning.
If a RoboCouch bolster cushion is used, the RoboCouch seat cushion should be placed on top of
it and attached using the hook and loop fasteners. The bolster cushion should be positioned on the
indexing bar using the same mounting position that will be used for treatment. For information on
the RoboCouch cushions, see “Chapter 7: Treatment Room Operations”.
WARNING: Follow the above guidelines to position the patient for pretreatment scanning.
Otherwise, the patient treatment position will not match the pretreatment scanning
position, and mistreatment can result.
For more information on the RoboCouch System, see “Chapter 7: Treatment Room Operations”.
For more information on the Patient Safety Zone, see “Chapter 2: Safety”.
1075883-ENG A Pretreatment Scanning Guidelines | 6-7

Supported Image Types

The CyberKnife System makes use of two types of image studies: primary CT image studies and
secondary images. This section describes how the primary CT image study is used and lists
supported image types for secondary images.
Primary CT Image Studies

The primary CT image study is used during treatment planning for the following tasks:
• Delineating structures
• Defining anatomical or artificial regions for tracking
• Dose calculation
During treatment delivery, the primary CT image study is used for patient positioning.
Secondary Images
Secondary images are used to identify and delineate structures. Supported secondary image types
include the following:
• MRI scans
• PET scans
• 3D Angiography
• Additional CT scans
Imaging guidelines for supported image types are given in the sections that follow.
CT Imaging Guidelines
The patient position during CT scanning should be the same as the patient position that will be
used to treat the patient. Bring all immobilization devices created for the patient to the CT scanner
to replicate the patient position.
Accuray has determined that some third party CT table tops may contain embedded "guide wires"
that may cause problems when used with the CyberKnife imaging system. If these table tops are
used, Accuray recommends that the patient be positioned so that the target or Region of Interest
(ROI) for tracking purposes does not intersect the "guide wires".
NOTE: The CyberKnife System supports treatment for patients

in supine positions for all tracking modes. Support for treatment
in prone positions depends on the tracking mode. For
information on supported prone positions, see “Chapter 8:
Treatment Delivery”. The CyberKnife System does not support
scans of patients positioned on their sides.
6-8 | Pretreatment Scanning Guidelines 1075883-ENG A

Basic Parameters for CT Imaging

The Medical ID for the CT image study must exactly match the Medical ID used in the CyberKnife
System.
NOTE: The Medical ID is limited to 16 characters. Do not use

spaces or punctuation (such as dashes, slashes, commas, and
so on) in the Medical ID or patient name.
You can only import CT image studies with axial slices to the CyberKnife System. Basic
parameters for CT imaging should be as follows:
• Axial or helical/spiral 1-to-1 pitch.
• IV contrast may only be used in secondary CT image studies.
NOTE: Do not use IV contrast in primary CT image studies.
• Gantry angle = 0°.

• Maximum 512  512  512 slices.
NOTE: Pixels must be square.
• Select a CT protocol to optimize for the patient anatomy, the tracking modality (see the
following tracking sections), and reduced noise that favors the following:
 High contrast image.
 Reduced artifacts with Metal Artifact Reduction (MAR) if metal present.
 Accurate delineation/contouring.
NOTE: Refer to the guidelines provided by your CT

manufacturer.
• The CT density model may depend on the selected protocol as well as the CT scanner.
You may need multiple density models. Refer to the Physics Essentials Guide for more
information on CT density models.
• No more than 1.5 mm slice thickness. Contiguous slices (no gaps).
NOTE: Variable slice thickness is not supported.
• Field of View (FOV):

 Must include entire circumference of patient.
 Must be a square image acquisition in the Left/Right and Anterior/Posterior
directions.
 Must include immobilization devices.

Guidelines for Acquiring Intracranial CT Image Studies

Follow these guidelines for acquiring intracranial CT image studies:
1. All patient immobilization devices that will be used during patient treatment must be used
during CT scanning. Include the CT table top, head mount, index bar, and any pads used.
2. Field of View (FOV):
• Include the entire circumference of the skull.
• Use the smallest FOV that encompasses the anatomy for the best pixel resolution.
• Include part of the headrest and extend 1 cm anterior past the tip of the nose.
• Include as much anatomy as possible.
3. The CT scan is used to create Digitally Reconstructed Radiographs (DRR) images. DRR
images must have a 0 – 1 cm gap anterior and superior to the patient skull.
AP and lateral scout images help ensure there are approximately 0 – 1 cm gaps anterior
and superior to the skull.
Anterior gap 0 – 1 cm
Superior gap 0 – 1 cm
Patient centered left-to-right in
the FOV
Figure 4 Field of View (FOV) for Synchrony Skull

Tracking treatment (red lines for illustration only)

CT Image Studies for Synchrony Skull Tracking Treatment

Follow these guidelines for acquiring CT image studies for treatment using Synchrony Skull
Tracking mode. For more information on this tracking mode, see “Chapter 8: Treatment Delivery”.
1. Set window levels as appropriate.
2. Set the Field of View (see Figure 4 on page 6-10):
• Patient must be centered laterally in the FOV.
• FOV must include the chin and extend 0 – 1 cm superior past top of skull.
• FOV must include the headrest and extend 0 – 1 cm anterior past the tip of nose.
3. Optimize for bone imaging.
Guidelines for Acquiring Extracranial CT Image Studies

• “CT Image Studies for Synchrony Fiducial Tracking System Treatment” on page 6-12
• “CT Image Studies for Synchrony Spine Tracking Supine” on page 6-12
• “CT Image Studies for Synchrony Spine Prone Treatment” on page 6-13
• “CT Image Studies for Synchrony Lung Tracking with Respiratory Modeling Treatment”
on page 6-14
• “CT Image Studies for Lung Optimized Treatment” on page 6-14
• “CT Image Studies for Treatments with Respiratory Modeling” on page 6-14
Follow these basic guidelines for acquiring extracranial CT image studies:
1. All patient immobilization devices that will be used during patient treatment must be used
during CT scanning (CT table top, head mount, index bar, VacBag, Bolster, Memory
Foam, and so on).
2. Use the smallest FOV that encompasses the anatomy for the best pixel resolution.
Include the entire circumference of the patient.
NOTE: Anatomy left out of the CT scan will cause beams to be

excluded by the Accuray Precision System.
3. The 512 slices should be centered on the fiducials:
• There must be a minimum of 10 – 15 cm inferior and superior to the fiducials.
• The scan should be centered (midline).
CT scanning guidelines for different tracking modes are given below.

CT Image Studies for Synchrony Fiducial Tracking System

Treatment
Follow these guidelines for acquiring CT image studies for treatment using the Synchrony Fiducial
Tracking mode. For more information on this tracking mode, see “Chapter 9: Synchrony Fiducial
Tracking”.
2. Set the Field of View (FOV):
• The patient must be centered Left/Right and Anterior/Posterior in the FOV.
• The tumor should be centered in the Inferior/Superior direction with a minimum 10 –
15 cm scanned in either direction.

3. Normal CT procedure should suffice.
CT Image Studies for Synchrony Spine Tracking Supine

Follow these guidelines for acquiring CT image studies for treatment using Synchrony Spine
Tracking Supine. For more information on this tracking mode, see “Chapter 10: Synchrony Spine
Tracking (Option)”.
2. Set the Field of View (FOV).
3. Optimize for bone imaging.


4. Avoid placing external objects such as those listed below in the field of view. Avoid using
contrast agents which can interfere with Synchrony Spine Tracking.
External objects in the region of interest can interfere with Synchrony Spine Tracking
algorithm. Ensure external objects are not included in the region of interest for treatment
planning and treatment delivery.
• Indexing bar
• Cervical collar
• Bone replacement materials
• Contrast agents
NOTE: Contrast-enhanced CT scans can be used as secondary

images and fused with the primary non-contrast CT image for
contouring purposes.
5. Acquire the CT scan during breath hold at the end of normal expiration.
CT Image Studies for Synchrony Spine Prone Treatment

For Synchrony Spine Prone treatments, it is essential to have the patient in the same position for
treatment as they were during pretreatment CT scanning, including all immobilization devices. A
reproducible patient position is the primary requirement during patient preparation for the CT scan.
Bring all immobilization devices created for the patient to the CT scanner to replicate the patient
position.
It is very important that the CT scan be taken during natural (not forced) inhalation or exhalation,
and that the same immobilization applied to the patient is used for both CT scanning and treatment
delivery. If any compression device is placed on the patient, it is essential that it be present for both
CT scanning and treatment delivery.
The size of any immobilization device placed between the hard surface of the treatment couch
table top and the patient should be minimized to reduce the distance from the couch surface to
highest point of the patient. Using an immobilization device that is thicker than the couch cushions
provided by Accuray increases the risk that the patient will be positioned outside the Patient Safety
Zone. For more information on the Patient Safety Zone, see “Chapter 2: Safety”.
of the PDP model increases the risk of collision with the treatment robot and may result in
serious injury or death of the patient.
Follow the guidelines for patient preparation for pretreatment scanning described in “Chapter 12:

CT Image Studies for Synchrony Lung Tracking with Respiratory

Modeling Treatment
Follow these guidelines for acquiring CT image studies for treatment using the Synchrony Lung
Tracking with Respiratory Modeling System. For more information on this tracking mode, see
“Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”.
2. Set the Field of View (FOV):

3. Optimize for bone imaging and for the visualization of the lung tumor.
CT Image Studies for Lung Optimized Treatment

Both Lung 1 View tracking and Spine Supine tracking treatments are based on the assumption that
the position and motion range of the target during treatment with respect to the spine alignment
center are well represented by the CT scans used for treatment planning. For this reason, it is very
important that the CT scans be taken during natural (not forced) inhalation and exhalation, and that
the same immobilization applied to the patient is used for both CT scanning and treatment delivery.
If any compression device is placed on the patient, it is essential that it be present for both CT
scanning and treatment delivery.
CT Image Studies for Treatments with Respiratory Modeling

For treatment that will use the Synchrony tracking System, the patient must wear the Synchrony
Respiratory Vest during CT scanning. The CT scan should be acquired during patient breath hold
at the end of normal expiration.
For more information on pretreatment scanning guidelines for treatment using the Synchrony

MRI Imaging Guidelines

Use the same patient immobilization setup that was used for CT imaging to ensure the same
patient position, in order to achieve fusion with the primary CT image study.
The Medical ID for the MRI images must exactly match the medical ID used in the CyberKnife
System. Spaces and punctuation (such as dashes, slashes, commas, and so on.) may not be used
in the Medical ID or patient name.
You can import an MRI image series acquired in any plane to the CyberKnife System. The
following MRI images are supported:
• Axial
• Coronal
• Sagittal
• Non-skew oblique (up to 30 degrees)
Basic parameters for MRI imaging should be as follows:
• IV Contrast may be used when indicated.
• Maximum 1024  1024  512 slices.
NOTE: Pixels must be square.
• Contiguous 1.0 – 3.0 mm slice thickness or volume scan.
NOTE: Variable slice thickness is not supported.
Guidelines for Acquiring Intracranial MRI Images

Follow these guidelines for acquiring intracranial MRI images:
1. Set windows to visualize anatomy.
2. Set the Field of View (FOV) to replicate the CT image.
• The patient must be centered laterally in the FOV.
• The FOV must include the chin and extend 1 cm superior past the top of the skull.
• The FOV must include the headrest and extend 1 cm anterior past the tip of the nose.

Guidelines for Acquiring Extracranial MRI Images

Follow these guidelines for acquiring extracranial MRI images:
1. Set windows to visualize anatomy.
2. Set the Field of View.
• The tumor should be centered in the Inferior/Superior direction.
PET Imaging Guidelines

patient position, in order to achieve fusion with the primary CT image study. PET images and CT
images must be sent separately to the CyberKnife System.
NOTE: PET images and CT images that have been previously

fused cannot be used by the CyberKnife System.
The Medical ID for the PET images must exactly match the medical ID used in the CyberKnife
System. Spaces and punctuation (such as dashes, slashes, commas, and so on.) may not be used
in the Medical ID or patient name.
Each image within a PET scan should meet the following conditions:
• Identical pixel dimensions
• Identical field of view
• Identical slice thickness
• Even slice spacing
• 16-bit monochrome data
• Attenuation corrected for Standardized Uptake Value (SUV) calculation
Record or enter the following information on the scanner workstation during the PET image
acquisition process, in order to compute the SUV on the Accuray Precision System:
• Patient weight (in kilograms, kg)
• Patient height (in centimeters, cm)
• Patient gender (Female, F; Male, M)
• Radionuclide half life (in seconds)

• Radionuclide total dose (in Becquerel, Bq)

• Radiopharmaceutical start date and time, in the following format:
MMDDYYYY HHMMSS
where:
MM is the month, DD is the day, and YYYY is the year
HH is the hour, MM is minutes, and SS is seconds.
• Scan date and time
NOTE: Different vendors store the scan date and time either as
the DICOM image series date and time or the DICOM image
acquisition date and time. This difference can result in different
statistics for the SUV calculation.
Angiography Imaging Guidelines

patient position, in order to achieve fusion with the primary CT image study.
The Medical ID for the angiography images must exactly match the medical ID used in the
CyberKnife System. Spaces and punctuation (such as dashes, slashes, commas, and so on.) may
not be used in the Medical ID or patient name.
The CyberKnife System supports 3DRA (3D Reconstructed Angiography). Angiography images
should meet the following conditions:
• 240° rotation
• 100 frames in 4 seconds
• Cone-beam scan
• 17 cm maximum Field of View
• Back-projection algorithm
Following 2D image acquisition, reconstruct the images as a tomographic study prior to importing
into the Accuray Precision System.
After being imported, 3DRA images can be fused with CT images.

Key Identifiers for DICOM Images

To understand fully how the CyberKnife System implements Digital Imaging and Communications
in Medicine (DICOM) images, refer to the document DICOM Conformance Statement for Accuray
CyberKnife® System (Accuray P/N 19055).
One key identifier is used to classify imported DICOM images. All patient data is linked by a unique
Medical ID. To maintain all image studies under one patient record in the CyberKnife System
database, the image studies should all have the same Medical ID.
NOTE: Multiple image series from the same image study will be
linked together in the CyberKnife System database. If an image
study is to be performed in multiple segments and then
combined, each segment should have the same Image Study
Unique Identification (UID). Each segment can have a different
Image Series UID.
Fiducial Placement
Fiducial Placement Principles
In order to treat the patient with ease and accuracy, a few key principles need to be taken into
consideration when fiducials are implanted for patient treatments with the CyberKnife System.
Using 3 or more fiducials significantly improves targeting accuracy. The recommended number of
fiducials is 4 - 6. An example fiducial configuration is shown in Figure 5 on page 6-18.
Figure 5 Example configuration of 5 fiducials
Fiducial placements should meet the following requirements:

• Minimum distance of 18.0 cm between fiducials.
6-18 | Fiducial Placement 1075883-ENG A

• The distance between the geometric centroid of the fiducial set and the geometric
centroid of the target must be 50 mm or less.
• Non-collinear placement (in the X-ray imaging plane): Right Anterior Oblique (RAO)/Left
Anterior Oblique (LAO) or Right Posterior Oblique (RPO)/Left Posterior Oblique (LPO) X-
ray images are acquired during patient treatments.
Ensure fiducial markers are not obscured in the 45 degree angle projections of the
imagining system by dense tissue or by other fiducials. (See Figure 7 “Patient coordinate
axes are based on the Head First Supine (HFS) patient position” on page 13).
WARNING: When fiducials are used for tracking, ensure that all required fiducials are
within the field of view and verify that they are visible in the DRRs.
• A minimum 15 degree angle between any grouping of 3 fiducials should be used.
NOTE: Fiducial placements that meet the requirements listed

above are recommended so that the CyberKnife System can
track and treat tumors with submillimeter accuracy.
You may find that some of the implanted fiducials are unusable. For example, implanted fiducials
may be unusable for any of the following reasons:
• Migration
• Close placement of fiducials (closer than 2.0 cm). For example, the fiducials labeled 1
and 2 in Figure 5 on page 6-18.
• Less than 15 degree angle between any grouping of 3 fiducials. For example, the angle
between the fiducials labeled 2, 1 and 3 in Figure 5 on page 6-18.
NOTE: The above fiducial placement errors adversely affect

tumor localization and treatment accuracy.
Fiducial Supplies
Information on approved fiducial supplies for soft tissue and for spine and bone is given below.
WARNING: Use only Accuray-approved fiducials for treatment with the CyberKnife
System. Fiducial tracking with the CyberKnife System has been validated using approved
fiducials only. Use of unapproved fiducials is not supported and could result in patient
mistreatment.
1075883-ENG A Fiducial Placement | 6-19

Fiducials Approved for Soft Tissue Tracking

The fiducials listed in Table 1 have been validated for use with the CyberKnife System for purposes
of soft tissue tracking.
Table 1 Fiducials validated for soft tissue tracking
Dimensions
Manufacturer’s (Diameter x
Manufacturer Type Part Number Length) Description
MT-NW-887-808 0.8 x 3.0 mm 3 sterile soft tissue gold

markers.

Gold Seed
markers.

markers.
CIVCO
CyberMark™ MT-NW-887-851 1.0 x 5.0 mm Sterile placement needles
Gold Seed (-853) (single or 3-pack) with 1.0 x
5.0 mm soft tissue marker.
Coupled™ MT-NW-887-710 1.0 x 3.0 mm Sterile placement needle with

Marker two 3 mm gold soft tissue
MT-NW-887-709 0.8 x 3.0 mm markers attached at a fixed
distance.
FP-0755 Coiled gold soft tissue marker

on a carrier for transport, easy
to deploy into most needle
hubs.
0.75 x 5.0 mm
Visicoil™
VC-075-005-PL Coiled gold soft tissue marker in
RadioMed Coiled Gold
a preloaded needle with bone
Markers
wax at the tip.
VC-010-005-PL 1.1 x 5.0 mm Coiled gold soft tissue marker in

a preloaded needle with bone
wax at the tip.
Olympus Gold Sphere N/A Diameter Individual gold spheres.

1.5 mm
Alpha Omega Gold Seed SMG0242-025 0.8 x 5.0 mm 25 gold seeds per vial,
packaged non-sterile. 19G thin
walled biopsy needle 10 - 11 cm
or 15 cm length.

Fiducials Approved for Implantation in Bone or Spine

The fiducials listed in Table 2 have been validated for use with the CyberKnife System for purposes
of implantation in and tracking of bony structures.
Table 2 Fiducials validated for implantation in bone or spine
Dimensions
Manufacturer’s (Diameter x
Manufacturer Type Part Number Length) Description
P/N 019005 Single self-drilling marker per

pack.
Stainless P/N 019006 Five (5) self-drilling markers per

Accuray 2.0 x 5.0 mm
Steel Screw pack.
P/N 019007 Ten (10) self-drilling markers per

pack.
Fiducial Placement Procedure

NOTE: Accuray does not make recommendations as to any
particular fiducial placement procedure. The fiducial placement
procedures presented here are developed by the medical
professionals listed and are only presented here as guidelines.
Post-placement Guidelines
For fiducials implanted for the treatment of spinal lesions, it is advised to wait 24 – 48 hours before
acquiring the CT scan therefore enabling resolution of any localized pain or swelling. For soft tissue
lesions, 1 week is recommended to allow adequate time thereby minimizing fiducial migration.
NOTE: It is imperative that the time between CT scanning and

treatment delivery is kept to a minimum for soft tissue lesions;
recommend time span is 24 – 48 hours. This will aid in reducing
the incidence of fiducial extraction errors related to fiducial
migration during treatment delivery.

Lung
The treatment of lung lesions using the CyberKnife System requires the implantation of gold seeds
referred to as fiducial markers. This outline reviews the procedure for placement of fiducial markers
using a percutaneous approach with CT guidance. In order to track lesions in 6D (translational and
rotational movements), a minimum of 3 fiducials are required for the software to track the lesion. It
is recommended to place a minimum of 4 fiducials, 1 more than is required for tracking in 6D, and
no more than 6. This recommendation is based on a study of the tracking accuracy possible in the
presence of uncertainties in fiducial localization both in the CT scan and live radiographic images.
(Murphy MJ Fiducial-based targeting accuracy for external-beam radiotherapy Med Phys 29(3)
334-344 (2002).)
Outline of Procedure
Lung information provided by Stephen T. Kee M.D., Associate Professor of Interventional
Radiology, Stanford University Medical Center.
The fiducial placement procedure is very similar to a CT guided lung biopsy. Anyone who has
experience with CT guided lung biopsies should be well aware of the methods employed and
potential complications of the placement of needles in lung tissue. Perform the procedure utilizing
the exact same methods used for a CT guided lung biopsy; the main difference being that once the
needle is placed in the lesion, fiducials are implanted rather than taking tissue out. The
complications and challenges are almost identical.
The first step is to obtain a detailed informed consent during which the patient is made aware of
complications pertinent to placement of any needle within the lung, namely pneumothorax and
hemorrhage. The incidence of pneumothorax with a single visceral pleural puncture is
approximately 15 – 30%; this increases if multiple visceral punctures need to be performed.
Hemorrhage can occur any time a needle is placed within the lung tissue resulting in hemoptysis.
The patient is placed on the CT table depending on the best approach to be used to access the
lesion. The procedure is performed using conscious sedation and the patient should be monitored
following hospital protocol for such a procedure. Images are acquired to locate the lesion and
assess the approach and puncture site. The area is prepped using sterile technique and local
anesthetic is injected at the intended puncture site. Under CT fluoroscopic guidance, the biopsy
needle is advanced into the target lesion. The smallest gauge biopsy needle through which the
gold seeds will fit should be used.
NOTE: The 19-gauge thin-wall needle is recommended for the

Alpha Omega gold seeds. In our practice, an increased
incidence of a pneumothorax using the larger gauge needle has
been noted.

Figure 6 Proper fiducial placement

with 3 gold seeds
When deciding what trajectory to use in order to place the needle within the lesion, the ideal route
allows for placement of multiple fiducials within the lesion without having to puncture the visceral
pleural multiple times. There is a significantly lower incidence of pneumothorax should the visceral
pleura be transversed once rather than multiple times. When placing the needle within the lesion
attempt to advance the needle to the back wall of the lesion and place the first fiducial in this
location. Withdraw the needle from the initial fiducial placed, verify with imaging, then implant the
second fiducial. Angle the needle medial or lateral for placement of the other fiducials repeating
the process described above on the opposing side of the lesion. Whenever possible, every attempt
should be used to place the fiducials within the lesion as long as the fiducial placement guidelines
are met (see Figure 6 on page 6-23). CT scanning can be used to verify proper fiducial placement.
Image patient at the end of the procedure to assess for complications. Obtain a chest X-ray 3 hours
after the procedure to ensure no late onset of pneumothorax.
NOTE: Most lung lesions measure 3 – 5 cm in diameter making

it possible to place 4 – 6 fiducials within the lesion with a single
visceral puncture. In an extremely large lesion, it may be
necessary to place multiple needles within the lesion to achieve
adequate positioning of the fiducials.

Potential Complications
Pneumothorax — Occurs in approximately 30% of all biopsy cases; less than 10% require
treatment. A small pneumothorax can be observed and if stable in size requires no further
treatment. A pneumothorax greater than 20 – 30% requires either aspiration or placement of a
chest tube. Aspiration of air from a pneumothorax can be done through a sheathed needle while
the patient is still on the CT table. Placement of a chest tube usually requires the patient to be
supine and is often performed after the post-procedure chest X-ray. In our experience at Stanford,
placement of a chest tube has been required in a minimum of cases, less than 5%. Should a chest
tube be required, this usually requires an overnight admission to a step down unit with continuous
wall suction. A chest X-ray is performed the next day. If the pneumothorax be resolved and stable,
the patient is discharged.
Hemoptysis — Occurs in approximately 10 – 50% of cases whenever a needle is introduced into
the lung. It is less common in patients who do not have a biopsy, therefore it is rarely observed with
fiducial placement procedures. Prior to the procedure evaluate if the patient is taking anti-
coagulants. Should hemoptysis occur, the major concern is the patient’s alarm at seeing that they
are coughing up blood. Typically this complication ceases spontaneously due to the low blood
pressure within the pulmonary arteries. It is usually not life threatening. It is important to adequately
inform the patient during consent and remain calm while rendering the appropriate supportive care.
Points To Consider
The major downside with performing fiducial placement in the lung is the difficulty of obtaining a
good trajectory to place the needle within the lesion while taking into consideration the surrounding
anatomy, that is, the ribcage. Anyone who has performed multiple lung biopsies should be able to
adequately guide the placement of a needle into the lesion without great difficulty. CT and CT
fluoroscopic guidance is recommended for the placement of fiducials as it allows for better
visualization of the entire lung and lesion and enables the operator to rapidly identify complications
during the procedure.
If a pneumothorax should develop during the procedure attempt to complete the fiducial placement
procedure if at all possible. It may be necessary to place a chest tube during the procedure to re-
inflate the lung. If the patient is stable and can tolerate it, the procedure should be resumed and
completed. Should a pneumothorax develop during the placement of the first needle consider
leaving it in place and introduce a second needle into the lesion to complete the procedure.
Another point to consider is the often used statement that "the enemy of good is perfect”. During
the procedure the goal is to get multiple fiducials placed into the lesion in the best locations. It is
not absolutely necessary to get 5 fiducials in the most perfect place within the lesion to treat the
patient. Placement of 3 fiducials within or adjacent to a tumor will be sufficient to track and treat the
patient. Therefore, should the procedure become more complicated than expected, or should the
patient become unable to tolerate a long procedure rapidly placing 3 fiducials, adhering to the
fiducial placement principles, in and around the tumor should be adequate in most cases.
There is always the possibility of placing a fiducial within a significant sized pulmonary vein which
could become a serious complication as it may travel and become lodged in the heart, lungs, or
brain. This has not occurred but is possible, therefore it is mentioned in this section. It is important
to include this as a potential complication when obtaining patient consent. Documentation of the
discussion between the physician, patient, and preferably a relative is recommended.

Conclusion
The key to success is to adequately inform the patient, perform the procedure with caution using
the standard approach for needle biopsies, be prepared for potential complications, and be
familiarized with the fiducial placement principles.
Pancreas/Liver
Pancreas and liver information provided by Stephen T. Kee M.D., Associate Professor of
Interventional Radiology, Stanford University Medical Center.
Outline of Procedure
The risks of the procedure are essentially identical to those of an image guided biopsy; however,
depending upon the number of needle repositions required in order to adequately place the
fiducials these risks may be somewhat higher. Most of the risks associated with placement of
needles in soft tissues is hemorrhage; these risks are kept to a minimum if a single needle puncture
can be used in order to place multiple fiducials and if adequate imaging is obtained prior to the
procedure in order to identify potential hazards. A detailed informed consent outlining the potential
complications to the patient should be the first step.
The diagnostic imaging technique of choice is CT or CT-fluoroscopy; however, other operators
have performed this procedure using ultrasound guidance and this is quite feasible particularly for
large lesions. If the patient is considered a candidate for treatment with the CyberKnife System
while in the operating room, placement of the fiducial markers using direct visualization could be
an option.
The patient is placed on the CT table depending on the best approach to be used to access the
lesion. The procedure is performed using conscious sedation and the patient should be monitored
following hospital protocol for such a procedure. Images are acquired to locate the lesion and
assess the approach and puncture site. The area is prepped using sterile technique and local
anesthetic is injected at the intended puncture site. Under CT guidance, the biopsy needle is
advanced into the target lesion. The smallest gauge biopsy needle through which the gold seeds
will fit should be used.
NOTE: The 19-gauge thin-wall needle is recommended for the

Alpha Omega gold seeds. When deciding what trajectory to use
in order to place the needle within the lesion, the ideal route
allows for placement of multiple fiducials within the lesion without
having to reposition the needle multiple times. There is a
significantly lower incidence of hemorrhage should the organ
involved be transversed once rather than multiple times. When
placing the needle within the lesion attempt to advance the
needle to the back wall of the lesion and place the first fiducial in
this location. Withdraw the needle from the initial fiducial placed,
verify with imaging then implant the second fiducial.

Figure 7 Proper fiducial placement

with 4 gold seeds
Angle the needle medial or lateral for placement of the other fiducials repeating the process
described above on the opposing side (or wall) of the lesion. Whenever possible, every attempt
should be used to place 4 – 6 fiducials within the lesion as long as the fiducial placement guidelines
are met (see Figure 7 on page 6-26). This can prove to be challenging with lesions less than 3 cm
in diameter. With smaller lesions, it is acceptable to place fiducials in the organ tissue surrounding
the lesion. CT scanning should be used frequently to verify proper fiducial placement.
Potential Complications
Hemorrhage is the most likely complication when puncturing the liver, pancreas, and other soft
tissue regions in the body. Use of a small gauge needle and knowledge of critical structures
surrounding the lesion should minimize this complication. Should the concern of hemorrhage be
present for whatever reason following placement of the last fiducial, a small amount of gel-foam
slurry can be injected into the needle as it is being removed to immobilize the track. The gel-foam
slurry is created by cutting up small amounts of gel-foam, mixing with either saline or lidocaine.
Transgression of a section of bowel when advancing the needle towards a lesion particularly for
pancreatic lesions is a possibility. There are usually no necessary precautions to be taken if the
stomach or small bowel is to be transgressed, however, if the large bowel is transgressed then it
is recommended to place the patient on broad spectrum antibiotics for one week. Every attempt
should be made to avoid puncturing these structures especially the large bowel.

Another potential complication is immobilization of fiducials to a distal site. In theory, placement of

a fiducial in a significant artery could result in distal immobilization. This has not occurred in our
practice but warrants mention in this paper. If there is significant arterial flow through the needle
upon removal of the stylet, placement of a fiducial at this location is not recommended. Instead,
remove the needle, assess the patient’s condition, and if stable proceed by selecting another
location to place the fiducial.
Points To Consider
Typically, during placement of fiducials in pancreatic lesions the imaging does not include
administration of intravenous contrast. Therefore, the contrast study from the patient’s previous
imaging should be studied to ensure that no significant vessels will be transgressed with the
placement of the needle and fiducials. If there are any doubts, a contrast CT study should be
performed during placement. There are some situations in which structures must be transgressed
to access the lesion for fiducial placement. In our practice, the preference is to cross "nothing" first,
stomach second, liver third, small bowel fourth and large bowel as an extreme last resort. As stated
above, if the large bowel is punctured the patient should be administered antibiotics.
Conclusion
The fiducial placement procedure is very similar and only slightly more elaborate than a standard
image guided biopsy. Anyone who has experience with CT guided biopsies should be well aware
of the methods employed and potential complications of the placement of needles in soft tissue
organs such as the pancreas and liver. Perform the procedure utilizing the same methods used for
an image guided biopsy, the main difference being that once the needle is placed in the lesion,
fiducials are implanted rather than taking tissue out. The complications and challenges are almost
identical. The key to success is to adequately inform the patient, perform the procedure with
caution using the standard approach for needle biopsies, be prepared for potential complications
and be familiarized with the fiducial placement principles.
Cleaning and Sterilization

Sterility
Implantable screw radiographic markers are supplied non-sterile and must be sterilized prior to
use. Refer to the manufacturer's instructions on sterilization.


Chapter 7: Treatment Room
Operations
Introduction
This chapter describes treatment room operations when using the CyberKnife Treatment Delivery
System. The following topics are covered:
• “Preparing the Treatment Room” on page 7-2
• “Manually Changing Fixed Collimators” on page 7-3
• “Xchange Robotic Collimator Changer” on page 7-8
• “Patient Immobilization Devices” on page 7-23
• “Standard Treatment Couch” on page 7-23
• “RoboCouch Patient Positioning System (Option)” on page 7-31

Preparing the Treatment Room

The patient does not need to be present while the treatment room is prepared. Standard hospital
housekeeping practices should be used in the treatment room.
Power On the CyberKnife System

Powering on the CyberKnife System takes between 15 and 30 minutes. It is recommended that the
system be completely powered on before the patient is brought into the treatment room.
For instructions on powering on the CyberKnife System with the treatment couch and imaging
system, see “Chapter 4: System Startup and Shutdown”.
Turn on Patient Monitoring System

Turn on the closed circuit TV monitoring system and intercom. Ensure that they function properly.
The patient should be monitored directly by personnel or by unobscured closed circuit TV view at
all times while in the treatment room.
Load Patient Data

The treatment plan for the patient specifies the type of collimator that must be installed on the X-
ray head of the treatment robot prior to treatment delivery: a single fixed collimator, multiple fixed
collimators, or the Iris Variable Aperture Collimator. The treatment plan also specifies the collimator
aperture.
Select the treatment plan on the treatment delivery computer and load patient data, as described
in “Chapter 8: Treatment Delivery”.
Move Treatment Robot to the Perch Position

Move the treatment robot to its starting position, called the perch position.To move the treatment
robot to the perch position manually, use the program called prch in the CK Main folder on the
treatment robot Teach Pendant.
WARNING: Do not remove the treatment robot Teach Pendant from the Treatment Room
during treatment delivery. The Teach Pendant should only be used in the Treatment Room
in order to safely monitor operation of the treatment robot.
For more information on manual operation of the treatment robot using the Teach Pendant, see
“Chapter 4: System Startup and Shutdown”.
7-2 | Preparing the Treatment Room 1075883-ENG A

Treatment Delivery Manual Chapter 7: Treatment Room Operations
Manually Changing Fixed Collimators

Treatment room operations include installing the correct collimator on the treatment robot. The
correct collimator depends on the treatment plan for the patient.
For treatment plans using multiple fixed collimators, the collimator must be changed between
treatment paths. This section describes how to manually remove the currently installed fixed
collimator and install the correct fixed collimator.
NOTE: If your system includes the optional Xchange Robotic

Collimator Changer, see “Xchange Robotic Collimator Changer”
on page 7-8 for information on automatic collimator exchange.
The CyberKnife System detects the size of the fixed collimator that is currently installed on the X-
ray head of the treatment robot. Depending on the treatment plan you select, you may need to
change the collimator before treatment begins. Additionally, if the treatment plan uses multiple
fixed collimators, you need to change the collimator between treatment paths.
The CyberKnife System includes 12 interchangeable fixed collimators with apertures (in
millimeters) of 5, 7.5, 10, 12.5, 15, 20, 25, 30, 35, 40, 50, and 60 (Figure 1) The aperture is stamped
on one or both faces, depending on the collimator. Each collimator is a different length and weighs
more than 12 lb (5 kg).
Figure 1 Interchangeable Fixed Collimators
WARNING: Do not change the collimator when the X-ray head is over the patient. Always
move the treatment robot to the perch position before changing collimators. Otherwise,
the collimator may cause serious injury to the patient if it is dropped.
1075883-ENG A Manually Changing Fixed Collimators | 7-3

WARNING: When removing or installing a fixed collimator, use two hands and support the
collimator securely with your palm underneath the front face. Be careful not to drop the
collimator on your foot or any other part of your body, or on the X-ray detectors of the
imaging system. Otherwise serious injury to yourself or equipment damage can occur.
A fixed collimator is held in place by a spring-loaded retaining latch pin inside the fixed collimator
housing of the X-ray head. The retaining pin latches underneath the collimator lip. The collimator
is then secured on the housing by a retaining nut (see Figure 2).
WARNING: Never leave a fixed collimator hanging only by the retaining pin when the X-
ray head is over the patient or yourself. Support the collimator with your hand until the
collimator is secured on the fixed collimator housing by the retaining nut. Otherwise, the
collimator may cause serious injury to the patient if it is dropped.
Contact
Detection
Collimator System
Lip
Fixed Collimator
Housing*
Fixed
Collimator
Retaining Nut
*Retaining Pin not shown
Figure 2 Fixed collimator and collimator housing
7-4 | Manually Changing Fixed Collimators 1075883-ENG A

Manually Removing a Fixed Collimator

If the incorrect fixed collimator is installed for the treatment plan you selected, you need to remove
the collimator from the fixed collimator housing on the X-ray head and then install the correct one.
This is a two-step process: first remove the retaining nut and then remove the fixed collimator.
 To remove a fixed collimator, follow these steps:
1. Make sure the treatment robot is in the perch position.
2. Slide the Contact Detection Sensor up inside the fixed collimator housing of the X-ray
head until the sensor locks in place and the retaining nut is exposed (Figure 3).
Contact Detection Sensor

Extended

Pushed Up Inside
the Fixed Collimator
Housing
Retaining Nut
Exposed
Figure 3 Contact Detection Sensor
3. Remove the retaining nut from the fixed collimator housing. There are two styles of
retaining nut:
• Style A: Unscrew the retaining nut to remove it from the housing.
• Style B: Rotate the retaining nut counterclockwise less than one turn to release it
from the housing.

4. Place the palm of your hand firmly underneath the fixed collimator to support it. Then
release the spring-loaded retaining pin and slowly slide the collimator out of the housing.
There are two styles of retaining pin:
• Style A: Pull the collimator retaining pin to release it (Figure 4).
Collimator
Retaining Pin
Figure 4 Style A: Collimator Retaining Pin
• Style B: Press the collimator release lever to release the retaining pin (Figure 5).
r
Collimator
Release Lever
Figure 5 Style B: Collimator Release Lever
NOTE: If you feel significant friction between the fixed collimator

and the housing, contact Customer Support.
7-6 | Manually Changing Fixed Collimators 1075883-ENG A

Manually Installing a Fixed Collimator

If the incorrect fixed collimator is installed, remove it as described in “Manually Removing a Fixed
Collimator” on page 7-5.
WARNING: Use only fixed collimators that have been commissioned with the CyberKnife
System. Otherwise, the dose delivered to the patient will be different than expected, which
could result in under- or overdosing the patient.
 To install a fixed collimator, follow these steps:

1. Make sure the treatment robot is in the perch position.
2. Slide the Contact Detection Sensor up inside the fixed collimator housing of the X-ray
head until the sensor locks in place.
3. Pick up the correctly sized fixed collimator (front face down) and support it securely with
two hands.
4. Slide the collimator up into the housing, until the spring-loaded retaining pin inside latches
and holds the collimator in place.
5. Secure the collimator retaining nut on the housing. There are two styles of retaining nut:
• Style A: Screw the retaining nut securely onto the housing.
• Style B: Rotate the retaining nut clockwise less than one turn until it seats securely
on the housing. Ensure that the retaining nut is oriented so that the protruding ridge
on its top face is positioned behind the retaining pin on the housing.
The collimator should move approximately 3 mm further into the housing when the
retaining nut is secured.
NOTE: The fixed collimator must be completely secured inside

the housing by both the spring-loaded retaining pin and the
retaining nut. Otherwise, the CyberKnife System generates an E-
Stop.
6. Pull the Contact Detection Sensor down from inside the fixed collimator housing until it
clicks into place (Figure 3). Test the Contact Detection Sensor by squeezing it firmly.
Verify that a clicking sound can be heard.
NOTE: Depending on your CyberKnife System version, the

Contact Detection Sensor for fixed collimators generates an E-
Stop (Error 623) when it is not pulled down completely so that it
covers the collimator retaining nut. For more information on Error
623, see “Error 623: Contact Detection Sensor” on page 8-89".

Xchange Robotic Collimator Changer

This section describes how to use the Xchange Robotic Collimator Changer with the CyberKnife
System. It covers the following topics:
• “Xchange Collimator Table (Model B)” on page 7-10
• “Xchange System Safety Considerations” on page 7-15
• “Xchange System Operation” on page 7-16
• “Treatment Delivery Using the Xchange System” on page 7-18
• “Error Handling With the Xchange System” on page 7-21
• “Switching to Manual Operation” on page 7-22
The Xchange System allows you to automatically exchange collimator housings and fixed
collimators before and during treatment, without entering the Treatment Room (see Figure 6). The
Xchange System supports the standard interchangeable fixed collimators and the Iris Collimator.
When a treatment plan uses a single fixed collimator, the Xchange System automatically changes
the collimator as needed before treatment delivery. With treatment plans that use multiple fixed
collimators, the Xchange System shortens treatment time by automatically changing collimators
between treatment paths. The Xchange System is required to attach and detach the fixed
collimator and the Iris Collimator housings.
Figure 6 Xchange Robotic Collimator Changer

(Model B)
7-8 | Xchange Robotic Collimator Changer 1075883-ENG A

The Xchange System includes the following components:

• Xchange collimator table.
• Xchange calibration isoposts for calibrating the Xchange System.
• 12 interchangeable fixed collimators with aperture (in millimeters) of 5, 7.5, 10, 12.5, 15,
20, 25, 30, 35, 40, 50, 60, as well as a blank fixed collimator.
• Secondary housing for fixed collimators that attaches to the X-ray head.
• Retaining nut to secure a fixed collimator on the secondary housing.
• Optional Iris Variable Aperture Collimator, with aperture adjustable under computer-
control. It provides the same 12 apertures as the fixed collimators.
1075883-ENG A Xchange Robotic Collimator Changer | 7-9

Xchange Collimator Table (Model B)

The Xchange collimator table is available in 2 models, depending on whether your CyberKnife
System includes interchangeable fixed collimators only, or both fixed collimators and the Iris
Collimator. Operation of the Xchange System is the same regardless of the collimator table model.
Model B of the Xchange collimator table includes the following features:
• Collimator cups: For sorting and positioning fixed collimators for pick up and drop off by
the treatment robot.
• Retaining nut remover: For removing or installing the fixed collimator retaining nut on
the secondary housing.
• Quick-check sensor: For checking alignment of the Xchange collimator table before
collimator exchange.
NOTE: Only Accuray Field Service can calibrate the Xchange

System.
The Xchange collimator table Model B supports both fixed collimators and the Iris Collimator (see
Figure 7). With Model B, the Xchange, up to 3 calibration isoposts and pinhole adapters can be
stored in the drawer of the Xchange table. Alternately, isoposts and the pinhole and blank
collimators can be stored in the AQA transport case.

Guide Pins
Receptacle for Iris
Collimator*
Fixed Collimator on
Collimator Cup
Secondary Housing
in Receptacle
Quick-check Retaining Nut

Sensor Remover
*Iris Collimator and Guide Pins
not shown
Figure 7 Xchange collimator table (Model B)
If your Xchange System includes Model B and the Iris Collimator, the secondary housing for fixed
collimators can be removed from the X-ray head and replaced with the Iris Collimator. These
operations are performed automatically by the Xchange System. The secondary housing and the
Iris Collimator are attached to and released from the X-ray head by a pneumatic control system.
Model B includes two receptacles where the secondary housing and the Iris Collimator are
deposited when dropped off by the treatment robot.
If your Xchange System includes Model B and fixed collimators only (no Iris Collimator), the
secondary housing is permanently attached to the X-ray head, and the receptacles are covered.
Receptacle for Fixed Collimator Secondary Housing

The receptacle for the fixed collimator secondary housing includes the following features to ensure
proper pickup and dropoff (see Figure 8):
• Optical presence sensors: Detect the presence of objects in the receptacle before
dropoff.
• Fixed Collimator presence sensors: Detect the presence of the secondary housing
(with fixed collimator and retaining nut attached) on the base.

Optical
Presence
Sensors
Secondary Housing
Presence Sensors
Figure 8 Receptacle for fixed collimator secondary

housing (Model B)
Receptacle for Iris Collimator

The receptacle for the Iris Collimator is larger than the receptacle for the fixed collimator secondary
housing. It includes the following features to ensure proper pickup and dropoff (see Figure 9):
• Optical presence sensors: Detect the presence of objects in the receptacle before
dropoff.
• Iris Collimator presence sensors: Detect the presence of the Iris Collimator on the
table base.

Optical Presence
Sensors
Iris Collimator
Presence Sensors
Figure 9 Receptacle for Iris Collimator (Model B)
Collimator Cups
With the Xchange table Model B, the collimator size for each collimator cup is labeled as shown in
Figure 10. Each collimator cup contains 4 presence sensors that detect when a fixed collimator is
present and whether it is upside-down. The collimator cups are spring-loaded and may move
noticeably when pressure is applied.
With Model B, the treatment robot rotates the fixed collimator after it is lowered into the cup. The
dropoff ramp pushes the collimator release lever to release the retaining pin (see Figure 10). Then
the collimator is released into the cup.

Collimator
Presence
Sensors
Dropoff Ramp
Collimator Cup
Size (mm)
Figure 10 Collimator cup for fixed collimators

(Model B)

Xchange System Safety Considerations
WARNING: Do not attempt to lift the secondary housing for fixed collimators or the Iris
Collimator. These components are quite heavy and can cause injury or damage if
dropped. Always use the Xchange System to install these components. It is not possible
to install them manually. Store these components on the Xchange collimator table.
WARNING: Personal injury may occur if you stick your fingers or other body part into the
path of a moving IRIS aperture. Do not stick your fingers or other part body part into a
moving IRIS aperture.
Each Iris Collimator has a unique Serial Number as well as system calibration files and beam data
that are associated with a specific CyberKnife System. After your CyberKnife System is
commissioned with a particular Iris Collimator, you cannot switch to a different Iris Collimator.
CAUTION: Use only the Iris Collimator that has been commissioned with your CyberKnife
System. Your CyberKnife System will not recognize the Serial Number of a different collimator.
An Accuray Service call is required to change the Serial Number that your CyberKnife System
recognizes, and then your CyberKnife System must be recommissioned.
CAUTION: Observe the following safety precautions when operating the Xchange System.
• Do not lean, sit, or stand on the Xchange collimator table. Otherwise, the
Xchange table may require recalibration by Accuray Field Service.
• Do not operate the Xchange System with the Xchange calibration isoposts
mounted on the Xchange table. Place them in the storage drawer before
operating the Xchange System.
• With the Xchange collimator table Model B, do not place objects other than the
fixed collimators, secondary housing, and the Iris Collimator on the Xchange
table. Otherwise, the Xchange table may require recalibration by Accuray Field
Service.
• The Xchange collimator table does not include any user-serviceable
components. If problems occur, contact Customer Support.
• Do not position yourself between the Treatment Robot and the Xchange
collimator table when the Treatment Robot is in the process of exchanging
collimators.

Xchange System Operation

When you start treatment, the CyberKnife System detects the collimator type and aperture of the
currently installed collimator and displays the information on the Equipment Readiness screen of
the treatment delivery computer. If the collimator type and aperture do not match those specified
in the treatment plan, you are prompted to begin the automatic collimator exchange process. With
treatment plans that use multiple fixed collimators, the prompt is repeated between treatment
paths.
At each position during collimator exchange (approach, drop off, and pick up), sensors in the
Xchange collimator table and in the housing on the X-ray head check the proper positioning and
alignment of Xchange System components. During collimator exchange, the treatment robot
moves as described in the section that follows.
Collimator
Collimator
Cup
Housing for Fixed
Collimators
Retaining Nut
Remover
Figure 11 Pickup and Dropoff of Fixed Collimator

Changing Fixed Collimators

This section is valid for the Xchange System (Model B).
When fixed collimators are automatically exchanged, the treatment robot moves as follows:
1. Moves from the perch position to the Xchange collimator table.
2. Points the LINAC towards the quick-check sensor to check alignment of the Xchange
table.
3. Lowers the collimator retaining nut onto the retaining nut remover, rotates a partial turn to
detach the retaining nut from the housing on the X-ray head, and lifts up.
4. Drops off the currently installed fixed collimator in the appropriate collimator cup, then lifts
up.
5. Picks up the correct fixed collimator, then lifts up.
6. Lowers over the collimator retaining nut, rotates a partial turn to secure the retaining nut
on the housing of the X-ray head, and lifts up.
7. Moves back to the perch position.
Automatic Collimator Housing Change

The treatment robot goes through the following steps when automatically exchanging a fixed
collimator or the Iris Collimator housing:
1. Moves from the perch position to the Xchange collimator table.
2. Points the LINAC towards the quick-check sensor to check Xchange table alignment.
3. Lowers the currently installed collimator housing into its receptacle. The pneumatic
control system releases the housing automatically. Then the treatment robot lifts up.
NOTE: A fixed collimator and the retaining nut must be installed

on the housing prior to dropoff. Otherwise the housing cannot be
deposited in its receptacle on the Xchange table.
4. Picks up the required collimator housing. The pneumatic control system latches
automatically to hold the collimator housing. Then the treatment robot lifts up.
5. Moves back to the perch position.
6. If a fixed collimator has been installed but is not the correct collimator for treatment, the
treatment robot automatically changes it.
The Iris aperture leaves are adjusted automatically as the Treatment Robot moves before
and during treatment, as required.

Treatment Delivery Using the Xchange System

NOTE: Before you begin a collimator exchange, you should
follow the procedures for loading patient data, verifying patient
and treatment data, and patient alignment described in “Chapter
To automatically exchange collimators before and during treatment, follow the steps below.
 To use the Xchange System:
1. Power up the CyberKnife System with the Xchange System. The power-up procedure is
the same as the standard procedure. For more information, see “Chapter 4: System
Startup and Shutdown”.
2. Log into Demonstration, Plan QA, Phantom, or Treatment mode as the
primary user (see “Chapter 4: System Startup and Shutdown”).
3. Select the treatment plan on the treatment delivery computer and load patient data, as
described in “Chapter 8: Treatment Delivery”.
4. Make sure the treatment robot is located at the perch position.
Move the treatment robot to the perch position manually if necessary (see “Move
Treatment Robot to the Perch Position” on page 7-2).
5. Make sure the fixed collimators are placed correctly on the Xchange collimator table and
the storage drawer is closed.
• Collimators must be placed according to size in the correct collimator cups. The size
of each collimator is stamped on one or both faces, depending on the collimator.
• Fixed collimators should be placed face down in the collimator cups.
6. If your Xchange System includes the Iris Collimator, make sure the system is in one of the
following configurations:
• The Iris Collimator and the fixed collimator secondary housing are both present in
their receptacles on the Xchange table.
• The Iris Collimator is present in its receptacle, and the fixed collimator secondary
housing (with fixed collimator and retaining nut attached) is installed on the X-ray
head.
NOTE: If the fixed collimator secondary housing is installed on

the X-ray head, a fixed collimator and the retaining nut must also
be installed. Otherwise, you cannot begin the automatic
exchange process.
• The Iris Collimator is installed on the X-ray head, and the fixed collimator secondary
housing (with fixed collimator and retaining nut attached) is present in its receptacle.
7. Make sure the Xchange collimator table is free of all other objects.
8. Align the patient, as described in “Chapter 8: Treatment Delivery”.

9. Go to the Readiness phase to begin the equipment readiness check. For more
information on the equipment readiness check and confirming delivery warning message,
see “Checking Equipment Readiness” on page 8-75.
The Equipment Readiness screen is displayed (see Figure 12). For more information on
this screen, see “Chapter 5: Treatment Delivery System Overview”.
Figure 12 Equipment Readiness screen
10. The Collimator section of the Equipment Readiness screen displays the type of
collimator currently installed (fixed collimator with a particular aperture, or Iris Collimator).
If the current collimator matches the collimator specified in the treatment plan, a Laser
Alignment Check is required. The Laser Alignment Check button icon is enabled
and text in the Collimator section prompts you to perform a Laser Alignment Check.
Click the Laser Alignment Check button to perform the check (Figure 13).

If the current collimator type does not match the collimator type specified in the treatment plan, text
in the Collimator section prompts you to exchange collimator housings and the appropriate
exchange button is enabled. In this case, the Laser Alignment Check is performed during the
collimator exchange, and a Laser Alignment Check is not required after the correct collimator is
installed. Text reports the status of the collimator exchange.
A B C
Figure 13 A. Laser Alignment button B. Fixed Collimator

button C. Iris button
If a collimator type change is required, press the enabled collimator button (see
Figure 13). The Xchange System performs the exchange described in “Automatic
Collimator Housing Change” on page 7-17.
NOTE: Before starting robot motion for the exchange, the

system powers off and stops communicating with the collimator
housing (Iris). The Readiness screen displays the text "Not
Connected" until the exchange is complete and the system once
again is communicating with the housing.
If the Iris Collimator is installed during the exchange, it is automatically initialized. The
typical wait time is five minutes. The actual wait time is shown on the Equipment
Readiness screen.
11. When the correct collimator is installed, a Laser Alignment Check is performed if
required, and the treatment robot is ready, the Start button in the Equipment Readiness
screen is enabled and turns green. Click the Start button to start treatment delivery.
After treatment delivery is completed, the treatment robot returns to the perch position.
12. If the treatment plan includes multiple treatment paths that specify different fixed
collimator apertures, after completion of each treatment path, the robot will return to
perch and automatically pick up the next collimator and then automatically start the next
path. No user interaction is required.

Error Handling With the Xchange System

The following errors may occur when using the Xchange System. For more information on
Xchange System errors, see Appendix B, “Error Messages”.
• If the treatment robot is not located at the perch position before changing collimators, an
error occurs. You must manually move the treatment robot to the perch position using the
Teach Pendant.
• If the fixed collimator housing is currently installed without a fixed collimator and retaining
nut, an error occurs. You must manually install a fixed collimator on the housing and
secure it with the retaining nut before the Xchange System can be used.
• If the retaining nut becomes loose during treatment delivery, an error occurs. You must
enter the treatment room and secure the retaining nut on the housing.
• If the fixed collimators are not sorted or positioned correctly on the Xchange collimator
table, an error occurs. For example, if a collimator is placed in the wrong collimator cup, a
collimator is placed upside-down, or the correct collimator is not present on the Xchange
table, an error occurs.
• If the Xchange table drawer is open, an error occurs. You must close the drawer.
• If the Xchange table loses power or is disconnected from the network, the text
Communication Error is displayed in the Equipment Readiness screen and an
E-Stop occurs.
In the cases above, resolve the problem manually if necessary. Then reset the error. If a problem
persists, call Customer Support.
If the treatment robot stops when it is in contact with or close to the Xchange collimator table, the
MoveUp program on the Teach Pendant should be used to move the treatment robot safely away
from the Xchange table. For information on using the MoveUp program, see “Chapter 4: System
Startup and Shutdown”.

Switching to Manual Operation

With the Xchange table Model B, manual operation with fixed collimators is available if the fixed
collimator secondary housing is currently installed. If an unrecoverable error occurs when the fixed
secondary housing is not installed, manual operation using the fixed collimators is not possible. In
this case, call Accuray Customer Support.

Patient Immobilization Devices

Proper initial patient alignment should replicate as closely as possible the patient position during
the primary CT scan. Use the same head and body immobilization system for treatment that the
patient wore during the CT scan. In some instances, the patient immobilization system needs to be
attached to the table before the patient can be properly placed in the restraint.
Verify that the treatment couch is free of unnecessary objects.
Adjust the orientation of the treatment couch so that the alignment is the same as that recorded
during the primary CT scan.
For more information on patient preparation and patient immobilization, see “Chapter 6: Patient
Preparation”.
Standard Treatment Couch

This section covers the following topics for the standard treatment couch:
• “Manual Operation of the Treatment Couch” on page 7-23
• “Optional Foot Extension for Feet-First Positions” on page 7-28
• “Loading the Patient onto the Standard Treatment Couch” on page 7-30
Manual Operation of the Treatment Couch

You can use the treatment couch Hand Controller to move the standard treatment couch under
manual control in five degrees of freedom (three translations and pitch and roll rotations). To align
the patient, follow the steps described in “Chapter 8: Treatment Delivery”.
Treatment Couch Hand Controller

The standard treatment couch Hand Controller (Figure 14) and Readout Display Unit (Figure 15)
can be used to move the treatment couch under manual control. Table 1 on page 7-25 describes
the buttons on the Hand Controller.

Enable Buttons
(one on each side)
Figure 14 Standard treatment couch Hand

Controller
WARNING: The standard treatment couch does not detect collisions with surrounding
objects. Release the Enable buttons to stop motion when you see a potential collision.
WARNING: Ensure all body parts are kept away from any moving components of the
treatment couch. Do not position yourself, the patient, or other people between moving
components of the treatment couch and any stationary object or wall in the Treatment
Room. Otherwise injury or death can result.
WARNING: An operator or patient may be pinched when occupying a location between

moving components or between moving components and a fixed object in the room. An
operator should assess the risk before changing the position of components and be
vigilant when components are moving.
WARNING: The Hand Controller cable is a possible trip hazard.
7-24 | Standard Treatment Couch 1075883-ENG A

WARNING: Do not remove the Hand Controller from the Treatment Room. The Hand
Controller should only be used in the Treatment Room, in order to safely monitor
movement of the treatment couch.
NOTE: Movement directions on the treatment couch Hand

Controller are labeled based on the Head First Supine (HFS)
patient position.
Table 1 Buttons on the standard treatment couch Hand Controller
Button Description
LEFT/RIGHT Moves the treatment couch in the patient left or right direction (along the Left-
Right axis)
ANT/POST Moves the treatment couch in the patient anterior or posterior direction (along
the Anterior-Posterior axis).
INF/SUP Moves the treatment couch in the patient inferior or superior direction (along
the Inferior-Superior axis).
ROLL L/R Rotates the treatment couch about the Inferior-Superior axis towards the left or
right of the patient (roll).
HEAD U/D Rotates the treatment couch to bring the patient head up or head down (pitch).
HOME Moves the treatment couch to the home position. This position is programmed
as a convenient position of the treatment couch for the patient get on or off the
table.
TREAT Moves the treatment couch to the nominal treatment position. The nominal
treatment position for the first treatment session for a plan is obtained from a
stored position for the type of anatomy being treated (head or body). For
subsequent sessions, the treatment position used in the previous treatment
session is used.
Enable Both Enable buttons must be pressed before any treatment couch movement
can occur.
The E-STOP LED has three possible states:

• Off: Indicates that there are no E-Stop’s engaged in the system. The treatment couch can
be moved manually or under computer control (from the treatment delivery computer) in
this state.
• Green: Indicates that there is a CyberKnife System E-Stop. In this state, the couch can
be moved in manual control only. All computer-controlled motions from treatment delivery
computer are disabled.
1075883-ENG A Standard Treatment Couch | 7-25

• Yellow: Indicates that the treatment couch E-Stop is engaged. In this state, both manual
and computer-controlled motions are disabled.
The MOVE LED is green whenever any button that performs a move is depressed.
Readout Display Unit

The treatment couch Readout Display Unit (Figure 15) displays the position of the treatment couch
at all times. Translations are displayed in millimeters, and rotations are displayed in degrees.
Treatment couch positions can be displayed in two coordinate systems:
• Absolute: Absolute coordinates are with respect to a native coordinate system of the
treatment couch. The treatment couch is at zero in all five axes (the X, Y, and Z
translation axes and the roll and pitch rotation axes) when it is centered, level, and at the
lowest, most inferior position.
When the display is in Absolute mode, the position indicators (X, Y, Z, R for roll, and P for
pitch) are delimited from the position number by a colon. For example:
X: 27 R: 0.2
Y: -2.7 P: -0.1
Z: 248
• Relative: Relative coordinates are with respect to a previous reference in absolute co-
ordinate systems. The reference can be reset to the current treatment couch position by
pressing the ZERO button.
When the display is in Relative mode, the position indicators (X, Y, Z, R for roll, and P for
pitch) are delimited from the position number by the symbol “>”. For example:
X> 27 R> 0.2
Y> -2.7 P> -0.1
Z> 248
Pressing the REL/ABS button toggles the display between Relative and Absolute modes.
Pressing the ZERO button changes the display to Relative mode, if it is not already in that mode,
and resets the current treatment couch position as the reference for calculating the relative
coordinates.

Figure 15 Treatment Couch Readout Display Unit .
NOTE: The relative positions on the Readout Display Unit do not

correspond to the alignment center. Numbers on the Readout
Display Unit are different from the Couch Correction text
fields on the Alignment and Tracking window, which do
correspond to the alignment center.
In some circumstances, if you press and hold a movement button on the Hand Controller for more
than 5 seconds without pressing the Enable buttons, the treatment couch enters a calibration mode
for that axis. When this occurs, the message, "Press ZERO to Calibrate <axis name>
axis" is displayed on the Readout Display Unit. Calibration mode should only be used for
recalibrating the zero position of each axis. If this occurs, wait for a brief period to return to the
normal mode of operation, then contact Accuray Customer Support.
WARNING: DO NOT press the ZERO button when the Readout Display Unit displays the
message "Press ZERO to Calibrate <axis name> axis" and the treatment couch is not in
the correct location for recalibrating the zero position for that axis. Doing so will
compromise the calibration of the treatment couch and will affect the system’s ability to
detect potential collisions between the treatment robot and the treatment couch or patient.

Optional Foot Extension for Feet-First Positions

For Head First patient positions, the superior end of the table top of the standard treatment couch
narrows to support the patient’s head. For Feet First patient positions, additional support may be
needed to support the patient’s feet.
An optional foot extension is available for the standard treatment couch to assist in Feet First
treatments (see Figure 16). The removable foot extension provides additional support for the feet
at the superior end of the table top. The foot extension is manufactured by CIVCO (CIVCO P/N
MT-IL3006-002).
NOTE: The removable foot extension is intended for Feet First

patient positions only.
Figure 16 Optional foot extension for feet-first

patient positions (standard treatment couch only)

The removable foot extension attaches to the superior end of the table top using the CIVCO
Prodigy® Lok-Bar. For patient treatment in the Feet First position, the foot extension should be
attached at the “H2” index mark (see Figure 17).
Figure 17 Foot extension attached to index mark

“H2” on table top
WARNING: Do NOT use the foot extension for Head First treatments or attach it at index
marks other than “H2”. Otherwise, an overload condition of the treatment couch can
occur and patient injury of damage to equipment can result.

Loading the Patient onto the Standard Treatment

Couch
When loading a patient onto the standard treatment couch, load the patient within 46 inches
(1180 mm) of the support column centerline (see Figure 18). This "load zone" is a fixed location
relative to the support column and is independent of the position of the table top at the time of
patient loading.
Load Zone Load Zone Load Zone
Support Column Support Column Support Column

Centerline Centerline Centerline
Figure 18 Load zone for standard treatment couch
WARNING: DO NOT sit, stand, or otherwise place any loads outside of the load zone of
the standard treatment couch.
DO NOT load patients on the table top outside of the 46 inch (1180 mm) load zone.
If a load is placed on the ends of the table top away from the support column, for example,
by loading the patient or sitting at either end of the table top, there is the potential for the
table top to partially detach from the support column and descend to the floor. This could
lead to patient injury depending on the position of the patient at the time.

RoboCouch Patient Positioning System

(Option)
This section describes how to use the RoboCouch Patient Positioning System with the CyberKnife
System.
• “RoboCouch System Components” on page 7-32
• “RoboCouch System Safety Features” on page 7-46
• “Error Handling With the RoboCouch System” on page 7-47
• “Treatment Delivery Using the RoboCouch System” on page 7-48
The RoboCouch System is a computer-controlled system for positioning patients using a
manipulator with 6 degrees of freedom. The RoboCouch System is capable of moving the patient
under computer control in 3 translation directions (Inferior/Superior, Left/Right, Anterior/Posterior)
and 3 rotation directions (roll, pitch, and yaw). The maximum load supported by the RoboCouch
System is 500 lb (227 kg). Patient weight includes any pads, restraints, and devices that are loaded
on the table top.
Figure 19 Room layout with RoboCouch system.
1075883-ENG A RoboCouch Patient Positioning System (Option) | 7-31

RoboCouch System Components

The RoboCouch System includes the following components:
• “RoboCouch Manipulator” on page 7-32
• “RoboCouch Column Cover” on page 7-33
• “RoboCouch Controller” on page 7-35
• “RoboCouch Flat Table Top Configuration” on page 7-36
• “RoboCouch Hand Controller and Cradle” on page 7-36
• “RoboCouch Teach Pendant” on page 7-45
RoboCouch System components are described in the sections that follow.
RoboCouch Manipulator
WARNING: The RoboCouch manipulator is a powerful piece of equipment. Treat it with

the same caution given to the treatment delivery robot. Be sure to understand how the E-
Stops function and how to use them. Read “RoboCouch System Safety Features” on
page 7-46 and “Chapter 2: Safety” before operating the RoboCouch System, or else the
patient or user may suffer serious injury or death.
The RoboCouch manipulator is a 6-axis robot capable of positioning the patient in six degrees of
freedom.
The 6 axes of the RoboCouch and hazard regions are shown in Figure 20.
7-32 | RoboCouch Patient Positioning System (Option) 1075883-ENG A

Hazard
Region
Between
Arms
Upper
Arm
Table Top
Lower
Arm
Figure 20 Components of RoboCouch manipulator

and hazard regions
RoboCouch Column Cover
WARNING: When the RoboCouch System is in motion, avoid all locations that could pose
a potential crush hazard. Such locations include (see Figure 20):
Pay attention to people and other objects in the room at all times to avoid severe injury or
death.
The RoboCouch column cover encloses the vertical translation axis (Axis A1) of the RoboCouch
manipulator. Axis A1 provides vertical travel for the RoboCouch table top. Roller shades on the
column cover move up and down with movement of Axis A1. The following configurations are
available for the RoboCouch column cover:

• Column cover installed in a corner of the treatment room. A brake release button is
located on the column cover (see Figure 21).
Brake Release
Button
Figure 21 RoboCouch column cover for corner

installation

• Freestanding column covers have a door panel in that provides access to a brake release
button and the RoboCouch Teach Pendant (see Figure 22).
Figure 22 Freestanding RoboCouch column covers.

Brake release button is located behind door panel.
WARNING: Ensure that objects do not become caught in the roller shades that cover the
vertical translation axis (Axis A1). Contact with the motors and drive shaft of Axis A1 can
result in injury.
CAUTION: Observe the following safety precautions when accessing the column cover:
• Do not apply pressure to the roller shades on the column cover.

• The door on the wall-mounted column cover is for service access only.
• The door on the freestanding column cover is for service access only, except for
access to the brake release button (see Figure 22).
RoboCouch Controller
The RoboCouch controller controls the manipulator and interfaces with other components of the
CyberKnife System, including E-Stop signals. The RoboCouch controller is located in the
Equipment Room.

RoboCouch Flat Table Top Configuration

The RoboCouch Flat Table Top configuration is shown in Figure 23.
Figure 23 RoboCouch Flat Table Top configuration
The flat table top provides patient support. It is fabricated from carbon fiber and designed to provide
uniform radiolucency for the Target Locating System.
The headrest for the RoboCouch Flat Table Top configuration is the same as that for the standard
treatment couch.
RoboCouch Hand Controller and Cradle
WARNING: Do not remove the Hand Controller from the Treatment Room. The Hand
Controller should only be used in the Treatment Room, in order to safely monitor
movement of the treatment couch.
WARNING: Do not move the RoboCouch System and the treatment robot simultaneously.
WARNING: The Hand Controller cable is a possible trip hazard.
The RoboCouch System includes a Hand Controller that allows manual movement of the
RoboCouch System in the treatment room. The following components are included with the Hand
Controller:
• RoboCouch Hand Controller
• Charging Cradle
• Synchrony interface module

Hand Controller
The RoboCouch includes the following components:
• RoboCouch Hand Controller
• Charging Cradle
• Wireless Synchrony Respiratory Tracking interface module
Synchrony
Respiratory
RoboCouch Tracking
Hand Interface
Controller Module
Charging
Cradle
Figure 24 RoboCouch Wall-Mounted Hand Controller and Cradle
The Cradle is a unit for storing the RoboCouch Hand Controller, and for both storing and charging
the wireless Synchrony Respiratory Tracking interface module. The Cradle provides an interface
between the Hand Controller and the RoboCouch Controller. The Cradle is wall-mounted and
includes a hook to keep the Hand Controller cable off the floor.
An LED indicator on the front of the Cradle is lit when there is power to the Cradle for charging the
Synchrony Respiratory Tracking interface module. For more information on the Synchrony
Respiratory interface module, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
RoboCouch Hand Controller Functions

An LED indicator on the front of the Cradle is lit when there is power to the Cradle for charging the
Synchrony Respiratory Tracking interface module. For more information on the Synchrony
Respiratory Tracking interface module, see “Chapter 12: Synchrony Respiratory Tracking System
(Option)”.

The RoboCouch Hand Controller allows manual movement of the RoboCouch System in the
treatment room. The Hand Controller provides manual and semi-automated control of all six
degrees of freedom of the RoboCouch System. The sections that follow describe Hand Controller
controls.
LED E-Stop
Indicator
Couch E-Stop
Status Button
Indicator
Contact
Sensor Speed
Indicator Indicator
Button
Position
Control
Buttons
Enable Button
(Located on
Back of Hand
Movement Controller)
Control
Buttons
Figure 25 RoboCouch Hand Controller (Rotate

Mode and Translate Mode controls shown)

The RoboCouch Hand Controller includes these controls and indicators:

• E-Stop button (at top end of Hand Controller)
• Enable button (on back of Hand Controller)
• LED E-Stop indicator
• Position Control buttons
• Movement Control buttons
• Speed indicator button
• Contact Sensor indicator
• Couch Status indicator
E-Stop Button
The Emergency Stop (E-Stop) button is located at the top end of the RoboCouch Hand Controller.
Pressing the E-Stop button generates a system-wide E-Stop, including the RoboCouch System.
You cannot override this E-Stop using the RoboCouch Hand Controller.
Enable Button
The Enable button located on the back of the RoboCouch Hand Controller enables manual control
of the RoboCouch System. This button must be depressed while performing any manual
movements with the Hand Controller.
NOTE: If you move the RoboCouch System using the

RoboCouch Hand Controller at medium or fast speeds and the
SPDP detects a potential collision, all moving devices are
stopped and the Hand Controller switches to slow speed. After
you release and re-engage the Enable button on the Hand
Controller, the SPDP allows movement at slow speed using the
Hand Controller until there is no further collision risk. You can
then resume normal jogging speeds.
NOTE: Releasing the Enable button while the RoboCouch

System is moving causes an abrupt stop that can be
uncomfortable for the patient. Use this method to stop movement
only in an emergency.
A more gentle stop is achieved by releasing the Position Control

or Movement Control button without releasing the Enable button.

LED E-Stop Indicator

An LED E-Stop indicator located at the top of the front face of the RoboCouch Hand Controller
changes to indicate the following conditions:
• Off: Indicates that there is no communication between the Hand Controller and the
treatment delivery computer. In this state, both a local (RoboCouch System) E-Stop and
a system-wide E-Stop are generated.
• Yellow blinking: Indicates that a local (RoboCouch System) E-Stop and a system-wide
E-Stop are engaged that cannot be overridden. In this state, both manual and computer-
controlled motions are disabled.
• Yellow: Indicates that there is a CyberKnife System E-Stop. In this state, the RoboCouch
System can be moved under manual control only. All computer-controlled motions from
the treatment delivery computer are disabled.
• Green: Indicates that the Enable button on the back of the Hand Controller is pressed
and the RoboCouch System is ready to respond to the manual controls.
• Green blinking: Indicates that the RoboCouch System is moving under control of the
Hand Controller.
WARNING: Monitor the RoboCouch System closely at all times for potential collision with
surrounding objects. If you see a potential collision, release the Enable button on the back
of the Hand Controller to stop RoboCouch movement.
Position Control Buttons

The RoboCouch Hand Controller includes the Position Control buttons shown in Table 2 on
page 7-41. LED indicators next to each button have the following states:
• Off: The button is disabled.
• Solid white: The RoboCouch System is powered up and button is enabled.
• Blinking green: The treatment couch is currently on the path to the indicated position. In
this state, the treatment couch is not necessarily moving.
NOTE: The blinking continues until the treatment couch reaches

the indicated position. You must continue to press both the
Enable button and the Position Control button during movement.
If you press another Position Control button while the treatment

couch is moving, the first button switches to solid white. The
second button switches to blinking green and the treatment
couch moves to the new position.
• Solid green: The treatment couch has reached the indicated position.

Table 2 Position Control buttons
Button Description
Horizontal Load Position: Moves the RoboCouch System to the horizontal

patient loading position. This position is programmed as a convenient position
of the treatment couch for the patient to get on or off the table and is set at an
average wheelchair height of 19 inches.
The Horizontal Load Position button applies to the RoboCouch Flat Loading
configuration.
This button is not currently used.
Treat Position: Moves the RoboCouch System to the nominal treatment

position. The treatment position for the first treatment session for a treatment
plan is given by a default position for the type of anatomy being treated (head
or body). For subsequent sessions, the treatment position for the previous
treatment session is used.
The Treat Position button applies to the RoboCouch Flat Loading configuration.
For more information on loading the default or previous treatment position, see
This button is not currently used.
When you press the Position Control buttons, the nominal (default) speed is used, unless you
select another speed (see “The Translate Mode controls are shown in .” on page 7-43).
Movement Control Area

Translate mode and Rotate mode use the same 3 buttons on the Hand Controller. You switch
between Rotate mode and Translate mode by clicking either the Rotate or Translate button. These
controls are described below.
Rotate Mode Controls

The Rotate Mode controls are shown in Table 3.
NOTE: Rotation directions on the RoboCouch Hand Controller

are labeled based on the Head First Supine (HFS) patient
position.

Table 3 Rotate Mode controls
Button Description
Rotate: Click the Rotate button to activate the Rotate buttons,

described below.
Yaw: Rotates the RoboCouch table top about the anterior-

posterior axis towards the patient left or right (yaw).
Roll: Rotates the RoboCouch table top about the inferior-

superior axis towards the left or right of the patient (roll).
Pitch: Rotates the RoboCouch table top to bring the patient head
up or head down (pitch).
The Yaw, Pitch, and Roll buttons include a center icon and arrows indicating the direction of
rotation. In normal operation, the center icon and the arrows are lit when the button is enabled.
If treatment couch rotation exceeds a software limit in one direction, the following occurs:
• Movement of the treatment couch stops.
• All rotation arrows turn off (unlit) except for one.
• The one remaining arrow that is lit indicates the allowed direction to reverse the rotation
so that the treatment couch is back within the software limit.

Translate Mode Controls

The Translate Mode controls are shown in .
NOTE: Translation directions on the RoboCouch Hand

Controller are labeled based on the Head First Supine (HFS)
patient position.
Button Description
Translate: Click the Translate button to activate the Translate

buttons, described below.
Inferior/Superior: Moves the RoboCouch System in the patient

inferior or superior direction (along the inferior-superior axis).
Left/Right: Moves the RoboCouch System in the patient left or right

direction (along the left-right axis).
Anterior/Posterior: Moves the RoboCouch System in the patient

anterior or posterior direction (along the anterior-posterior axis).
Speed Indicator Button

Pressing the Speed Indicator button switches the speed of the RoboCouch System, in both
Translate mode and Rotate mode. The Speed Indicator shows the selected speed.
The following speeds can be selected:

• Low speed: First bar lit.
• Nominal (default) speed: First two bars lit.
• High speed: All bars lit.
WARNING: Do not use high speed when the patient is on the treatment couch. Sudden
stops during high speed movement may startle the patient and result in injury.

NOTE: If you move the RoboCouch System using the

RoboCouch Hand Controller at medium or fast speeds and the
SPDP detects a potential collision, all moving devices are
stopped and the Hand Controller switches to slow speed. After
you release and re-engage the Enable button on the Hand
Controller, the SPDP allows movement at slow speed using the
Hand Controller until there is no further collision risk. You can
then resume normal jogging speeds.
Contact Sensor Indicator
Contact Sensor Indicator
The Contact Sensor Indicator is an LED display on the Hand Controller that indicates the status of
the contact sensors located on the RoboCouch table top (see “RoboCouch System Safety
Features” on page 7-46).
If contact occurs between the table top and the lower arm of the RoboCouch manipulator, or with
an object located between the table top and the lower arm, the contact sensor triggers an E-Stop
and the Contact Sensor Indicator (a yellow exclamation point icon) blinks.

Couch Status Indicator
The Couch Status Indicator is an LED display on the Hand Controller that indicates the status of
the RoboCouch System. Status conditions that may occur are listed in Table 4 on page 7-45.
Depending on the status, the indicator bars are lit as follows:
• Off
• Solid green
• Green blinking
• Yellow blinking
NOTE: When an indicator bar on the Couch Status Indicator

blinks green or yellow, Position Control buttons, Rotate Mode
controls, and Translate Mode controls are disabled on the Hand
Controller.
Table 4 Couch Status Indicator – RoboCouch Flat Table Top configuration
Couch Status Indicator Description
Table Top indicator bar is solid green. Seat indicator bar and Foot
Extension indicator bar are not used.
RoboCouch Teach Pendant

The RoboCouch has a service-only RoboCouch Teach Pendant that is accessed through the door
panel of the freestanding column cover.

RoboCouch System Safety Features

The RoboCouch System includes the following safety features:
• Software limits on the RoboCouch controller.
• Limit switches on the RoboCouch manipulator “wrist” to prevent excess rotations (Axes
A4 and A5). See Figure 20 on page 7-33.
• Limit switches on vertical travel (Axis A1). See Figure 20 on page 7-33.
• Contact detection on the upper arm of the RoboCouch manipulator. This contact sensor
triggers an E-Stop interlock if contact occurs between the upper arm and either the
treatment couch, another object, the wall, or the patient.
• Contact detection at the foot of the treatment couch.
• An Enable button on the Hand Controller (see “Enable Button” on page 7-39).
• An E-Stop button on the Hand Controller and on the Teach Pendant (see “E-Stop Button”
on page 7-39).
NOTE: For the RoboCouch with the freestanding column cover,

the Teach Pendant accessed through the door panel is for Field
Service use only.
For instructions on manually lowering the RoboCouch table top for patient unloading during power
interruption (see “Lowering the Patient During a Power Interruption” on page 7-47).
Bypassing a RoboCouch Contact Sensor E-Stop

If contact is detected between the RoboCouch manipulator or table top and a person or object, a
contact sensor E-Stop occurs. When the E-Stop is engaged, you cannot use the RoboCouch Hand
Controller.
In an emergency situation when contact occurs, you can temporarily bypass the contact sensor E-
Stop. This allows you to use the Hand Controller to move the RoboCouch manipulator or table top
out of contact. When you bypass a RoboCouch contact sensor E-Stop, all contact sensors and
motion limit switches are bypassed. In this state, no E-Stop will be triggered if contact occurs again
or if the RoboCouch manipulator hits a limit switch.
WARNING: When a RoboCouch contact sensor E-Stop is bypassed, an E-Stop will NOT be
triggered if contact occurs again. There will be NO protection against collision or crushing
of people or objects, and injury or death can result. Monitor RoboCouch movement
closely to ensure no collision occurs. If you see a potential collision, release the Enable
button on the back of the Hand Controller to stop RoboCouch movement.
When the E-Stop is bypassed, the RoboCouch System can only be moved at slow speed using the
Hand Controller.
 To temporarily bypass a RoboCouch contact sensor E-Stop:

1. Push and hold the E-Stop bypass button for the RoboCouch contact sensors. As shown
in Figure 26 for, this button is located on the side of Axis A5 to the patient’s left (in the
HFS patient position).
Figure 26 Bypass button for RoboCouch contact

sensor E-Stop
2. While pressing the E-Stop bypass button, use the RoboCouch Hand Controller to
manually move the RoboCouch manipulator out of contact.
Lowering the Patient During a Power Interruption

A brake release button is provided to manually lower the patient if an emergency situation occurs
during a power interruption. For the RoboCouch this button is accessed through the free-standing
column cover of the RoboCouch System (see Figure 22 on page 7-35).
WARNING: If an emergency situation occurs during a power interruption, press the brake
release button to lower the RoboCouch table top to its minimum height for easier
unloading of the patient.
The brake release button is only active during a power interruption. You may choose not to use the
brake release button if it is possible for the patient to be unloaded without lowering the table top.
CAUTION: If the brake release button is pressed to lower the RoboCouch table top, a service
call to Accuray is required to reset the RoboCouch System.
Error Handling With the RoboCouch System

Resolving an E-Stop Condition
If an E-Stop is triggered during RoboCouch System operation, an error message is displayed in
the Error Handling System window on the treatment delivery computer. The error message
suggests actions to determine the cause of the E-Stop and resolve the condition.
 To resolve an E-Stop condition:

• Check whether the E-Stop button on the RoboCouch Hand Controller is depressed (see
“RoboCouch Hand Controller and Cradle” on page 7-36).
• Check whether the E-Stop button on the RoboCouch table-mounted cradle is depressed
(see “RoboCouch Hand Controller and Cradle” on page 7-36)
• Check whether the E-Stop button on the RoboCouch Teach Pendant is depressed.
• Check the position of the RoboCouch Teach Pendant mode selector switch (the key
switch located on the front of the Teach Pendant). An E-Stop is generated if the switch is
not in External mode, indicated by the following icon:
• Check the contact sensors. An E-Stop is triggered if contact is made with areas covered
by the RoboCouch contact sensors (see “RoboCouch System Safety Features” on
page 7-46). To bypass a contact sensor E-Stop, see “Bypassing a RoboCouch Contact
Sensor E-Stop” on page 7-46).
• Check the safety limit switches. An E-Stop is triggered if the limits switches on Axes A1,
A4, or A5 are tripped. To bypass a limit switch interlock, press the bypass button and
move the A1, A4, or A5 axis with the RoboCouch hand control.
Treatment Delivery Using the RoboCouch System

This section describes procedures for using the RoboCouch System during treatment delivery. It
includes the following topics:
• “Powering On the RoboCouch System” on page 7-48
• “Loading Patient Data” on page 7-49
• “Using the RoboCouch System to Load the Patient” on page 7-50
• “Patient Alignment” on page 7-50
• “Pausing Treatment Couch Movement” on page 7-52
• “Treatment Delivery” on page 7-52
• “Patient Realignment” on page 7-53
For more detailed information on treatment delivery, see “Chapter 8: Treatment Delivery”.
Powering On the RoboCouch System

The procedure for powering on the CyberKnife System with the RoboCouch System is the same
as that with the standard treatment couch. For information on powering up the CyberKnife System,
see “Chapter 4: System Startup and Shutdown”.

Loading Patient Data

For information on loading patient data and verifying patient and treatment data, see “Chapter 8:
Path downloading occurs while treatment files are being loaded. During path downloading, the
RoboCouch System is loaded with the alignment position from any previous treatment session of
the treatment plan.
If there is no previous treatment position stored for the treatment plan, a default position associated
with the treatment plan anatomy type is loaded into the RoboCouch controller. For more
information on path downloading, see “Chapter 8: Treatment Delivery”.
After treatment files have been successfully downloaded, the Alignment > Couch phase is
displayed automatically (see Figure 8 on page 8-17). You are then ready to begin initial positioning
of the treatment couch, as described in the next section.

Using the RoboCouch System to Load the Patient

Observe the safety precautions below during operation of the RoboCouch System.
WARNING: When the RoboCouch System is in motion and under control of either the
Hand Controller or the Teach Pendant, avoid all locations that could pose a potential
crushing hazard. Such locations include (see Figure 20 on page 7-33):
Pay attention to people and other objects in the room at all times.
WARNING: The treatment couch table top can be slippery. Make sure patients are
properly secured for the type of treatment they are receiving.
 To load the patient using the RoboCouch System:

6. Place any immobilization devices on the table top, as needed. Mount the headrest on the
head of the table top, but do not tighten the position adjustment screw(s).
7. Bring the patient into the Treatment Room. Assist the patient onto the treatment couch.
Make sure the patient is placed in the immobilization devices and positioned on the table
top in the same way as during the pretreatment CT scan.
8. When the table top is in the horizontal Treat Position, adjust the position of the headrest
under the patient’s head. Then tighten the position adjustment screw(s).
Patient Alignment
When the RoboCouch System is in the nominal treatment position, you are ready for the
Alignment > Couch phase. Figure 27 shows the automatic patient positioning controls in the
Alignment > Couch phase that you use with Couch Mode to visually align the Live X-ray and
DRR images.

Figure 27 Automatic Patient Positioning Window
For information on using the Automatic Patient Positioning window, see “Chapter 8: Treatment
Delivery”. The description in Chapter 7 applies to the RoboCouch System as well as the standard
treatment couch.
of the Hand Controller to stop RoboCouch movement (see “RoboCouch Hand Controller
and Cradle” on page 7-36).
WARNING: The RoboCouch System does not detect when the patient is outside the
nominal patient setup boundaries. After patient alignment or realignment with the
RoboCouch System, ensure that the patient is within the nominal alignment boundaries.
See the section, "The Patient Safety Zone," in “Chapter 2: Safety”.
WARNING: Making large movements of the treatment couch from the treatment delivery
computer outside the treatment room may increase the risk of equipment colliding with or
pinching the patient. For better visibility, make large movements of the treatment couch
inside the treatment room with the hand pendant.

Pausing Treatment Couch Movement

RoboCouch System movement using the treatment delivery computer in Treatment mode is not
monitored by the Proximity Detection Program (PDP) or the Supplemental Proximity Detection
Program (SPDP). Monitor all RoboCouch System movement to prevent potential collisions.
RoboCouch System movement can be terminated at anytime by clicking the Interlock button in
the E-Stop/Interlock controls (Figure 28).
Interlock
button
Figure 28 Interlock button
Treatment Delivery
NOTE: Seat angles greater than 15° must be taken into account
during treatment planning. Otherwise, the Patient Safety Zone
will be violated and you will not be able to proceed with
treatment. For more information on the Patient Safety Zone, see
“Chapter 2: Safety”.
During treatment delivery, no alignment operations are allowed using the RoboCouch System.
During treatment delivery, the treatment robot repositions the LINAC to correct the beam direction
for patient displacement. The treatment robot corrects for both translational and rotational
displacements.
For CyberKnife Systems that include the RoboCouch System, the robot corrects the beam
direction up to 10 mm along each translation axis (for treatments that do not use the Synchrony
tracking System), and up to ±1.5 degrees for rotations (yaw, pitch, and roll).
During patient alignment or realignment, the rotational correction limits can be changed to values
below these maximum values using the Imaging Parameters window. Rotational corrections during
treatment delivery can also be disabled in the Imaging Parameters window. For more information
on displacement corrections during treatment delivery, see “Chapter 8: Treatment Delivery”.

Patient Realignment
All alignment functionality provided for patient alignment is also provided during patient re-
alignment. For more information, see “Chapter 8: Treatment Delivery”.
WARNING: The RoboCouch System does not detect when the patient is outside the
nominal patient setup boundaries. After patient alignment or re-alignment with the
RoboCouch System, ensure that the patient is within the nominal alignment boundaries.
See the section, "The Patient Safety Zone," in “Chapter 2: Safety”.


Chapter 8: Treatment Delivery
Introduction
The chapter describes the general workflow for treatment delivery using the CyberKnife Treatment
Delivery System.
• “Workflow for Patient Alignment and Treatment Delivery” on page 8-3
• “Approving Plans for Treatment Delivery and DRR Generation” on page 8-5
• “Loading Patient and Treatment Data” on page 8-5
• “Initial Patient Positioning” on page 8-10
• “Visually Aligning the Patient” on page 8-15
• “Optimizing the X-ray Technique” on page 8-22
• “Performing Patient Alignment” on page 8-27
• “Checking Readiness for Treatment Delivery” on page 8-56
• “Interrupting Treatment” on page 8-82
• “Patient Realignment After a Pause or Error” on page 8-91
• “Makeup Fractions” on page 8-92
• “Phantom Mode” on page 8-93
• “Demonstration Mode” on page 8-93
• “Plan QA Mode” on page 8-100
This chapter assumes that the CyberKnife System is powered up and that you are logged into the
treatment delivery computer. It also assumes you are familiar with "Chapter 5: Treatment Delivery
System Overview" that describes the user interface of the Treatment Delivery System.

This chapter provides general procedures that apply to all tracking modes and describes
Synchrony Skull Tracking mode. For detailed information on other tracking modes, see the
following chapters:
• "Chapter 9: Synchrony Fiducial Tracking"
• "Chapter 10: Synchrony Spine Tracking (Option)"
• "Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)"
• "Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging (Option)"
• "Chapter 15: Lung Optimized Treatment (Option)"
8-2 | Introduction 1075883-ENG A

Treatment Delivery Manual Chapter 8: Treatment Delivery
Workflow for Patient Alignment and Treatment

Delivery
The workflow for patient alignment and treatment delivery in the Treatment Delivery System user
interface is divided into phases. Each phase focuses on a particular user task. Patient alignment
is itself separated into three phases. Additionally, the workflow depends on whether the
SynchronyTracking System is used during treatment.
Figure 1 shows the user interface workflow for treatments that do not use Synchrony Tracking with
Respiratory Modeling. This workflow applies to Synchrony Skull Tracking mode, Synchrony
Fiducial Tracking mode, and Synchrony Spine Tracking Supine.
Figure 1 Workflow for patient alignment and treatment delivery for treatments that
do not use Respiratory Modeling (Synchrony Skull Tracking mode, Synchrony
Fiducial Tracking mode, Synchrony Spine Tracking Supine).
Figure 2 shows the user interface workflow for Synchrony Fiducial Tracking with Respiratory
Modeling mode and Synchrony Spine Tracking with Respiratory Modeling mode.
use Respiratory Modeling (Synchrony Fiducial Tracking with Respiratory Modeling
mode and Synchrony Spine Tracking with Respiratory Modeling).
1075883-ENG A Workflow for Patient Alignment and Treatment Delivery | 8-3

Figure 3 shows the workflow for patient alignment and treatment delivery using Synchrony Lung
Tracking with Respiratory Modeling and Lung 1 View Tracking with Respiratory Modeling.
use Respiratory Modeling (Synchrony Lung Tracking with Respiratory Modeling
mode and Lung 1 View tracking with Respiratory Modeling)
For information on using Synchrony Respiratory Tracking System, see "Chapter 12: Synchrony
Respiratory Tracking System (Option)".
The goal of each user interface workflow phase for treatments that do not use Respiratory
Modeling (see Figure 1) is as follows:
• Overview phase: Load patient, treatment plan, and treatment fraction data. Verify that
patient and treatment data are correct.
• Alignment > Couch phase: Load the patient onto the treatment couch. Visually align
the patient, using translational couch movements only. Take at least one Live X-ray
image and confirm visual alignment of the Live X-ray and DRR images.
• Alignment > Technique phase: Find the optimal X-ray technique. This X-ray
technique will be the default for future treatment fractions unless it is changed.
• Alignment > Align phase: Ensure the patient is aligned within acceptable bounds for
treatment delivery or Respiratory modeling if the SynchronyTracking System will be used.
• The Physician Setup Approval button allows a physician to electronically approve the
current patient alignment. For more information see “Physician Setup Approval of Patient
Alignment” on page 8-52.
With the TxViewTM licensed option, you can remotely approve

patient alignment in the Alignment > Align phase (treatments that do
not use Respiratory Modeling) and the Alignment > Respiratory
phase (treatments that use Respiratory Modeling). For more
information on the TxView remote approval workflow, see
“Requesting Remote Approval of Patient Alignment (TxView
Option)” on page 8-53.
• Readiness phase: Check that the patient is within the Patient Safety Zone. Check
equipment readiness before starting treatment delivery. Resolve, when applicable, and
confirm all delivery warning messages. Exchange collimators or perform a Laser
Alignment Check, as needed. These steps can optionally be performed earlier during the
Alignment > Couch phase.
• Delivery phase: Start treatment delivery. Monitor and verify patient alignment and
tracking results during treatment delivery.
Tasks performed during these phases are described in the sections that follow.
8-4 | Workflow for Patient Alignment and Treatment Delivery 1075883-ENG A

Approving Plans for Treatment Delivery and

DRR Generation
Before a treatment plan can be delivered, it must be approved for delivery and Digitally
Reconstructed Radiograph (DRR) images must be generated from the patient CT image series.
DRR images consist of one or more pairs of orthogonal images constructed from a patient or
phantom CT image series. Each DRR image represents a simulated X-ray view of the patient
corresponding to the orientation of one of the X-ray detectors of the X-ray imaging system.
DRR images are required for patient alignment and motion tracking during treatment. During
treatment, real-time X-ray images of the patient are compared with the set of DRR images to
determine the position of the target. The treatment robot then corrects the position of the LINAC to
compensate for target displacement.
Treatment plan approval and DRR generation are performed using the iDMS Data Management
System. For more information, see the Data Management Manual.
Loading Patient and Treatment Data

WARNING: Follow hospital procedures for verifying the patient and treatment plan
information. If there is any discrepancy, do not prescribe the treatment plan for the
patient.
WARNING: Do not attempt to modify a treatment file. Improperly changed data can result
in injury or death to the patient.
On the day of treatment, on the treatment delivery computer, power on the CyberKnife System as
described in "Chapter 4: System Startup and Shutdown". The startup procedure, including X-ray
tube warmup, should be completed before the patient arrives.
Loading patient and treatment data includes the following steps:
• “Select the Patient, Plan, and Fraction” on page 8-6
• “Verify Patient and Treatment Data” on page 8-8
1075883-ENG A Approving Plans for Treatment Delivery and DRR Generation | 8-5
Select the Patient, Plan, and Fraction

The first step to load patient and treatment data is to select the patient, treatment plan, and fraction.
 To select the patient, treatment plan, and fraction:
1. On the CyberKnife System Menu, click the Treatment button and log in as described in
"Chapter 4: System Startup and Shutdown". You may also add participants, as described
in "Chapter 5: Treatment Delivery System Overview".
After a successful login, the Load Patient Data screen is displayed (see Figure 4). This
screen lists patients with treatment plans that have been approved for delivery. It may
take a moment for data to be retrieved from the data server of the iDMS Data
Management System.

Figure 4 Load Patient Data screen
8-6 | Loading Patient and Treatment Data 1075883-ENG A

2. Click to select a patient name from the Patient list. After a moment, the Plan list is
populated with the names of approved treatment plans for that patient. Treatment plans
are not listed until DRR images have been generated on the iDMS Data Management
System.
NOTE: A validation check of the treatment plan and treatment

plan DRR images is performed before treatment plans are
displayed in the Plan list. The validation check confirms that the
system data used to create the treatment plan and generate the
DRR images matches current system data. If necessary, new
valid DRR images will automatically be generated on the iDMS
Data Management System.
3. To refresh the Patient list with patients that have newly approved treatment plans and
the Plan list with treatment plans that have newly generated DRR images, click the
Refresh button. It may take a few moments for the lists to be updated.
4. Click to select a treatment plan from the Plan list. After a moment, the Fraction list is
populated with fraction numbers for that treatment plan.
5. Click to select a fraction from the Fraction list.
Under the lists, the Patient, Plan, and Fraction sections display information about
the selected patient, treatment plan, and fraction as you select them.
In the Fraction section, if the Delivered / Prescribed (MU) progress bar displays
a non-zero percentage, the fraction is a makeup fraction, and the text makeup is
displayed next to the fraction number.
For more information on the text fields of the Load Patient Data screen, see "Chapter 5:
Treatment Delivery System Overview".
6. Click the Load button to begin downloading patient and treatment data from the iDMS
Data Management System to the treatment delivery computer.
Or, click the Exit button to return to the CyberKnife System Menu.
After you click the Load button and patient and treatment data is downloaded, you are ready to
verify that the data is correct in the Overview phase.
1075883-ENG A Loading Patient and Treatment Data | 8-7

Verify Patient and Treatment Data

In the Overview phase, you verify that patient and treatment data are correct. The left screen of
the Overview phase displays patient and treatment information (see Figure 5). You must verify
that this information is correct before you can proceed.
WARNING: Verify that this patient is in fact the one to be treated and the treatment plan is
the correct one to use.
Figure 5 Overview phase (left screen)
The top of the right screen of the Overview phase summarizes patient and treatment data (see
Figure 6).
Figure 6 Overview phase (right screen)
When this window appears, the first Data Verified checkbox is active. You must verify that
patient, treatment plan, and treatment fraction information in the three columns on the left screen
are correct.
8-8 | Loading Patient and Treatment Data 1075883-ENG A

 To verify that patient and treatment information is correct:

1. If the patient information is correct, click the first Data Verified checkbox. The second
Data Verified checkbox in the treatment plan information section becomes active.
If information is not correct, click the Interlock button at the bottom of the left screen,
followed by the Exit Treatment button on the Error Handling System screen. After
clicking OK, you will return to the CyberKnife System Menu.
2. If the treatment plan information is correct, click the second Data Verified checkbox.
The third Data Verified checkbox in the treatment fraction information section
becomes active.
If information is not correct, click the Interlock button.
3. If the treatment fraction information is correct, click the third Data Verified checkbox.
Treatment files, including treatment paths, DRR images, and other treatment data, are
downloaded from the treatment delivery computer to the Target Locating System (TLS) computer.
The initial alignment position for the treatment couch is also downloaded to the treatment couch
Hand Controller.
After treatment files have been successfully downloaded, the Alignment > Couch phase is
displayed automatically (see Figure 8 on page 8-15). You are then ready to begin initial positioning
of the treatment couch, as described in the next section.
You are now ready to move to the Alignment > Couch phase to begin patient alignment
procedures.
For more information on the Overview phase, see "Chapter 5: Treatment Delivery System
Overview".
1075883-ENG A Loading Patient and Treatment Data | 8-9

Initial Patient Positioning

The goal of initial patient positioning is to reproduce as closely as possible the patient position
during the pretreatment CT scan. For information on pretreatment scanning guidelines, see
"Chapter 6: Patient Preparation".
• “Supported Patient Positions” on page 8-10
• “Initial Alignment of the Treatment Couch” on page 8-12
Supported Patient Positions

The patient positions supported by the CyberKnife System depend on the following:
• the tracking mode used for treatment.
• use of Synchrony Tracking with Respiratory Modeling for treating targets that move with
respiration.
Table 1 lists supported and unsupported patient positions for CyberKnife treatment.
WARNING: Treating or attempting to treat a patient using an unsupported patient position

can lead to mistreatment of the patient.
NOTE: Treatment in the prone position is supported only for

Synchrony Fiducial Tracking and Synchrony Spine Tracking,
with or without Respiratory Modeling.
8-10 | Initial Patient Positioning 1075883-ENG A

Table 1 Supported (Yes) and unsupported (No) patient positions
Supine Prone
Head First Feet First Head First Feet First

Tracking Mode (HFS) (FFS) (HFP) (FFP)
Synchrony Fiducial Tracking Yes Yes Yes Yes
Synchrony Fiducial Tracking with Yes Yes Yes Yes

Respiratory Modeling
Synchrony Skull Tracking Yes No No No
Synchrony Spine Tracking Supine Yes Yes No No
Synchrony Spine Tracking Prone (with or No No Yes Yes

without Respiratory Modeling)
Synchrony Lung Tracking with Respiratory Yes No No No

Modeling
Lung 1 View with Respiratory Modeling Yes No No No
For more information on the see "Chapter 12: Synchrony Respiratory Tracking System (Option)".
Ensure that the patient and all devices are within the Patient Safety Zone defined by the
PDP model, even if the patient is not in the HFS position. For more information on the
Patient Safety Zone, see "Chapter 2: Safety".
WARNING: In the user interface of the Treatment Delivery System, patient coordinate
axes and screen controls are labeled based on the Head First Supine (HFS) position (see
Figure 7). Be aware of this convention if the patient position used for treatment is not HFS.
1075883-ENG A Initial Patient Positioning | 8-11

ANT
INF
RGT
Figure 7 Patient coordinate axes are based on the

Head First Supine (HFS) patient position
During treatment planning, only treatment plans that specify supported combinations of tracking
mode and patient position are allowed. You cannot save a treatment plan that specifies an
unsupported patient position in the Accuray Precision Treatment Planning System. For more
information on the Accuray Precision System, see the Treatment Planning Manual.
Initial Alignment of the Treatment Couch

• “Aligning the Standard Treatment Couch” on page 8-13
• “Aligning the RoboCouch System” on page 8-14
When treatment files are downloaded from the treatment delivery computer, the treatment couch
Hand Controller is loaded with one of two initial alignment positions:
• Previous alignment position: If the treatment couch position from a previous treatment
session exists for the treatment plan, this position is downloaded to the Hand Controller.
• Default alignment position: If no previous position exists, a default position is
downloaded that is associated with the anatomy type. For head treatments, the default
position moves the center of the skull to the machine center. For body treatments, the
treatment couch moves to one of two default positions, depending on the body anatomy
specified in the treatment plan.

For information on the Hand Controllers for the standard treatment couch and the optional
RoboCouch Patient Positioning System, see "Chapter 7: Treatment Room Operations".
WARNING: The treatment couch table top can be slippery. Make sure patients are
properly secured for the type of treatment they are receiving.
Aligning the Standard Treatment Couch

 To perform initial alignment of the standard treatment couch:
1. Verify that the treatment couch is free of unnecessary objects.
2. Press the HOME button on the Hand Controller to move the treatment couch to the
patient loading position.
3. Bring the patient into the Treatment Room.
4. Assist the patient onto the treatment couch.
Follow the instructions to load the patient in the section, “Loading the Patient onto the
Standard Treatment Couch”, in "Chapter 7: Treatment Room Operations".
WARNING: DO NOT sit, stand, or otherwise place any loads outside of the load zone of
the standard treatment couch.
DO NOT load patients on the table top outside of the 46 inch (1180 mm) load zone.
If a load is placed on the ends of the table top away from the support column, for example,
by loading the patient or sitting at either end of the table top, there is the potential for the
table top to partially detach from the support column and descend to the floor. This could
lead to patient injury depending on the position of the patient at the time.
For more information on the load zone of the standard treatment couch, see "Chapter 7:
Treatment Room Operations".
Use the same immobilization device that was used for pretreatment scanning. Make sure
the patient is placed in the immobilization device and positioned on the table top in the
same way as during the pretreatment CT scan.
For more information on immobilization devices, see "Chapter 6: Patient Preparation".
5. Press the TREAT button on the Hand Controller to move the treatment couch to the
appropriate initial alignment position. In this position, the anatomy to be treated is in the
field of view of the X-ray imaging system.
1075883-ENG A Initial Patient Positioning | 8-13

The treatment couch moves to either the previous or default alignment position,
depending on whether this is the first treatment session or a subsequent treatment for the
treatment plan.
6. If a position measurement device or alignment lasers are available in the Treatment
Room, you can use them to help fine tune the initial alignment position. Using the Hand
Controller, move the treatment couch to align the anatomy to be treated at the machine
center.
NOTE: For initial patient alignment, adjust translations only.

Since the patient was positioned on a flat table top during the CT
scan, rotations may not be needed for initial patient alignment.
Aligning the RoboCouch System

 To perform initial alignment of the RoboCouch System:
1. Follow the instructions to prepare the RoboCouch table top and load the patient as
described in the section, “Using the RoboCouch System to Load the Patient”, in "Chapter
7: Treatment Room Operations".
Use the same immobilization device that was used for pretreatment scanning. Make sure
the patient is placed in the immobilization device and positioned on the table top in the
same way as during the pretreatment CT scan.
.
WARNING: Before using a bolster , make sure the matching RoboCouch cushions were
used during pretreatment scanning. Otherwise, the patient treatment position will not
match the pretreatment scanning position, and mistreatment can result.
For more information on immobilization devices and pretreatment scanning, see "Chapter
6: Patient Preparation".
Follow the instructions to move the RoboCouch System to the treatment position as
described in the section, “Using the RoboCouch System to Load the Patient”, in "Chapter
7: Treatment Room Operations".
The treatment position corresponds to the initial alignment position. In this position, the
anatomy to be treated is in the field of view of the X-ray imaging system. The RoboCouch
System moves to either the previous or default alignment position, depending on whether
this is the first treatment session or a subsequent treatment for the treatment plan.
2. Follow the instructions to adjust the headrest, secure the thermoplastic mask (if needed),
and extend the footrest (if needed), as described in the section, “Using the RoboCouch
System to Load the Patient”, in "Chapter 7: Treatment Room Operations".
3. If a position measurement device or alignment lasers are available in the Treatment
Room, you can use them to help fine tune the initial alignment position. Using the Hand

Controller, move the RoboCouch System to align the anatomy to be treated at the
machine center.
NOTE: For initial patient alignment, adjust translations only.

Since the patient was positioned on a flat table top during the CT
scan, rotations may not be needed for initial patient alignment.
After initial alignment of the treatment couch, the next step is patient alignment. Patient alignment
begins with the acquisition of Live X-ray images of the patient, as described in the next section.
Visually Aligning the Patient

The goal of the Alignment > Couch phase is visual alignment of the patient, using translational
couch movements only. You take at least one Live X-ray image and confirm visual alignment of the
Live X-ray and DRR images before proceeding to the next phase. By properly aligning the patient,
the next phase (the Alignment > Technique phase) can be performed with images properly
in view.
Figure 8 shows the Alignment > Couch phase (left screen) for Synchrony Skull Tracking mode
before Live X-ray images have been acquired. The DRR images are displayed in grayscale and fill
each image panel for Camera B (left) and Camera A (right) of the imaging system. The green
human body icon in each image shows the patient orientation relative to the X-ray source.
Figure 8 Alignment > Couch phase (left screen) for Syn-

chrony Skull Tracking mode before image acquisition
In the Alignment > Couch phase, the following tasks are performed:
1075883-ENG A Visually Aligning the Patient | 8-15

• “Acquiring Live X-ray Images” on page 8-16

• “Analyzing the Images” on page 8-18
• “Moving the Couch in the Alignment > Couch Phase” on page 8-19
Acquiring Live X-ray Images

Click the Acquire button to take a pair of Live X-ray images (see Table 2).
WARNING: Make sure no one but the patient is in the Treatment Room when Live X-ray
images are acquired.
Table 2 Buttons in the patient position display
Tool Tip Button Description
Acquire Acquires a pair of Live X-ray images.

The In Progress indicator is displayed at the bottom of
the left screen and controls are disabled during image
acquisition.
The device status indicator for the X-ray sources turns
green when the X-ray sources are ready and flashes
yellow as Live X-ray images are acquired.
The Acquired images counter increments by 2 for each
image pair acquired.
For Synchrony Spine Tracking treatments, serial exposure is used to reduce scatter: X-ray images
are taken one at a time, first using one x-ray source and then the other, unless the Respiratory
Modeling System has been enabled.
If the Respiratory Modeling System is enabled, and for every other tracking mode, synchronous
exposure is used: X-ray images are taken using both X-ray sources simultaneously.
Figure 9 shows the left screen with acquired images, after the Live X-ray and DRR images have
been visually aligned using Couch Mode. The Live X-ray images are overlaid on the DRR images
and displayed in a teal color scale.
8-16 | Visually Aligning the Patient 1075883-ENG A


chrony Skull Tracking mode after image acquisition and
visual alignment
Using the default X-ray parameters is recommended. For Synchrony Fiducial Tracking mode, you
may need to adjust X-ray parameters for XRS A (X-ray source A) and XRS B (X-ray source B)
using the dropdown lists (see Figure 10):
Figure 10 X-ray parameter dropdown list
• kV: Voltage (in kilovolts)

• mA: Current (in milliamps)
• ms: Exposure time (in milliseconds)
WARNING: Use the minimum X-ray technique that meets all other tracking requirements.
Overexposure of X-rays can cause skin burns.

When you expand the kV dropdown list, available values are displayed in groups of 10. Click on
a group to select values in increments of 1 kV. You can also adjust mA and ms values by
selecting from available values in the dropdown lists.
The tracking algorithm does not provide feedback to the user in the Alignment > Couch phase.
Algorithm errors are not displayed.
Controls are available for handling blocked imaging nodes and situations when the treatment robot
is stopped at a blocked node or between nodes. In the Alignment > Couch phase, these
controls are useful if treatment is interrupted at a blocked imaging node and you are confirming
alignment of the patient before resuming treatment. These controls are also available in the
Delivery phase. For more information on handling blocked imaging nodes during treatment
delivery, see “Visual Inspection of Tracking Results” on page 8-76.
Analyzing the Images

The goal of this task is to confirm visual alignment of the main anatomical or other features in the
Live X-ray and DRR images.
WARNING: During initial patient setup, visually compare the DRR and Live X-ray images
to ensure that features in are similar in both. Otherwise, patient injury or death can occur.
Table 3 on page 8-32 describes the image panel controls available in some or all of the workflow
phases to aid image analysis and visual alignment. You can use the Blend Tool (the vertical slider
to the right of each image panel) to shift between displaying the Live X-ray or DRR images. In
Figure 9 on page 8-17, the Pan/Zoom controls and the Window/Level controls have also been
used to help visually identify skeletal features in the images.
After confirming acceptable visual alignment, you can proceed to the Alignment > Technique
phase, as described in “Optimizing the X-ray Technique” on page 8-22. Otherwise, you can move
the couch as needed until the Live X-ray and DRR images align according to your specifications,
as described below.

Moving the Couch in the Alignment > Couch

Phase
• “Using Couch Mode” on page 8-19
• “Pausing Movement of the Treatment Couch” on page 8-20
• “Patient Realignment During Treatment Delivery” on page 8-21
Using Couch Mode

Figure 11 shows the automatic patient positioning controls in the Alignment > Couch phase
which you use with Couch Mode to visually align the Live X-ray and DRR images.
Move Couch
Button
Figure 11 Patient positioning controls in the Alignment >

Couch phase (shown for standard treatment couch)
Couch Mode allows you to shift the Live X-ray image relative to the DRR image so that anatomical
or other features match. To do this, select the Couch icon (below each image panel; see Table 3
on page 8-32). Then click and drag in the Live X-ray image. You do this separately for Image A and
Image B.
NOTE: Couch Mode simulates motion of the treatment couch.

Using Couch Mode to shift the Live X-ray and DRR images
relative to each other does not move the treatment couch.
As the relative position of the images is adjusted, the target translational offsets of the treatment
couch in the Couch Position (mm) textboxes shown in Figure 11 are automatically updated.
(The Couch Position (deg) textboxes are not updated in the Alignment > Couch phase.)
The textboxes indicate the target position of the treatment couch at which the currently shown
overlay of Live X-ray images and DRR images would be achieved. Arrows above the textboxes
point in the positive direction. Values indicate couch movement relative to its current position.
To move the Live X-ray image back to its original, unshifted position, click the Reset icon.

To move the treatment couch to the target position indicated in the Couch Position (mm)
textboxes, click the Move Couch button. Values in the textboxes change and approach zero as
the desired treatment couch position is achieved.
WARNING: Treatment couch movement is not monitored by the collision detection

system of the CyberKnife System. Visually observe all movement of the treatment couch
to prevent potential collisions.
After moving the treatment couch, you acquire a Live X-ray image and then analyze the image to
confirm visual alignment, as described above.
If you are unable to improve patient alignment using Couch Mode, visually inspect the patient
position and try manually aligning the patient using the treatment couch Hand Controller. For more
information, see “Manual Alignment Using the Hand Controller” on page 8-51.
Pausing Movement of the Treatment Couch

You can pause movement of the treatment couch at any time.
 To pause treatment couch movement:
1. Click the Interlock button in the E-Stop/Interlock controls at the bottom of the left
screen (available in every workflow phase) to immediately stop movement of the
treatment couch. A recoverable E-Stop is generated.
Interlock Button
Figure 12 Interlock button in E-Stop/Interlock controls
For more information on the Interlock button, see “Interrupting Treatment” on page 8-82. For
information on recoverable E-Stops, see “Error Handling” on page 8-84.

Patient Realignment During Treatment Delivery

If patient displacements during treatment exceed the maximum correction values of the treatment
robot, an E-Stop is generated. The automatic patient positioning system of the treatment couch can
be used to realign the patient:
• With the standard treatment couch, the automatic patient positioning system can adjust
the patient position for all three translations and for roll and pitch.
• With the optional RoboCouch System, the automatic patient positioning system can
adjust the patient position for all three translations and all three rotations, including yaw.
WARNING: The automatic patient positioning system does not detect when the patient or
the treatment couch is outside the Patient Safety Zone. After patient alignment or
realignment, ensure that the patient is within the Patient Safety Zone (see “Checking the
Patient Safety Zone” on page 8-58). Otherwise collision of the treatment robot with the
patient may result. For more information on the Patient Safety Zone, see "Chapter 2:
Safety".
Performing a Patient Safety Zone Check

In the Alignment > Couch phase, you can optionally perform a Patient Safety Zone Check
using controls on the right screen. This check helps you determine if the patient is within the Patient
Safety Zone. This step is required during the Readiness phase. For more information, see
“Checking the Patient Safety Zone” on page 8-58.
Performing a Collimator and Laser Alignment

Check
In the Alignment > Couch phase, you can optionally exchange collimators or perform a Laser
Alignment Check, as needed, using controls on the right screen. This step is required during the
Readiness phase. For more information, see “Checking Equipment Readiness” on page 8-67.
Proceeding to the Next Treatment Phase

After confirming acceptable visual alignment, click the Technique tab to proceed to the
Alignment > Technique phase, where you refine the X-ray technique.

Optimizing the X-ray Technique

The goal of the Alignment > Technique phase for Synchrony Skull Tracking mode is to find
the optimal X-ray technique. This X-ray technique will be the default for future treatment fractions
unless it is changed. You start by analyzing the existing images from the Alignment > Couch
phase.
• “Modifying X-ray Parameters” on page 8-25
WARNING: The Live X-ray images should have the same image quality as the DRR
images. Otherwise, the tracking algorithm may not be able to identify and track features
correctly.
Figure 13 shows the Alignment > Technique phase (left screen) for Synchrony Skull
Tracking mode with the Live X-ray images from the Alignment > Couch phase.
8-22 | Optimizing the X-ray Technique 1075883-ENG A

Figure 13 Alignment > Technique phase (left screen) for

Synchrony Skull Tracking mode with images from
Alignment > Couch phase
The top row of images corresponds to XRS B (X-ray source B) and the bottom row to XRS A (X-
ray source A):
• Raw Image: The raw (unprocessed) Live X-ray image.
• Enhanced Image: The Live X-ray image, enhanced for contrast by the tracking
algorithm.
• DRR image: The DRR image for reference.
Table 3 on page 8-32 describes the image panel controls available in some or all of the workflow
phases to aid image analysis. The goal is to determine whether to adjust the X-ray technique to
allow adequate visualization, identification, and tracking of the features to be used for alignment
and tracking.
You can also analyze image details and compare image quality with previous images in the
Image History table on the right screen (see Figure 14). The goal is to determine the optimal
X-ray technique for XRS A and XRS B independently, by evaluating image quality and Brightness
values of the last image taken in the Alignment > Couch phase and images taken in the
Alignment > Technique phase.
1075883-ENG A Optimizing the X-ray Technique | 8-23

Figure 14 Image History table of the Alignment > Technique

phase (right screen) for Synchrony Skull Tracking mode
The Image History Camera B (top) and Image History Camera A (bottom) tables show
image details. Tables are emptied if the treatment couch is moved. Details for the last image taken
in the Alignment > Couch phase are displayed. A new row is added with each image
acquisition. Controls let you do the following:
• Click an Image ID to highlight a row. Higher numbers are more recent. The corresponding
image in the pair is automatically selected in the other table, and the Enhanced Image is
displayed to the right of the table.
A green checkmark shows which rows match the current X-ray technique selected in the
dropdown lists on the right screen.
• Select controls at the bottom of the image panels to the right of each table to aid image
analysis (see Table 3 on page 8-32).
• Select either Enhanced Image or Raw Image for image display.
• Click a column heading to sort rows. Use the scroll bar on the right or the Up and Down
arrow keys on the keyboard to scroll through a table.

Select an X-ray technique that results in X-ray images that look similar to the DRR images and
Brightness values as close to 1 as possible.
 To select an X-ray technique from a previous image:
• Click the Select Technique button (located between the two Image History
tables; see Figure 14) to automatically populate the XRS A and XRS B dropdown lists
with the X-ray techniques corresponding to the currently selected image pair. These will
become the new default settings. You do not need to acquire another image.
• To select X-ray techniques corresponding to images from two different image pairs, use
the XRS A and XRS B dropdown lists to manually select X-ray parameters (see
“Acquiring Live X-ray Images” on page 8-16). Then acquire a new image to make these
values the new default settings.
If you have selected a satisfactory X-ray technique, you can proceed to the Alignment > Align
phase. Otherwise, you can modify the X-ray technique as needed until you are satisfied with the
image quality, as described below.
Modifying X-ray Parameters
WARNING: Use the minimum X-ray technique that meets all other tracking requirements.
Overexposure of X-rays can cause skin burns.
You may need to modify the X-ray parameters to enable adequate visualization, identification and
tracking of the features used for alignment and tracking:
• For Synchrony Skull Tracking mode: The goal is to achieve Live X-ray images that
look similar to the DRR images.
NOTE: For pediatric, elderly, or other patients with low bone

density, changes in X-ray technique may require adjusting the
brightness range threshold or gradient threshold. When making
adjustments, ensure correlations are stable through translations
and rotation and that the patient is not moving. For more
information on adjusting brightness and gradient thresholds, see
“Max Brightness Error (%)” on page 8-43.
• For Synchrony Fiducial Tracking: The goal is to achieve Live X-ray images in which
the fiducials can be clearly seen against the background.
• For Synchrony Spine Tracking: See "Chapter 10: Synchrony Spine Tracking
(Option)", for information on setting X-ray parameters.
• For Synchrony Lung Tracking with Respiratory Modeling: See "Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling (Options)", for information on
setting X-ray parameters.
• For Lung 1 View with Respiratory tracking: See "Chapter 15: Lung Optimized
Treatment (Option)", for information on setting X-ray parameters.

You can use the XRS A and XRS B dropdown lists to manually select X-ray parameters or the
Select Technique button to select an X-ray technique from a previous image acquisition. The
Imaging Interval is the minimum required time interval between X-ray images (in seconds).
For more information on using the dropdown lists, see “Acquiring Live X-ray Images” on page 8-16.
NOTE: The Treatment Delivery System always waits for at least

the minimum required time interval before taking the next pair of
Live X-ray images.
After changing the X-ray technique, you acquire new Live X-ray images and then evaluate the
image quality and Brightness value, as described above. Algorithm errors are not displayed in the
After finding the optimal X-ray technique, click the Align tab to proceed to the Alignment >
Align phase, where you perform patient alignment.

Performing Patient Alignment

WARNING: During initial patient setup, verify that the position of the alignment center in
the DRR images meets recommendations given in the Treatment Planning Manual. If
recommendations are not met, generate a new treatment plan in the Accuray Precision
System. For more information, see the Treatment Planning Manual.
The goal of the Alignment > Align phase for the Synchrony Skull Tracking mode is to make
sure the patient is aligned within acceptable bounds for treatment delivery.
The existing Live X-ray images from the Alignment > Technique phase are automatically
correlated with the DRR images. During image correlation, the Synchrony Skull Tracking algorithm
attempts to identify the features to be tracked and calculates offsets between the Live X-ray and
DRR images. The calculated offsets are displayed in the Offsets panel. The offset values indicate
ho w much the treatment couch should be moved to align features in the Live X-ray and DRR
images.
Figure 15 shows the Alignment > Align phase (left screen) for Synchrony Skull Tracking mode
after image correlation.
Figure 15 Alignment > Align phase (left screen) for Syn-

chrony Skull Tracking mode after image correlation
1075883-ENG A Performing Patient Alignment | 8-27

The left screen displays the Live X-ray images in a teal color scale overlaid on the DRR image in
grayscale for Camera B and Camera A of the imaging system. The Acquire button is enabled,
allowing you to acquire Live X-ray images. The left screen includes the following additional controls
described in the sections that follow:
• Offsets panel: After image correlation, the Offsets panel displays suggested treatment
couch movements to position the patient in correct alignment (see Figure 16 on
page 8-30). During patient alignment, you use the calculated offset values to move the
treatment couch so that features in the Live X-ray and DRR images are aligned. For more
information, see “Evaluating Calculated Offsets” on page 8-29.
• Patient position controls: Automatic patient positioning controls indicate desired motion of
the treatment couch relative to its current position (see Figure 22 on page 8-48). The
Move Couch button moves the treatment couch by this amount. The controls also
show the current absolute rotational position of the treatment couch. For more
information, see “Moving the Couch in the Alignment > Align Phase” on page 8-48.
• Algorithm parameter slider bars: Slider bars allow you to monitor the calculated value of
algorithm parameters and change the value of their thresholds (see Figure 19 on
page 8-42). The algorithm parameters depend on the tracking mode. Calculated values
are updated each time an image is acquired and image correlation is performed. When a
calculated value exceeds its threshold, a threshold violation occurs. For more
information, see “Monitoring and Adjusting Algorithm Parameters” on page 8-41.
• Rotational Bounds Checking Enabled checkbox: When this checkbox is
enabled, an interlock is triggered if patient rotational displacements computed by the
tracking algorithm exceed the maximum allowed rotational displacements. This checkbox
is enabled by default. For more information, see “Checking Readiness for Treatment
Delivery” on page 8-56.
The Alignment > Align phase has the following steps:
• “Analyzing Imaging Results” on page 8-29: You start by evaluating the calculated offset
values to determine if you need to move the treatment couch. You also review the Live X-
ray images to verify that there are sufficient skeletal features in the images and that
anatomy in the Live X-ray and DRR images matches.
• “Moving the Couch in the Alignment > Align Phase” on page 8-48: You move the
treatment couch as needed and acquire new Live X-ray images.
• (Optional) Use of the Physician Setup Approval button which allows a physician to
electronically approve the current patient alignment in the Alignment > Align phase
(treatments that do not use Respiratory Modeling) and the Alignment > Respiratory phase
(treatments that use Respiratory Modeling). For more information on Physician Setup
Approval, see “Physician Setup Approval of Patient Alignment” on page 8-52.
• (Optional) “Requesting Remote Approval of Patient Alignment (TxView Option)” on
page 8-53. With the TxView licensed option, you can remotely approve patient alignment
in the Alignment > Align phase (treatments that do not use Respiratory Modeling) and the
Alignment > Respiratory phase (treatments that use Respiratory Modeling).
8-28 | Performing Patient Alignment 1075883-ENG A

Analyzing Imaging Results

• “Evaluating Calculated Offsets” on page 8-29
• “Visually Identifying Features to Be Used for Tracking” on page 8-32
• “Monitoring and Adjusting Algorithm Parameters” on page 8-41
• “Analyzing the Image History” on page 8-46
Evaluating Calculated Offsets

The tracking algorithm calculates the offset between the Live X-ray and DRR images by identifying
and matching landmarks in the images. The landmarks depend on the tracking mode specified in
the treatment plan:
• Synchrony Skull Tracking mode: Identifies and tracks skeletal features of the skull.
Tracking these features relies on the fixed relationship between the target volume and
skeletal features of skull.
• Synchrony Fiducial Tracking mode: Identifies and tracks implanted fiducials. Tracking
fiducials relies on the fixed relationship between the target volume and the fiducials.
• Synchrony Spine Tracking modes: Tracks bony anatomy of the spine. Tracking these
features relies on the fixed relationship between the target volume and bony anatomy of
the spine.
• Synchrony Lung Tracking with Respiratory Modeling mode: Tracks lung tumor
volume relative to soft tissue anatomy.
The Offsets panel displays suggested movements of the treatment couch needed to align the
patient (see Figure 16). The Offsets panel displays the following information:
• Axis: Arrows for translations and rotations point in the positive direction. The human
body icons match the patient orientation in the treatment plan.
• Calculated: Offsets (in millimeters or degrees) between the Live X-ray and DRR
images calculated by the tracking algorithm.
• Applied: Offsets sent to the treatment robot. These values are only displayed during
treatment delivery in the Delivery phase.

Figure 16 Offsets panel in Alignment > Align phase

for Synchrony Skull Tracking mode
Depending on the tracking mode, calculated offset values are displayed for translation only, or for
both translation and rotation:
• Synchrony Skull Tracking mode: Computed values are displayed for the 3 translations
(Left/Right, Anterior/Posterior, and Superior/Inferior directions) and 3 rotations (Left/Right
roll, Head-Up/Head-Down pitch, and Clockwise/Counterclockwise yaw).
NOTE: For trigeminal paths, the treatment robot does not correct
for rotations. All rotations are automatically disabled. However,
the Couch Corrections text fields still display rotational
offsets for the purpose of monitoring.
• Synchrony Fiducial Tracking mode: When 2 or fewer fiducials are used for tracking,
only computed values for the 3 translations are displayed. When 3 or more fiducials are
used for tracking, computed values are also displayed for the three rotations. For more
information, see "Chapter 9: Synchrony Fiducial Tracking".
• Synchrony Spine Tracking modes: Computed values are displayed for the 3
translations and 3 rotations. For more information, see "Chapter 10: Synchrony Spine
Tracking (Option)".
• Synchrony Lung Tracking with Respiratory Modeling mode: Computed values are
displayed for the 3 translations only. The values displayed for the 3 rotations are constant
values obtained from Synchrony Spine Tracking alignment. For more information, see
"Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)".
• Lung 1 View Tracking with Respiratory Modeling mode: Computed values are
displayed for the 3 translations only. The values displayed for the 3 rotations are constant

values obtained from Synchrony Spine Tracking alignment. For more information, see
"Chapter 15: Lung Optimized Treatment (Option)".
Evaluate the calculated offset values. They indicate couch movement needed to align features in
the Live X-ray and DRR images. The Live X-ray images are automatically shifted relative to the
DRR images using the calculated translational offsets. The overlaid Live X-ray and DRR images
show you how these images would align if the treatment couch is moved using the translational
offsets.
To reset the Live X-ray image displays to their original, unshifted positions, click the Reset icon
in Couch Mode (see Table 3 on page 8-32). You can then shift the Live X-ray images and DRR
images manually relative to each other to determine whether anatomical or other features are
aligned. Click the Offset icon in Couch Mode to shift the Live X-ray images again by the
translational offsets. For more information on moving the treatment couch, see “Moving the Couch
in the Alignment > Align Phase” on page 8-48.
Steps depend on the alignment scenario:
• Offsets are within tolerances required for treatment delivery, and you can verify that there
are sufficient skeletal features in the images and that anatomy in the Live X-ray and DRR
images matches.
 You can proceed to the next treatment phase, the Readiness phase.
 To reduce offsets, you can move the treatment couch using the Move Couch
button. See “Moving the Couch in the Alignment > Align Phase” on page 8-48.
• An orange box around an offset value indicates an offset is not within required tolerances
and an out-of-bounds error has occurred. For more information on the required
tolerances, see “Displacement Corrections During Treatment Delivery” on page 8-62. An
orange box around a tracking algorithm slider bar indicates that a threshold violation has
occurred.
 You can use image analysis tools in Table 3 on page 8-32 to make sure the images
include sufficient skeletal features. Check that anatomy is aligned in the Live X-ray
and DRR images.
button. See “Moving the Couch in the Alignment > Align Phase” on page 8-48.
 You can also adjust algorithm parameters as needed. See “Monitoring and Adjusting
Algorithm Parameters” on page 8-41

Visually Identifying Features to Be Used for Tracking

• “Using Image Panel Controls” on page 8-32
• “Using Offset Mode” on page 8-40
WARNING: Misidentifying image features that appear similar to anatomical structures

used for tracking may result in mistreatment. Carefully review images to correctly identify
anatomical structures used for tracking.
Using Image Panel Controls

• “Using the Window/Level Controls” on page 8-39
• “Using the Crosshairs” on page 8-40
Table 3 describes image panel controls to aid image analysis as you verify that the features to be
tracked are correctly identified. These controls can help you to visually locate the same feature in
the DRR and Live X-ray images. Table 4 on page 8-38 lists keyboard and mouse shortcuts
available for some of these controls.
NOTE: Depending on the workflow phase and tracking mode,

not all controls may be available.
Table 3 Image panel controls to aid image analysis
Control Description
Pointer: Click in an image to display the following information:

• The pixel intensity in the DRR image (first) and the Live X-ray image (second),
as a percentage of the maximum pixel intensity.
• The (x, y) coordinate, in millimeters (mm), where (0, 0) is the center of the
image.
(Synchrony Fiducial Tracking, Synchrony Lung Tracking with Respiratory
Modeling and Lung 1-ViewTracking with Respiratory Modeling only) You can also
use Offset Mode when the Pointer is turned on. For more information, see “Using
Offset Mode” on page 8-40.

Table 3 Image panel controls to aid image analysis (continued)
Control Description
Movie Mode: Use Movie Mode to cycle through all Live X-ray images in the
Respiratory model one at a time in respiratory sequence. This makes tumor
motion more visible and helps you verify that tumor motion is being tracked.
• Click the Play icon to start Movie Mode.
• Click the Pause icon to pause Movie Mode.
• Use the zoom slider bar to increase or decrease playback speed.
• Or, click the Plus icon or the Minus icon to change playback speed.
• Click the Reset icon to reset the playback speed to its default.
Pan/Zoom: Zoom in and out and pan the image.

• Click and drag in the image to pan.
• Drag the zoom slider bar to zoom in and out.
• Or, click the Zoom Plus icon or the Zoom Minus icon.
• Click the Reset icon to reset the pan and zoom.
Couch: Adjust the position of the Live X-ray image relative to the DRR image by
clicking and dragging in either the Live X-ray image or DRR image. See “Visually
Aligning the Patient” on page 8-15. Depending on the treatment phase and the
tracking mode, the following icons are displayed:
• Click the Reset icon to move the Live X-ray image back to its original,
unshifted position.
• Click the Reset icon to fill the Couch Position (mm) and Couch
Rotation (deg) textboxes with zero values. The Live X-ray image moves
to its unshifted position, to show existing alignment.
• Click the Offsets icon to fill the Couch Position (mm) and Couch
Rotation (deg) textboxes with the calculated offset values. The Live X-ray
image shifts by the translational offsets, to show the alignment that would
result if the couch is moved by these amounts.
You can toggle back and forth between these icons. The icons only shift the Live
X-ray image relative to the DRR image. They do not move the couch.

Control Description
Window/Level: Adjust the window (contrast) and level (brightness) of the image.
A histogram representing the distribution of pixel intensities is displayed. Controls
help you visually identify anatomical or other features in the Live X-ray images.
They affect the image display only. See “Using the Window/Level Controls” on
page 8-39.
• Click in the image and drag up or down to adjust the window. Or, click and
drag the left and right edges of the histogram to move them towards the
center to adjust both the window and level.
• Click in the image and drag left or right to adjust the level. Or, click and drag
the vertical line at the center of the histogram to the left or right.
• Click the Invert Contrast icon to invert image contrast. Inverting image
contrast may make it easier to visually identify anatomical and other features.
• Click the Lock icon to apply the same window and level settings to all
images. Click again to unlock settings.
• Click the Reset icon to reset window and level settings to their defaults.
(Synchrony Fiducial Tracking mode only) You may need to modify the Window/
Level settings for the Live X-ray images to see the fiducials.
Checkerboard: Displays the Live X-ray and DRR image in a pattern of alternating
squares to help visually evaluate image alignment. Click the icon once to display
the checkered pattern. Click again to display the pattern rotated 90°. Click once
more to turn off the checkered pattern.
Drag the red dot at the center of the checkered pattern to move the intersection of
squares in the image. Cannot be used with the Blend Tool.
ITTV Outline: (Lung 1 View Tracking with Respiratory Modeling only) If the
treatment plan is based on a Simulation Plan, displays a dark blue Internal Target
Tracking Volume (ITTV) contour in the DRR image that is not used for tracking.
For more information, see the Treatment Planning Manual.
The ITTV Outline is turned off by default. See "Chapter 15: Lung Optimized
Treatment (Option)".

Control Description
Tumor Outline: For Synchrony Lung Tracking with Respiratory Modeling mode
and Lung 1 View Tracking with Respiratory Modeling; lower right of image panel)
Displays a graphic overlay of the tumor outline (Target Tracking Volume, TTV) in
the DRR images and Live X-ray images that corresponds to the tumor contour
specified during treatment planning. With Lung 1 View Tracking with Respiratory
Modeling, the tumor outline is only displayed in the Live X-ray image that is used
for tracking.
• A dark blue outline indicates the reference tumor outline in the DRR images.
• A teal blue outline indicates where the tumor has been identified by the
tracking algorithm in the Live X-ray images.
• Red and green outlines indicate the reference tumor outline projected onto the
Live X-ray image in Offset Mode.
The Tumor Outline is turned on by default. See "Chapter 11: Synchrony Lung
Tracking with Respiratory Modeling (Options)", and "Chapter 15: Lung Optimized
(For Synchrony Skull Tracking mode only; lower right of image panel) displays
target contours projected onto the DRR in the same colors as the target volumes
of interest VOIs created during treatment planning)
The Tumor Outline is turned off by default. Once selected, use the Blend Tool to
adjust the opacity of the DRR so the VOIs are visible.
Crosshairs: Displays a pair of crosshairs to aid in alignment of the Live X-ray and
DRR images. Can be used with other image panel controls. See “Using the
Crosshairs” on page 8-40.
Fiducial ROI: (Synchrony Fiducial Tracking mode only) Displays a square yellow
box in the Live X-ray image for each Region of Interest (ROI) where the fiducial
extraction algorithm searches for fiducial candidates. Each box is centered on a
fiducial candidate.
The size of the box changes when the Tracking Range (mm) parameter is
adjusted. For more information, see "Chapter 9: Synchrony Fiducial Tracking".

Control Description
Fiducial Markers: (Synchrony Fiducial Tracking mode only) Displays markers in

the Live X-ray and DRR images to identify fiducial locations:
• Yellow diamonds show the reference fiducial locations in the DRR images.
• Green circles show where fiducials have been identified by the tracking
algorithm in the Live X-ray images. Only shown for fiducials that have been
enabled for tracking.
• Red and blue circles show the reference fiducial locations projected onto the
Live X-ray image in Offset Mode. For more information, see "Chapter 9:
Synchrony Fiducial Tracking".
You can verify that the green circle markers in the Live X-ray images actually mark
fiducials by toggling the Fiducial Markers on and off and visually noting the
fiducials under each marker.
Align Center: (Synchrony Spine Tracking modes only) Displays a marker that
corresponds to the align center selected during treatment planning. See "Chapter
10: Synchrony Spine Tracking (Option)".
Region of Interest: (Synchrony Spine Tracking modes in Technique phase only)

Displays the Region of Interest (ROI) Width as a yellow box in the Raw Image.
The histogram display is based on the ROI.
Skeletal Mesh: (Synchrony Spine Tracking modes in Align and Respiratory
phases only) Displays the skeletal mesh used for tracking.
See "Chapter 10: Synchrony Spine Tracking (Option)".
Blend Tool: Use the Blend Tool to change the blending of the Live X-ray and
DRR images.
• Drag the cursor over the green marks at the right of each image to display
the hidden slider. Drag the slider up and down to change the blending.
• Click the Automatic Blend icon to alternate continuously between the Live
X-ray and DRR images as you watch. The Live X-ray image will fade in and
out automatically.
• Click the up or down arrow below the slider to increase or decrease the speed
of the automatic blend (represented by a number).
• Click the Pause icon to pause the automatic blend.
• Click the Reset icon to reset the blend to the default (50% Live X-ray
image and 50% DRR image).
Cannot be used with Checkerboard.

Control Description
Full Content DRR: (Synchrony Spine Tracking modes only) Displays the
unsegmented (full content) DRR images. See "Chapter 10: Synchrony Spine
Tracking (Option)".
Full Content DRR: (Synchrony Lung Tracking with Respiratory Modeling mode
and Lung 1 View Tracking with Respiratory Modeling only) Displays the
unsegmented (full content) DRR images. See "Chapter 11: Synchrony Lung
Tracking with Respiratory Modeling (Options)", and "Chapter 15: Lung Optimized
Segmented DRR: (Synchrony Spine Tracking modes only) Displays the

segmented DRR images, in which all image content except the spine is removed.
See "Chapter 10: Synchrony Spine Tracking (Option)".
Spine Removed DRR: (Synchrony Lung Tracking with Respiratory Modeling

mode and Lung 1 View Tracking with Respiratory Modeling mode only) Displays
the segmented DRR images, in which the spine and other bony structures are
removed and remaining DRR image content is displayed. See "Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling (Options)", and "Chapter 15:
Lung Optimized Treatment (Option)".
Tumor Region DRR: (Synchrony Lung Tracking with Respiratory Modeling mode
and Lung 1 View Tracking with Respiratory Modeling mode only; upper right
corner of image panel) Displays the tumor region DRR images, in which all image
content that is not in the immediate region of the tumor is removed. See "Chapter
11: Synchrony Lung Tracking with Respiratory Modeling (Options)", and "Chapter
15: Lung Optimized Treatment (Option)"
X-ray Technique Changed: (left edge of image panel) Indicates that the X-ray
technique has changed since the currently displayed image was acquired.
Couch Moved: (left edge of image panel) Indicates that the couch position has
changed. Therefore the current image correlation results are invalid and a new
image is required.

Table 4 Keyboard and mouse shortcuts for image panel controls
Shortcut Image panel control
p Turn on Pointer. On by default.
f Turn on/off Movie Mode.
z Turn on/off Pan/Zoom.
c Turn on/off Couch Mode.
w Turn on/off Window/Level.
b Turn on/off Checkerboard.
i Turn on/off ITTV Outline. (Lung 1 View Tracking with

Respiratory Modeling only)
t Turn on/off Tumor Outline (Target Tracking Volume, TTV for

Synchrony Lung Tracking with Respiratory Modeling mode and
Lung 1 View Tracking with Respiratory Modeling mode, and
planning VOI target contour for Synchrony Skull Tracking mode)
x Turn on/off Crosshairs.
r Turn on/off Fiducial ROI. (Synchrony Fiducial Tracking mode)

Turn on/off Skeletal Mesh. (Synchrony Spine Tracking modes)
m Turn on/off Fiducial Markers. (Synchrony Fiducial Tracking

mode)
Turn on/off Align Center. (Synchrony Spine Tracking modes)
scroll wheel Use the Blend Tool. Use the mouse scroll wheel to change the
blending of the Live X-ray and DRR images.
CTRL + Zoom in and out. (Click in this Workflow Guide help window
scroll wheel to scroll through text.)

Using the Window/Level Controls

The Window/Level controls allow you to adjust the window (contrast) and level (brightness) of the
image. The controls affect the image display only. They do not affect the X-ray image data used
by the tracking algorithm. These controls can help you visually identify anatomical or other features
in the Live X-ray images.
In this mode, a histogram representing the distribution of pixel intensities in the image is displayed
at the bottom of the image (see Figure 17).
Figure 17 Window/Level controls showing histograms for

DRR image (upper) and Live X-ray image (lower)
 To adjust the window (contrast) of the image:

• Click in an image and drag the cursor up and down.
• Alternatively, in the histogram, click and drag the left and right edges of the histogram to
move them towards the center. Dragging the left and right edges of the rectangle adjusts
both the window and level settings of the image, thus changing the displayed range of
pixel intensities.
 To adjust the level (brightness) of the image:
• Click in an image and drag the cursor left and right.
• Alternatively, inside the histogram, click and drag only the center vertical line to the left
and right to adjust the level setting. The window setting remains constant.
 To reset the window and level settings to their defaults:
• Click the Reset icon.
 To invert the image contrast:
• Click the Invert Contrast icon to invert the contrast of the image. Inverting the contrast
of an image may make it easier to visually identify anatomical and other features. For
Synchrony Fiducial Tracking mode, inverting the contrast can sometimes help to identify
the fiducials.
 To apply window and level settings to all images in a row in the Alignment > Technique
phase:
• Click the Lock icon to apply window and level changes to all images in a row (that is,
to all images corresponding to either Camera A or Camera B of the X-ray imaging
system).
• Click the Lock icon again to unlock window and level settings so that they do not apply to
all images in a row.

• To set an image back to its default settings, click the Reset icon. If window and level
settings have been locked for all images in a row, clicking this icon applies to all the
images.
Using the Crosshairs

Turning on Crosshairs Mode (see Table 3) displays a pair of crosshairs in the image to aid in the
alignment of DRR and Live X-ray images. The vertical crosshair is green, and the horizontal
crosshair is red.
You can move the crosshairs in the DRR images to the location of the features to be tracked, for
example, the bony anatomy of the skull, other skeletal features, fiducials, or the target tumor.
Visually check whether the crosshairs correctly mark the feature location in the Live X-ray images.
For Synchrony Fiducial Tracking mode and Synchrony Lung Tracking with Respiratory Modeling
mode, if the crosshairs are not located on the same feature in the DRR and Live X-ray images, you
can use Offset Mode to determine the offset values needed to align the images. For more
information, see “Using Offset Mode” on page 8-40.
 To move the crosshairs:
• Click and drag the intersection of the crosshairs to move both crosshairs together.
• Click and drag either the vertical or horizontal crosshair to movie it independently.
Using Offset Mode

For Synchrony Fiducial Tracking mode, Synchrony Lung Tracking with Respiratory Modeling
mode, and Lung 1 View Tracking with Respiratory Modeling, you can use Offset Mode to assist the
tracking algorithm by shifting the fiducial ROIs or the tumor outline manually.
 To use Offset Mode:
1. For Synchrony Fiducial Tracking mode, turn on the Pointer and Fiducial Markers in the
image panel (see Table 3 on page 8-32). Use the Blend Tool to adjust the blending of the
Live X-ray image so that it is 100%.
For Synchrony Lung Tracking with Respiratory Modeling mode or Lung 1 View Tracking
with Respiratory Modeling, turn on the Pointer and Tumor Outline in the image panel.
2. For Synchrony Fiducial Tracking mode, move the cursor over one of the green circle
markers in the Live X-ray image. The circles turn red.
For Synchrony Lung Tracking with Respiratory Modeling mode, move the cursor over the
blue tumor outline in one of the Live X-ray images. For Lung 1 View Tracking with
Respiratory Modeling, do this in the image that will be used for tracking. The outline turns
red.
3. For Synchrony Fiducial Tracking mode, click in the Live X-ray image to grab the reference
group of circle markers. Drag the group of circles to overlay them on fiducials you have
visually identified in the Live X-ray image. The circles turn blue as you drag them.
Depending on the direction you drag them, the reference group of circles in the other
image may also move.
with Respiratory Modeling, click in the Live X-ray image to grab the tumor outline. Drag
the tumor outline in the Live X-ray image to overlay it on the feature you have visually

identified as the actual tumor. The outline remains red as you drag it. Depending on the
movement, the tumor outline in the opposing image may also move.
4. For Synchrony Fiducial Tracking mode, let go of the reference group of circle markers.
Both Live X-ray images are automatically correlated. The translational offsets determined
by moving the reference configuration of fiducials are input to the fiducial tracking
algorithm. Upon completion of the automatic correlation, green circle markers indicate the
new location of candidate fiducials in the Live X-ray image. Updated offset values are
displayed.
with Respiratory Modeling, let go of the tumor outline. It turns green while both Live X-ray
images are automatically correlated. The translational offsets determined by moving the
tumor outline are input to the Synchrony Lung Tracking with Respiratory Modeling
algorithm. Upon completion of the automatic correlation, a blue outline indicates the new
location of the tumor in the Live X-ray image. Updated offset values are displayed.
NOTE: Pressing and holding the <Shift> key delays image

correlation. This allows time to move the tumor outline in both
images when needed, before the images are correlated. When
you release the <Shift> key, image correlation is performed.
5. Verify that the fiducials or the tumor has been located correctly. Evaluate the updated
offsets (see “Evaluating Calculated Offsets” on page 8-29). You can then move the
treatment couch as needed (see “Moving the Couch in the Alignment > Align Phase” on
page 8-48).
WARNING: Couch movement is not monitored by the collision detection system of the
CyberKnife System. Visually observe all movement of the couch to prevent potential
collisions.
Monitoring and Adjusting Algorithm Parameters

• “Calculated Algorithm Parameters” on page 8-42
• “Adjusting Algorithm Parameters” on page 8-45

Calculated Algorithm Parameters

You can monitor values of several parameters calculated by the Synchrony Skull Tracking
algorithm. Values are updated when images are acquired or correlated. The calculated values are
displayed on the Acquisition Details tab of the Image History table (right screen), as
shown in Figure 18.
Figure 18 Calculated algorithm parameters for Syn-

chrony Skull Tracking mode on the Acquisition
Details tab
These calculated values are also displayed to the left of slider bars (left screen), where you can
adjust their thresholds (see Figure 19). If a parameter value exceeds its threshold (the red error
bar extends beyond the threshold cursor), a threshold violation occurs, and an orange box is
displayed around the slider bar. When a threshold violation occurs the first time you are in the
Alignment > Align phase during a treatment fraction, you cannot move to the next phase until
the threshold violation is resolved.
Figure 19 Slider bars for adjusting algorithm parameters

and thresholds in the Alignment > Align phase (left screen)
Calculated parameters for Synchrony Skull Tracking mode are described below.
• “Max Brightness Error (%)” on page 8-43
• “Max Gradient Error (%)” on page 8-44
For information on algorithm parameters for other tracking modes, see the following chapters:


dxAB (mm)
The dxAB (mm) parameter gives the relative distance along the Inferior/Superior axis of the align
center in the two projections (for Camera A and Camera B of the X-ray imaging system). This
difference is called dxAB. The Synchrony Skull Tracking algorithm calculates the dxAB value for
every image acquisition. When the calculated dxAB value exceeds the dxAB threshold value, a
dxAB error occurs. The Inferior/Superior axis is used because this axis is common to both
projections.
The default value of the dxAB threshold parameter is 2.5 mm. The value of this threshold should
be small. If you change this threshold value during patient alignment, you should ideally return to
the default value when patient alignment is completed.
NOTE: If you make a threshold value more lenient than the

default value, a warning appears requiring confirmation to
continue.
WARNING: If you change the value of the dxAB threshold parameter, it is important to
perform visual inspection after tracking results are displayed. Changing the value of this
parameter can cause the Synchrony Skull Tracking algorithm to produce incorrect
estimates of the patient position, which in turn can lead to misdirected radiation beams.
Use caution before changing this parameter value.
Max Brightness Error (%)

The Synchrony Skull Tracking algorithm computes a Max Brightness Error (%) value that
measures the similarity of the overall image intensity between the Live X-ray and DRR images.
This value is computed after correcting for coarse translational offsets.
NOTE: Choose an X-ray technique that results in a Max

Brightness Error (%) value as close to 1 as possible. For
information on setting X-ray parameters, see “Optimizing the X-
ray Technique” on page 8-22.
The Max Brightness Error (%) threshold parameter sets the allowed range of the overall intensity
of Live X-ray images relative to the DRR images. This threshold parameter applies to the Live X-
ray images after they have been acquired and processed. Ideally, the calculated Brightness (%)
ratio should be less than 2.0%. The default value of the Max Brightness Error (%) threshold
parameter is 5.0%.

Adjustment of the Max Brightness Error (%) threshold parameter should only be made when it is
not possible to improve the quality of the Live X-ray images relative to the DRR images by
modifying X-ray parameters in the Alignment > Technique phase.

continue.
WARNING: If you raise the value of the Max Brightness Error (%) threshold parameter, it is
possible for the Synchrony Skull Tracking algorithm to result in larger targeting errors.
WARNING: Pediatric, elderly, or other patients with low bone density may be exposed to
increased imaging dose while compensating adjustments are made to imaging technique.
Max Gradient Error (%)

The Synchrony Skull Tracking algorithm computes a Max Gradient Error (%) value that is the ratio
of the variance of the Live X-ray image to that of the DRR image. The Max Gradient Error (%) value
is used to detect external objects such as the treatment robot and cables that may block the X-ray
detectors. This value is computed after correcting for coarse translations.
The Max Gradient Error (%) threshold parameter sets the allowed range of the average variance
of the Live X-ray images relative to the DRR images. This parameter applies to the Live X-ray
images after they have been acquired and processed. The default value of the Max Gradient Error
(%) threshold parameter is 30.0%.
Adjustment of the Max Gradient Error (%) threshold parameter should only be made when it is not
possible to improve the quality of the Live X-ray images relative to the DRR images by modifying
X-ray parameters in the Alignment > Technique phase.

continue.
WARNING: If you raise the value of the Gradient Error (%) threshold parameter, it is
possible for the Synchrony Skull Tracking algorithm to result in larger targeting errors.

Adjusting Algorithm Parameters

The default settings for algorithm parameter thresholds are adequate for most cases and are
recommended for use. If the Synchrony Skull Tracking algorithm fails or a threshold violation
occurs, adjusting some of these values may allow successful tracking.

continue.
Slider bars on the left screen allows you to monitor and change the values of the following algorithm
parameter thresholds (see Figure 19 on page 8-42):
• dxAB (mm) threshold
• Max Brightness Error (%) threshold
• Max Gradient Error (%) threshold
For information on these parameters, see “Calculated Algorithm Parameters” on page 8-42.
Threshold violations are indicated when the red error bar extends beyond the adjustable threshold
cursor, and an orange box is displayed around the slider bar.
Current Adjustable Default Current

Calculated Threshold Value of Threshold
Value Cursor Threshold Value
Figure 20 Brightness slider bar
Slider bars include the following displays and controls:

• The current value of the calculated parameter is displayed to the left of the slider bar. The
border between the red and green portions of the slider bar also indicates the current
value.
• The threshold cursor allows you to adjust the value of the threshold. Values above this
threshold trigger a threshold violation. Drag the cursor to change the threshold. You can
also enter a threshold directly in the textbox.
 To change the value of a threshold:
• Click and drag the threshold cursor to adjust the threshold value. Alternatively, enter a
new value in the textbox to the right of the slider bar and press <Enter>.

• To return to the default value, click the Reset icon. Alternatively, click and drag the
threshold cursor to the vertical line on the slider bar. The vertical line indicates the default
value.

continue.
parameter can cause the Synchrony Skull Tracking algorithm to produce incorrect
WARNING: If you raise the value of the Maximum Brightness Error (%) threshold
parameter, it is possible for the Synchrony Skull Tracking algorithm to result in larger
targeting errors.
WARNING: If you raise the value of the Maximum Gradient Error (%) threshold parameter,
it is possible for the Synchrony Skull Tracking algorithm to result in larger targeting
errors.
Analyzing the Image History

The Image History table in the Alignment > Align phase (right screen) lets you view
details for all images acquired in all treatment phases for this treatment session. Figure 21 shows
the Image History table for Synchrony Skull Tracking mode.

Figure 21 Image History table for Synchrony Skull

Tracking mode in Alignment > Align phase (right
screen)
Click a column heading to sort rows. Use the scroll bar on the right or the Up and Down arrow keys
on the keyboard to scroll through the table.
Click on a row to highlight it and select a tab to view the following details:
• Acquisition Details: Displays acquisition time, X-ray technique, and data specific to
the tracking mode.
• Calculated Translation (mm) and Calculated Rotation (deg): The offsets
calculated by the tracking algorithm that were previously displayed in the Offsets panel.
• Absolute Couch Position (mm) and Absolute Couch Rotation (deg): The
absolute translational and rotational position of the couch for reference.
• Images tab: Displays the Live X-ray images. Select controls at the bottom of the image
to aid image analysis (see Table 3 on page 8-32).
• Calculated algorithm parameters: See “Calculated Algorithm Parameters” on page 8-42.

Depending on the tracking mode, additional tabs may be available. For information on the Image
History table for the Respiratory phase, see "Chapter 12: Synchrony Respiratory Tracking
System (Option)".
Moving the Couch in the Alignment > Align Phase

• “Using the Automatic Patient Positioning Controls” on page 8-48
• “Pausing Movement of the Treatment Couch” on page 8-20
• “Manual Alignment Using the Hand Controller” on page 8-51
Using the Automatic Patient Positioning Controls

The automatic patient positioning controls allow you to move the treatment couch automatically to
bring the patient into better alignment. Alignment controls help you determine how far and in which
directions to move the treatment couch to minimize the offset values.
The goal is to align the patient so that the Offsets values for translations and rotations are close
to zero. The closer to zero these values are, the more tolerance is available if the patient moves.
Figure 22 shows the automatic patient positioning controls in the Alignment > Alignment
phase. Controls are the same as in the Alignment > Couch phase, with the addition of an icon
in Couch Mode (see Table 3 on page 8-32), described further below.
Move Couch
Button
Figure 22 Patient positioning controls in the Alignment >
Align phase (shown for standard treatment couch)
NOTE: The textbox that controls yaw rotation is disabled for the
standard treatment couch.
Offset values calculated after image acquisition and image correlation automatically fill the Couch
Position (mm) and Couch Rotation (deg) textboxes.
Arrows above the textboxes point in the positive direction. Values in the textboxes indicate couch
movement relative to its current position. Values above the rotation textboxes show the absolute
rotational position of the couch.

Depending on tracking mode, values are displayed for translations only or for both translations and
rotations.
When the Rotational Bounds Checking Enabled checkbox is enabled, an interlock is
triggered if patient rotational displacements computed by the tracking algorithm exceed the
maximum allowed rotational displacements. This checkbox is enabled by default. For more
information, see “Checking Readiness for Treatment Delivery” on page 8-56.
In the Alignment > Align phase, high initial translational offsets can lead to false rotational
values. If calculated offset values for translation and rotation are high, disable rotational movement
initially, so that only translational adjustments of the treatment couch are made. Then acquire
another image to obtain updated offsets.
If the values in the Couch Position (mm) textboxes are beyond the physical limits of treatment
couch motion, an error occurs and the Error Handling System screen is displayed. If this occurs,
you can try manually aligning the patient using the treatment couch Hand Controller. For
Click a Lock icon to prevent a rotation axis from changing during automatic movement. Click
again to unlock it.
Click the Move Couch button to move the couch to the target position. Values in the textboxes
change and approach zero as the desired couch position is achieved. Slider bars for adjusting
algorithm parameters thresholds turn gray when the couch is moved, since previously calculated
parameter values are no longer relevant.

WARNING: The automatic patient positioning system does not detect when the patient or
the treatment couch is outside the Patient Safety Zone. After patient alignment or
realignment, ensure that the patient is within the Patient Safety Zone. Otherwise collision
of the treatment robot with the patient may result. For more information on the Patient
Safety Zone, see "Chapter 2: Safety".
You can also use Couch Mode to shift the Live X-ray image relative to the DRR image so that
anatomical or other features match. For more information, see “Using Couch Mode” on page 8-19.
NOTE: Couch Mode simulates motion of the treatment couch.

Using Couch Mode to shift the Live X-ray and DRR images
relative to each other does not move the treatment couch.
In Couch Mode, to move the Live X-ray image back to its original, unshifted position, to show
existing alignment, click the Reset icon. Clicking this icon fills the Couch Position (mm)
and Couch Rotation (deg) textboxes with zero values.

In the Alignment > Align phase, you can also click the Offsets icon to fill the Couch
Position (mm) and Couch Rotation (deg) textboxes with the calculated offset values. The
Live X-ray image shifts by the translational offsets, to show the alignment that would result if the
couch is moved by these amounts.
To move the treatment couch to the target position indicated in the Couch Position (mm)
textboxes in Couch Mode, click the Move Couch button. Values in the textboxes change and
approach zero as the desired treatment couch position is achieved.
After moving the treatment couch, you acquire a Live X-ray image and then analyze the image to
confirm visual alignment, as described above.
If you are unable to improve patient alignment using Couch Mode, visually inspect the patient
position and try manually aligning the patient using the treatment couch Hand Controller. For more

Manual Alignment Using the Hand Controller

You can use the treatment couch Hand Controller to manually move the patient into better
alignment. Manual alignment using the Hand Controller is useful in the following situations:
• For initial alignment of the patient prior to taking an X-ray image (see “Initial Alignment of
the Treatment Couch” on page 8-12).
• For alignment when using the automatic patient positioning controls is not possible (see
“Using the Automatic Patient Positioning Controls” on page 8-48).
• At any other time you choose to enter the Treatment Room to move the patient.
 To align the patient manually using the treatment couch Hand Controller:
For information on using the standard treatment couch Hand Controller or the RoboCouch Hand
Controller, see "Chapter 7: Treatment Room Operations".
NOTE: Keep the safety interlock key in the High Voltage

interlock (key switch) on the operator control panel when
manually moving the patient. Do not bypass the Treatment
Room door interlock.
1. For initial patient alignment, perform the steps described in “Initial Alignment of the
Treatment Couch” on page 8-12. Visually align the anatomy to be tracked at the machine
center.
2. Exit the Treatment Room and close the Treatment Room door.
3. On the treatment delivery computer, click the Acquire button in the Alignment >
Align phase.
WARNING: Ensure that the skeletal features, fiducials, or target tumor to be tracked is
correctly identified in the Live X-ray images by the tracking algorithm. If the features are
not correctly identified, see “Analyzing Imaging Results” on page 8-29 for troubleshooting
steps.
4. (Standard treatment couch only) If offset values are displayed in the Offsets panel, use
the Hand Controller to move the patient by the displayed amounts.
To do this, record the translational offset values displayed in the top 3 Offsets text fields
in the Alignment > Align phase (see Figure 16 on page 8-30).

Then re-enter the Treatment Room and use the Hand Controller to move the treatment
couch by the amount and in the translation directions that you recorded.
NOTE: If Offsets values are displayed, you may also use the
automatic patient positioning controls to move the treatment
couch by the displayed amounts.
5. If Offsets values are not displayed, try the following methods to align the patient:
• Enter the Treatment Room. Visually inspect the patient position and try manually
aligning the patient using the treatment couch Hand Controller. Visually verify that the
anatomy to be tracked is aligned at the machine center.
• (Standard treatment couch only) Use Couch Mode to determine how far to move the
treatment couch. Record the translational offset values displayed in the Couch
Position (mm) text boxes.
Then re-enter the Treatment Room and use the Hand Controller to move the
treatment couch by the amount and in the translation directions that you recorded.
NOTE: If you use Couch Mode to determine the translational

offset values, you may also use the automatic patient positioning
controls to move the treatment couch by the displayed amounts.
For more information on aligning the patient when Offsets values are not displayed, see
“Analyzing Imaging Results” on page 8-29.
Physician Setup Approval of Patient Alignment

The Physician Setup Approval button allows a physician to electronically approve the current
patient alignment which creates a record of approval information that is attached to the plan. Not
using Physician Setup Approval still allows for treatment, but no approval record is recorded.
Approval requires that the physician is onsite at the Treatment Delivery Console (TDC).
NOTE: Only physicians with the Setup Approval privilege may

approve plans. See the iDMS Data Management Manual for
more information on user administration and profiles.
For treatments that do not use Respiratory Modeling, once the patient has been aligned the
Physician Setup Approval button is available in the Alignment > Align phase.
For treatments that use Respiratory Modeling, once a valid Respiratory model is built, the
Physician Setup Approval button is available in the Alignment > Respiratory phase
• Click the Physician Setup Approval button and a log on dialog appears.
• Enter your credentials and click OK. The Physician Setup Approval button changes to
Approved with a green checkmark, and its tool tip displays the recorded date, time, and
approver.

Figure 23 Physician Setup Approval button with approved

check mark
Requesting Remote Approval of Patient

Alignment (TxView Option)
If the TxView option is enabled on your iDMS Data Management System, you can request Remote
Approval of the current patient alignment by a Physician. The current patient alignment images and
associated image correlation data are then flagged for review in the TxView application.
The approving Physician reviews the flagged patient alignment data (or the Respiratory model data
for treatments that use Respiratory Modeling) remotely using the TxView dashboard from a web
browser. The Physician either confirms the patient alignment for the treatment fraction or contacts
you for further consultation.
Requirements for Remote Approval

Before you can request Remote Approval, the following conditions must be met.
For treatments that do not use Respiratory Modeling, the patient alignment must be valid:
• The patient is not out-of-bounds.
• No algorithm thresholds are violated.
For treatments that use Respiratory Modeling:
• The patient alignment must be valid for all images in the Respiratory model.
The Respiratory model must be valid (containing at least 8 model points, including the Peak/Valley
and the Center Inhale/Exhale model points).
NOTE: The definition of out-of-bounds is different for treatments

that use Respiratory Modeling and treatments that do not. It
depends on the maximum displacement corrections of the
treatment robot during treatment delivery. For more information,
see "Chapter 12: Synchrony Respiratory Tracking System
(Option)".
 To request Remote Approval:

• For treatments that do not use Respiratory Modeling, click the Remote Approval button
in the Alignment > Align phase.

The images and correlation data associated with the current patient alignment are
flagged for review.
• For treatments that use Respiratory Modeling, click the Remote Approval button in the
Alignment > Respiratory phase.
The current Respiratory model, including all images and correlation data, is flagged for
review.
Table 5 shows how the button changes with request status.
If the approving Physician does not confirm the patient alignment data (or the Respiratory model
for treatments that use Respiratory Modeling), the Remote Approval button remains in the
Pending state. In this case, proceed as per your established procedures. Direct contact with the
approving Physician by phone or other means for further consultation may be required.
If the request for approval is in the Pending (Not Current) or Confirmed (Not Current) state (see
Table 5), you can send another request at any time. The state of the Remote Approval button
applies to the most recent request.
After receiving confirmation of patient alignment from the approving Physician, you can proceed to
the next treatment phase.
NOTE: You can proceed to the next treatment phase even when
the approval request is not in the Confirmed state.
Table 5 Status of Remote Approval
Button Description
Enabled: Remote Approval is enabled, the patient alignment is valid, and the
Respiratory model (for treatments that use Respiratory Modeling) is valid.
Remote Approval is enabled only in Treatment mode, in the Alignment >
Align phase (treatments that do not use Respiratory Modeling) and the
Disabled: Remote Approval is disabled.

The patient alignment is invalid and/or the Respiratory model (for treatments
that use Respiratory Modeling) is invalid.
Remote Approval is not available in Phantom, Demonstration, or Plan QA
mode.
The TxView option is not enabled on the iDMS System.
Pending: A request for Remote Approval was sent and is pending approval
in TxView.

Button Description
Pending (Not Current): The pending request for Remote Approval is not
current. Since the request was sent, the patient alignment data changed in
one or more of the following ways:
A new image was acquired.
An algorithm input parameter was changed, resulting in image recorrelation.
The Respiratory model (for treatments that use Respiratory Modeling) was
updated by adding or recorrelating an image.
Confirmed: The approving Physician confirmed the current patient

alignment data (or the Respiratory model for treatments that use Respiratory
Modeling) in TxView.
Confirmed (Not Current): The approving Physician confirmed the patient

alignment data flagged in TxView. However, the pending request was no
longer current. It was in the Pending (Not Current) state when confirmation
was provided.

Checking Readiness for Treatment Delivery

• “Checking the Patient Safety Zone” on page 8-58
• “Positioning the Patient Within the Patient Safety Zone” on page 8-61
• “Displacement Corrections During Treatment Delivery” on page 8-62
• “Setting Treatment Automation Parameters” on page 8-65
• “Performing a Collimator and Laser Alignment Check” on page 8-21
• “Checking Equipment Readiness” on page 8-67
The CyberKnife System begins a check of equipment subsystems in the Readiness phase.
Figure 24 shows the left screen of the Readiness phase. The screen includes the Delivery
Warning Messages panel for reviewing messages that must be resolved, if applicable, and
confirmed prior to starting treatment delivery, a status area for reporting system readiness, and an
Automation Parameters panel for setting parameters related to treatment automation.
Figure 24 Readiness phase (left screen) for non-

InTempo treatment
8-56 | Checking Readiness for Treatment Delivery 1075883-ENG A

For treatments that use the Synchrony Fiducial Tracking with InTempo Imaging, the left screen
also includes an InTempo Settings panel. For information on the Synchrony Fiducial Tracking
with InTempo Imaging, see "Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging
(Option)".
For treatments that use the SynchronyTracking System, the left screen also includes an Image
Burst Enabled checkbox, and text indicates whether the SynchronyTracking System has been
skipped. For more information on the SynchronyTracking System, see "Chapter 12: Synchrony
Respiratory Tracking System (Option)".
Figure 25 shows the right screen of the Readiness phase. The screen includes the Collimator
and Laser Alignment Check panel, where you make sure the correct collimator is installed.
It also includes the Proximity Detection Status panel, where you perform a Patient Safety
Zone Check.
Figure 25 Readiness phase (right screen)
1075883-ENG A Checking Readiness for Treatment Delivery | 8-57

Checking the Patient Safety Zone

• “PDP Measurement Tool” on page 7-43
• “Patient Size Control Area” on page 7-45
Once the patient is aligned and before you start treatment delivery, enter the Treatment Room and
make a visual check of the patient position. This check should be performed in accordance with
the patient safety guidelines described in "Chapter 2: Safety".
It is very important to make measurements to ensure that before treatment, the patient is located
within both the fixed safety zone and the dynamic safety zone of the Proximity Detection Program
(PDP) model. These dimensions depend on the treatment couch. In addition, the dimensions of
the fixed safety zone depend on whether a head or body treatment is planned, and the dimensions
of the dynamic safety zone for treatment depend on the size of the patient.
When aligning the patient, it is also important to position the patient so that the dynamic safety zone
of the treatment couch is within the fixed safety zone relative to the machine center.
Ensure that the patient and all devices are within the Patient Safety Zone defined by the
PDP model, even if the patient is not in the HFS position. For more information on the
Patient Safety Zone, see "Chapter 2: Safety".
PDP Measurement Tool

Accuray provides a Proximity Detection Program (PDP) measurement tool to help ensure that the
patient is within the fixed safety zone (see Figure 26). The PDP measurement tool has two
positions which are labeled 42 and 44 inches. This adjustable tool lets you verify the following:
• The patient is within the ~42 in (106.2 cm) height limit for head treatments (within the
fixed safety zone for head treatments).
• The patient is within the ~44 in (111.3 cm) height limit for body treatments (within the
fixed safety zone for body treatments).
• The patient is within the ~42 in (107.9 cm) superior limit for body treatments (within the
fixed safety zone for body treatments).

Figure 26 PDP measurement tool
For more information on the dimensions of the Patient Safety Zone and required measurements
before treatment delivery, see the section "The Patient Safety Zone," in "Chapter 2: Safety".
Always visually check the patient to confirm measurements. If you need to realign the patient
during the treatment process, it is recommended that you enter the Treatment Room and perform
a visual check of the patient position, following the patient safety guidelines in "Chapter 2: Safety".
NOTE: If the patient position exceeds the Patient Safety Zone,

there are limited changes that can be made to the patient
position at treatment time. Simulating the treatment plan prior to
treatment delivery is recommended to ensure patient safety.
To prevent this situation from occurring again in future cases,

follow the patient safety guidelines during initial patient
preparation. For more information, see "Chapter 6: Patient
Preparation".

Patient Size Control Area

The right screen of the Readiness phase includes a Proximity Detection Status panel
with a Patient Size dropdown menu that allows you to select a patient size (see Figure 27). This
panel provides information about the PDP model to help you determine if the patient is within the
Patient Safety Zone. This panel is also available on the right screen of the Alignment > Couch
phase and the Alignment > Lung phase.
Figure 27 Proximity Detection Status panel
The patient size sets the dimensions of the dynamic safety zone for treatment. You can select the
following patient sizes:
• Large: Based on size data for a 99 percentile male.
• Medium: Based on size data for a 75 percentile male.
• Small: Based on size data for a 50 percentile female.
the patient.
The Proximity Detection Status panel also includes a circular indicator that shows whether
the dynamic safety zone is positioned within the fixed safety zone. The circular indicator is updated
continually based on the current position of the treatment couch. The circular indicator displays the
following colors:
• Green: The dynamic safety zone is completely within the fixed safety zone. No PDP error
message is displayed.
NOTE: For head treatments, the treatment couch is always in

the green state.
• Orange: Some part of the dynamic safety zone is outside the fixed safety zone. There is
a higher risk of PDP errors occurring during treatment delivery. Before treatment can
commence, a confirmation message is displayed in the Delivery Warning
Messages panel on the left screen warning that the treatment couch is out of range.

Positioning the Patient Within the Patient Safety

Zone
NOTE: The steps below apply to a patient in the Head First
Supine (HFS) position.
 To ensure that the patient is positioned within the Patient Safety Zone for treatment, follow
these steps:
For information on Patient Safety Zone dimensions, see "Chapter 2: Safety".
1. Ensure that the most anterior height of the patient is within the dynamic safety zone that
you selected based on patient size.
2. Ensure that the patient is within the fixed safety zone for head or body treatment, based
on the anatomy chosen during treatment planning.
3. In either the Alignment > Couch phase or the Readiness phase, in the Patient
Size dropdown list of the Proximity Detection Status panel, select the patient
model that is appropriate for the size of the patient (Large, Medium, or Small).
the patient.
4. Be sure the patient is aligned as described in “Performing Patient Alignment” on

page 8-27.
5. When alignment is finished, check the Patient Size circular indicator in the
Proximity Detection Status panel.
NOTE: If the Patient Size circular indicator is not green,

realign the treatment couch.
of the PDP model increases the risk of collision with the treatment robot and can cause
serious injury or harm to the patient.
WARNING: Do NOT place pillows or other objects in an area that could cause Patient
Safety Zone violations. Do NOT position patient extremities so that safety zone violations
occur, or else the patient may be seriously injured or killed.
For examples of actions that may cause Patient Safety Zone violations, see "Chapter 2: Safety".

Displacement Corrections During Treatment

Delivery
During treatment delivery, the treatment robot repositions the LINAC to correct the beam direction
for patient displacement. The treatment robot corrects for both translation and rotation
displacements.
NOTE: No alignment operations using the treatment couch are

allowed during treatment delivery.
Rotational corrections depend on conditions described below.
Translational Corrections
The maximum corrections that the treatment robot can make along each translation axis
(X, Y, and Z) are shown in Table 6. An E-Stop is triggered if any translation displacement exceeds
the values shown below.
The maximum translational correction depends on whether the CyberKnife System uses the
standard treatment couch or the optional RoboCouch System. It also depends on whether the
treatment uses the SynchronyTracking System.
Table 6 Translational corrections by treatment robot
INF/SUP LFT/RGT ANT/POS

Maximum Correction (X Direction) (Y Direction) (Z Direction)
Standard treatment couch (treatments 10 mm 10 mm 10 mm

that do not use Respiratory Modeling)
RoboCouch System (treatments that do 10 mm 10 mm 10 mm

not use Respiratory Modeling)
Treatments that use Respiratory 25 mm 25 mm 25 mm

Modeling (either treatment couch)
NOTE: Aligning the patient until the total detected alignment

error is 2 mm or less (translation) is recommended. The smaller
the alignment error, the fewer errors are likely to occur during
treatment delivery.

Rotational Corrections
The maximum corrections that the treatment robot can make for rotation (roll, pitch, or yaw) before
an E-Stop is triggered depend on the following:
• whether the standard treatment couch or optional RoboCouch System is used.
• the tracking mode.
• the path template.
• whether Respiratory Modeling mode is enabled.
• whether rotational corrections are disabled.
The maximum allowed rotation displacements before an E-Stop is triggered are shown in Table 7
(for the standard treatment couch) and Table 8 (for the RoboCouch System).
Table 7 Maximum allowed rotational displacement (standard treatment couch)
Roll Pitch Yaw

Maximum Rotation (Left/Right) (Head Up/Head Down) (CW/CCW)
Synchrony Fiducial Tracking 1.5° 1.5° 3°

mode
(non-prostate path)
Synchrony Fiducial Tracking 2° 5° 3°

(prostate path)
All other tracking modes 1° 1° 3°
Rotational corrections disabled 5° 5° 5°
Trigeminal path No corrections

Table 8 Maximum allowed rotational displacement (RoboCouch System)
Roll Pitch Yaw

Maximum Correction (Left/Right) (Head Up/Head Down) (CW/CCW)
Synchrony Fiducial Tracking 1.5° 1.5° 3°

mode
(non-prostate path)
Synchrony Fiducial Tracking 2° 5° 3°

mode (prostate path)
All other tracking modes 1.5° 1.5° °
Rotational corrections disabled 5° 5° 5°
Trigeminal path No corrections
The following should be noted for rotational corrections:

• Rotational corrections can be disabled by deselecting the Robot Rotation
Corrections Enabled checkbox, available in the Readiness phase. In this case, if
any rotation displacement (roll, pitch, or yaw) exceeds 5°, an E-Stop is triggered.
• For trigeminal path templates, all rotational corrections are disabled automatically.
• For Synchrony Spine Tracking with Respiratory Modeling enabled, all rotational
corrections are disabled automatically. The default roll, pitch, and yaw values for
rotational bounds checking are set to 2.5°. For more information, see "Chapter 10:
Synchrony Spine Tracking (Option)".
• For prostate path templates, the maximum allowed rotation displacements (roll, pitch, and
yaw) are 2, 5, and 3 degrees, respectively. If any of these values is exceeded, an E-Stop
is triggered.
During patient alignment or realignment, the maximum allowed rotation displacements can be set
to lower values in the Imaging Parameters window.
NOTE: Aligning the patient until the total detected alignment

error is as close to 0 degrees (rotation) as possible is
recommended when the tracking algorithm provides 6D
information. The smaller the alignment error, the fewer errors are
likely to occur during treatment delivery.

Setting Treatment Automation Parameters

Figure 28 shows the Automation Parameters panel of the Readiness phase. This panel
allows you to set parameters related to treatment delivery automation. Parameters are described
below.
Figure 28 Automation Parameters panel in the

Readiness phase
• Rotational Bounds Checking Enabled checkbox: When this checkbox is

enabled, an E-Stop is triggered if patient rotational displacements computed by the
tracking algorithm exceed the maximum allowed rotational displacements.
roll, pitch, and yaw textboxes: The values in these textboxes set the maximum
allowed patient rotational displacements (in degrees). If rotational displacements exceed
these values, a Soft Stop is triggered.
The maximum allowed values are set by default and displayed to the right of the
checkbox. You can specify lower limits. The maximum limits depend on the treatment
couch, the tracking mode, the path template, whether Respiratory Modeling mode is
enabled, and whether the Robot Rotation Corrections Enabled checkbox is
selected.
If the Rotational Bounds Checking Enabled checkbox is deselected, the Robot
Rotation Corrections Enabled checkbox is deselected automatically.
• Robot Rotation Corrections Enabled checkbox: When this checkbox is selected,
the treatment robot corrects for rotational displacements during treatment delivery.
roll, pitch, and yaw textboxes: The maximum allowed values are set by default and
displayed to the right of the checkbox. You can specify lower limits. When the Robot
Rotation Corrections Enabled checkbox is deselected, the maximum allowed
rotational displacements for roll, pitch, and yaw are set to 5 degrees. In this case, if
any rotation displacement (roll, pitch, or yaw) exceeds 5°, an E-Stop is triggered.
• Disable Imaging checkbox: By default this checkbox is not selected. When this
checkbox is selected, Live X-ray images are not taken during treatment delivery.

 To change an automation parameter from its default setting:

1. Deselect the Default checkbox.
2. Enter lower limits for roll, pitch, and/or yaw in the textboxes.
If you deselect the Rotational Bounds Checking Enabled checkbox or the Robot
Rotation Corrections Enabled checkbox, or if you select the Disable Imaging textbox,
a Warning message will be displayed in the Delivery Warning Messages panel. You must review
and confirm the Warning message before you can proceed with treatment delivery.
Performing a Collimator and Laser Alignment

Check
In the Collimator and Laser Alignment Check panel of the right screen, the currently
installed collimator and the collimator specified in the treatment plan are listed.
Text on the screen lets you know any required action. If the current collimator and plan collimator
do not match, you need to exchange collimators. If they already match, you need to perform a
Laser Alignment Check. Controls for performing these actions (see Table 9) are disabled until the
first image is taken.
Table 9 Controls for exchanging collimators and performing a Laser Alignment Check
Button Description
Pick up Fixed Housing and/or Fixed Collimator: The

Xchange System automatically exchanges the current collimator
housing for the fixed collimator housing.
Depending on your CyberKnife System, you then need to install the
correct fixed collimator manually, or the fixed collimator will be picked
up automatically. See "Chapter 7: Treatment Room Operations", for
information on exchanging fixed collimators.
Pick up Iris Housing: The Xchange System automatically

exchanges the current collimator housing for the Iris Collimator.
Perform Laser Alignment Check: If the current collimator

matches the plan collimator, performs a Laser Alignment Check.
Text on the screen indicates whether the check has passed or failed
and describes any required user action.

If your configuration includes the optional Iris Variable Aperture Collimator, a wait period allows the
Iris Collimator to achieve the operating temperature set by the active temperature control system.
The typical wait time after the Iris Collimator is picked up from the Xchange collimator table is five
minutes.
Checking Equipment Readiness

The equipment readiness check includes a check of equipment subsystems, the status of the
Secondary Collimator System and laser alignment, and the status of the treatment robot.
Conditions that result in Warning messages will be described in the Delivery Warning
Messages panel (see Figure 29).
Figure 29 Delivery Warning Messages panel with

unconfirmed message

The Warning Message Status area of the screen at the right of the message panel will
display an orange exclamation point if issues are found.
Figure 30 Warning Message Status area when mes-

sages are unconfirmed
Each warning message must be read, understood, and when applicable, resolved before
confirming the message and proceeding to the Delivery phase.
 To confirm a Warning message in the Delivery Warning Messages panel:
1. Highlight the row containing the Warning message heading.
2. Review the Warning description and, if applicable, resolve the conditions that generated
the warning.
3. Click the Confirm button to confirm you have understood and, if applicable, resolved
the condition.
4. If there is more than one Warning message, highlight the next row. Then review and
confirm the Warning message as described above.
5. To review a previously confirmed Warning message, click the row containing its message
heading.
When all Warning messages have been confirmed, the Warning Message Status area of the
screen displays a green checkmark.
Figure 31 Warning Message Status area when all

messages are confirmed
When the Warning Message Status and Collimation System Status areas both
display green checkmarks, you are ready to start treatment delivery. Click the Delivery tab to go
to the Delivery phase.
For information on the optional TxView remote approval workflow, see “Requesting Remote
Approval of Patient Alignment (TxView Option)” on page 8-53.
For information on the optional Physician Setup Approval of Patient Alignment workflow, see
“Physician Setup Approval of Patient Alignment” on page 8-52.

Treatment Delivery
• “Starting Treatment Delivery” on page 8-71
• “Turning on the High Voltage” on page 8-72
• “Monitoring Treatment Delivery” on page 8-73
Before starting treatment delivery, perform a visual check of the patient position in the Treatment
Room. Follow the patient safety guidelines in “Checking the Patient Safety Zone” on page 8-58.
WARNING: Make sure no one but the patient is in the Treatment Room while treatment is
in progress.
WARNING: Confirm that patient anatomy is correctly aligned before treatment begins.
WARNING: Before starting treatment delivery, print the Path List report from the Accuray
Precision System. During treatment delivery, check off each beam as it is delivered using
the lines available in the report. Monitor the Beam Data window and verify that the dose
and monitor units (MU) displayed on the screen match the report. For information on
printing the Path List report, see the Treatment Planning Manual.
The Delivery phase for Synchrony Skull Tracking mode is shown in Figure 32 (left screen) and
Figure 33 (right screen). Controls on these screens allow you to monitor and verify patient
alignment and tracking results during treatment delivery.
1075883-ENG A Treatment Delivery | 8-69

Figure 32 Delivery phase (left screen) for Synchrony Skull Tracking mode
Figure 33 Delivery phase (right screen) for Synchrony Skull Tracking mode
8-70 | Treatment Delivery 1075883-ENG A

Starting Treatment Delivery
WARNING: Visually observe the patient at all times during treatment delivery. Watch
movement of the treatment robot on the Closed Circuit TV (CCTV) for potential collision. If
the treatment robot appears to be moving too close to the patient or to any other object in
the Treatment Room, or if the treatment robot moves in an unplanned manner, push the
nearest E-Stop button.
 To start treatment delivery:

1. Ensure that the safety interlock key is inserted into the High Voltage interlock (key switch)
on the operator control panel (see "Chapter 8: Treatment Delivery").
2. Click the Start button on the left screen of the Delivery phase.
Figure 34 Start button on left screen of Delivery phase
When the Start button is clicked, treatment delivery automation begins and the
Treatment Delivery System begins performing a complex sequence of actions. In
general, if new Live X-ray images are required, they are acquired automatically. Before
the first beam is delivered, a message is displayed prompting you to turn on the high
voltage to the LINAC (see Figure 35).
Figure 35 Turn on high voltage message

Turning on the High Voltage

To turn on the high voltage to the LINAC, you use the operator control panel.
 To turn on the high voltage to the LINAC:
1. On the operator control panel, turn the safety interlock key clockwise to the ON position in
the high voltage interlock (see Figure 36).
The key switch allows the high voltage to the LINAC to be turned on.
2. Push the ON button in the HIGH VOLTAGE section of the operator control panel to turn
on the high voltage to the LINAC.
After you turn on the high voltage, treatment radiation can be generated and delivered within
2 seconds of the LINAC High Voltage On cycle completing.
High Voltage
High Voltage ON and OFF LINAC Laser
Status Buttons Status
Emergency Stop
Button
Emergency Stop
Status
High Voltage LINAC Power Treatment Radiation

Interlock (Key Status Status
Switch)
Figure 36 Operator control panel

WARNING: During treatment delivery, do not attempt to use the Teach Pendant to move
the treatment robot unless instructed to by the Treatment Delivery System user interface.
Do not remove the Teach Pendant from the Treatment Room. The Teach Pendant should
only be used in the Treatment Room, in order to safely monitor operation of the treatment
robot.
WARNING: Monitor the patient continuously during treatment delivery using the CCTV
system and the Intercom System. Watch movement of the treatment robot for potential
collision. If the treatment robot appears to be moving too close to the patient or to any
other object in the Treatment Room, or if the treatment robot moves in an unplanned
manner, push the nearest E-Stop button.
WARNING: Visually monitor patent movement during treatment delivery. If unexpected

patient movement occurs, pause treatment and acquire Live X-ray images to confirm
patient alignment prior to proceeding.
Monitoring Treatment Delivery

• “Treatment Path Progress” on page 8-73
• “Visual Inspection of Tracking Results” on page 8-76
• “Adjusting the Image Interval Parameter” on page 8-80
• “Monitoring Treatment Data Graphs” on page 8-81
Treatment Path Progress

During treatment delivery automation, the treatment robot moves from node to node in the
treatment path. Typically, at each node where one or more beams will be delivered, the CyberKnife
System performs the actions below. The Treatment Delivery screen displays information about
treatment progress.
• Live X-ray images may be acquired and correlated with the DRR images:
 The imaging sequence depends on the value of the Image Interval parameter (or on
the value of the Max Image Age parameter if the Synchrony Fiducial Tracking with
InTempo Imaging is in use).

For information on the Image Burst Interval parameter for treatments that use
Respiratory Modeling, see "Chapter 12: Synchrony Respiratory Tracking System
(Option)".
 Text between the Treatment Monitoring graphs on the left screen indicates the
position of the treatment robot (also called the treatment manipulator) at the time the
images were acquired and the current position of the robot.
 In the Images counter, the number of acquired images increases by 2 for each pair
of images.
 (For treatments that do not use Respiratory Modeling) The calculated values in the
first column of the Offsets panel values are updated continually during treatment
delivery as new images are acquired.
For information about monitoring treatments that use Respiratory Modeling, see
"Chapter 12: Synchrony Respiratory Tracking System (Option)".
• Pointing of the LINAC is adjusted for the next beam and corrected for target
displacement. The second column of the Offsets panel displays the offset corrections
that are applied to the treatment robot.
Rotational corrections are not applied to the treatment robot if the Robot Rotation
Corrections Enabled checkbox is deselected. For Synchrony Spine Tracking with
Respiratory Modeling treatments, this checkbox is deselected by default and only
translational corrections are made during treatment delivery. For trigeminal paths
templates, all rotational corrections are disabled automatically. For more information on
displacement corrections during treatment delivery, see “Displacement Corrections
During Treatment Delivery” on page 8-62.
• The Beam’s Eye View panel of the right screen displays a diagram that simulates
adjustments to the collimator aperture and shape in real time during treatment.
• Radiation beam is delivered:
 The beam Sequence ID (SID) number for the current beam at the current node is
displayed as the Beam ID number in the Delivery Progress panel (see
Figure 37).
 While radiation is being delivered, the BEAM ON status indicator is lit on the operator
control panel (see Figure 36 on page 8-72) and the text BEAM is ON is displayed
above the Beam Delivery panel (and on the left screen below the Acquire
button).
 When no radiation is being generated, the indicator on the operator control panel is
off and the text BEAM is OFF is displayed above the Beam Delivery panel (and
on the left screen below the Acquire button).
 The cumulative monitor unit (MU) amount delivered for the current beam and fraction
increases in the Beam Delivery panel.
 The elapsed time that treatment has been in progress increases during treatment
delivery in the Delivery Progress panel.
 The estimated total time for delivery of the current fraction in the Delivery
Progress panel and the expected total number of images in the Images counter

are updated prior to each beam delivery. These estimates become increasingly
accurate as the end of a fraction is approached.

panels of the Beam Data window
As treatment proceeds, text between the Treatment Monitoring graphs on the left screen displays
information on the movement of the treatment robot:
• When the treatment robot arrives at an unblocked node, the Node text field displays the
current node number in white.
• When the treatment robot arrives at a blocked node, the Node text field displays the
current node number in yellow and the text "Imaging is blocked" is displayed at the
bottom of the left screen (see Figure 38).
• When the treatment robot is moving to a node, the destination node is displayed in blue.
The text "Robot moving to" is displayed next it. This text may reflect movement from
the previous node position to the next node position, or from the previous beam position
back to a node position.

The iDMS Data Management System is updated after each treatment fraction is completed. Any
screen captures obtained manually (using the F12 function key or <Print Screen> key) and a
screen shot of the final Delivery phase screens at the end of each treatment fraction are
automatically saved in the iDMS Data Management System in the Plan Administration application
for that treatment plan.
For more information on these screen displays, see "Chapter 5: Treatment Delivery System
Overview". For information on the Synchrony Fiducial Tracking with InTempo Imaging, see
"Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging (Option)".
Visual Inspection of Tracking Results
WARNING: After Live X-ray image acquisition:
• Visually verify the patient position and verify that the target has been correctly
identified by the tracking algorithm.
• Monitor Live X-ray images for any artifacts such as surgical implants.
If at any time it appears that the features to be tracked are not correctly located in the Live
X-ray images, pause treatment by clicking the Interlock button (see Figure 40 on
page 8-82) or push the nearest E-Stop button.
If it is determined by visual inspection of the Live X-ray images that the images are blocked, you
can mark the images as blocked.
NOTE: It is possible for image correlation to be performed

without generating an error, even though the target is not
identified correctly. In this case, the tracking algorithm produces
a "false positive" result. Visual inspection of the Live X-ray
images during treatment delivery is essential to identify false
positives.
Controls are available for handling blocked imaging nodes and situations when the treatment robot
is stopped at a blocked node or between nodes (see Table 10). These controls are also available
in the Alignment > Couch phase (see “Visually Aligning the Patient” on page 8-15).
• If treatment was interrupted at a blocked imaging node and you are confirming alignment
of the patient before resuming treatment.
• If treatment was exited at a blocked imaging node and you are beginning immediate
delivery of a makeup fraction.

Table 10 Controls for handling blocked imaging nodes
Button Description
Mark Image as Blocked: Marks the currently displayed Live X-ray

images as blocked. The images are crossed out on the screen, and a
checkbox on the button is selected.
During treatment delivery, marks the node position where those images
were taken as a user-designated blocked node. The node is not
permanently marked as blocked. It is only marked as blocked for the
remainder of the treatment plan, including the current fraction and all
future fractions.
Move Robot to Imaging Node: Moves the treatment robot to the

closest unblocked node for imaging. When the imaging position is
reached, the Acquire button becomes active, allowing you to take a
pair of Live X-ray images.
During treatment delivery, the robot may move forward (in the forward
unblocked node. This node may also be outside the treatment path.
NOTE: The appearance of the buttons in Table 10 may be

different depending on the particular system.
Figure 38 Pause button at blocked imaging node and images marked as blocked

For more information on visually verifying tracking results, see the following:
WARNING: For Synchrony Fiducial Tracking mode, after acquisition of Live X-ray images,
you must visually verify the patient position and the fiducial locations in the images. If it
appears that the patient anatomy or fiducials are not correctly identified, check the
following:
• First check patient alignment. Modify the patient position as required.

• If the patient is aligned correctly, check X-ray parameter settings and modify
as required.
• If X-ray parameter settings do not need adjustment, check imaging parameters
for the tracking mode. Modify imaging parameters as required.
For more information on the above procedures, see “Performing Patient Alignment” on
page 8-27.
 To respond to a node that is blocked:

An user-designated blocked node is a node that is marked as unblocked in the treatment planning
template but which is actually blocked. If this occurs, you can mark the node position as blocked
for the remainder of the treatment plan.
NOTE: It is possible for image correlation to be performed

without generating an error, even though a node is blocked. In
this case, the tracking algorithm produces a "false positive"
result. User-designated blocked nodes must be identified by the
user during treatment by visual inspection of the Live X-ray
images.
1. If treatment delivery is in progress, click the Pause button on the left screen.
A Soft Stop is triggered.
2. Click the Mark Image as Blocked button.
The Live X-ray images are crossed-out on the screen (see Figure 38).
3. Click the Resume button.
NOTE: Marking a node as blocked cannot be undone.

4. Then click the Move Robot to Imaging Node button.

The Treatment Delivery System will move the treatment robot to the closest unblocked
node and will then acquire new images.
For more information on marking nodes as blocked, see "Chapter 5: Treatment Delivery System
Overview".
Imaging Artifacts from LINAC Beam Strikes to the X-Ray

Image Detectors
LINAC beam strikes to the X-ray image detectors are rare but can occur. When the primary
radiation beam hits either detector, it may cause an artifact. This artifact may be present for up to
approximately 24 hours; however, the impact is often minimal after a few minutes. The effect of the
radiation on the detector decays exponentially, with the beam intensity determining the duration
that the artifact persists. This artifact can affect the target tracking, depending on the anatomy that
is being treated and the tracking algorithm that is used.
Interruptions may occur during treatments if the imaging artifact leads to violations of algorithm
thresholds or calculated offsets. Synchrony Skull Tracking, Synchrony Lung Tracking and
Synchrony Spine Tracking are more sensitive to these artifacts. Synchrony Fiducial Tracking is
typically not prone to these interruptions unless the artifact directly overlaps a fiducial and causes
mismatch identification errors.
Imaging artifacts typically do not negatively impact the tracking accuracy of the system. However,
the user should always carefully perform a visual image inspection after each live X-ray image
acquisition to ensure proper algorithm tracking. After live X-ray image acquisition, visually verify
that the target has been correctly identified by the tracking algorithm and monitor live X-ray images
for any artifacts. Check the history of the patient position, since a large change in calculated offsets
can indicate that the algorithm was affected. Monitor the algorithm parameters, since a large
increase in reported algorithm threshold errors may indicate that it was affected by the artifact.
Since a beam strike will only effect one detector at a time, the algorithm will likely be able to find
and track the target without errors. If there are concerns about the results of visual inspection,
algorithm error threshold messages, or sudden changes in reported offset values, acquire new x-
ray images again after a few minutes. If the problem persists, it may be necessary to wait longer
before continuing with the patient treatment. In some instances, the user will need to perform a
system reset.

Adjusting the Image Interval Parameter
WARNING: For all tracking modes, acquire Live X-ray images frequently enough during
treatment for proper tracking of patient movement. The appropriate imaging frequency
depends on patient anatomy and movement. Being unaware of patient movement for a
significant period of time can result in injury or death to the patient.
You can adjust the value of the Image Interval parameter in real-time during treatment delivery to
increase or decrease the maximum imaging frequency.
 To adjust the Image Interval parameter:
• Move the Image Interval (sec) slider bar under the leftmost Treatment Monitoring
graph.
• Alternatively, enter a new value for the Image Interval parameter (in seconds) in the text
box to the right of the slider bar, and then press <Enter>.
When you adjust the Image Interval value, the expected total number of X-ray images for all
fractions in the treatment plan is updated in the Images counter.
For more information on the Image Interval parameter, see "Chapter 5: Treatment Delivery System
Overview".
NOTE: If the Synchrony Fiducial Tracking with InTempo Imaging

is in use, the Max Image Age (sec) slider is displayed
instead. For information on the Max Image Age parameter, see
"Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging
(Option)".

Monitoring Treatment Data Graphs

During treatment delivery, the Treatment Monitoring graphs display treatment data that is updated
in real-time. These graphs allow you to monitor the values of various tracking algorithm parameters
and other data as a function of time or beam number. The graphs depend on the tracking mode
specified in the treatment plan. For more information on these graphs, see "Chapter 5: Treatment
Delivery System Overview".
The Treatment Monitoring graph for Synchrony Skull Tracking mode includes a Skull graph
display (Figure 39). This display shows the computed values of the following parameters as a
function of time:
• Brightness A: The computed Brightness value for Live X-ray image A.
• Brightness B: The computed Brightness value for Live X-ray image B.
• Gradient A: The computed Gradient value for Live X-ray image A.
• Gradient B: The computed Gradient value for Live X-ray image A.
• dxAB (mm): The computed value of the dxAB value (in millimeters).
These graphs allow you to observe the values of the above parameters during treatment delivery
as an indication of tracking reliability.
Figure 39 Treatment Monitoring graphs for

Synchrony Skull Tracking mode
For more information on treatment data graphs for other tracking modes, see the following
chapters:

Interrupting Treatment
WARNING: If any situation has the appearance of an emergency, immediately press the
nearest Emergency Stop (E-Stop) button to stop movement of the treatment couch and
treatment robot and terminate radiation delivery. For more information on Emergency
Stop procedures, see "Chapter 2: Safety".
Patient treatment can be interrupted using the following controls:

• “Hardware E-Stop Button” on page 8-82
• “Interlock Button” on page 8-82
• “Pause” on page 8-83
Treatment is also interrupted when the CyberKnife System detects an error. In this case, either a
recoverable E-Stop, unrecoverable E-Stop, or Soft Stop occurs, depending on what caused the
error. For information, see “Error Handling” on page 8-84.
Hardware E-Stop Button

In an emergency, push the nearest hardware E-Stop button to trigger an E-Stop. Treatment couch
movement, treatment robot movement, X-ray image acquisition, and radiation delivery are
immediately terminated and the high voltage to the LINAC is turned off.
For information on recovering from an E-Stop, see “Error Handling” on page 8-84. For more
information on the E-Stop button, see "Chapter 2: Safety".
Interlock Button
When you click the Interlock button on the bottom of the left screen on the treatment delivery
computer, a recoverable software E-Stop is triggered (see Figure 40). Treatment couch
movement, treatment robot movement, X-ray image acquisition, and radiation delivery are
immediately terminated and the high voltage to the LINAC is turned off.
Interlock Button
Figure 40 Interlock button in E-Stop/Interlock controls
8-82 | Interrupting Treatment 1075883-ENG A

For information on recovering from a recoverable E-Stop after clicking the Interlock button, see
“Error Handling” on page 8-84.
Pause
If a stop is not needed immediately, the Pause button (also referred to as the Soft Stop button)
on the left screen of the Delivery phase can be used to interrupt treatment (see Figure 41).
Figure 41 Pause button on left screen of Delivery phase
When you click the Pause button, treatment is interrupted at the next convenient opportunity. Any
in-progress treatment robot movement, X-ray image acquisition, or beam delivery is completed
before the Soft Stop is engaged.
WARNING: Do not use the Pause button if you need to immediately terminate radiation
delivery or stop treatment robot movement. If any situation has the appearance of an
emergency, immediately press the nearest Emergency Stop (E-Stop) button. For more
information on Emergency Stop procedures, see “Chapter 2: Safety” on page 2-1.
When a Soft Stop is engaged, the button is replaced by the treatment Resume button (see
Figure 42). Clicking the Pause button begins a 180 second countdown. The LINAC high voltage
remains on during the countdown. After 180 seconds, the LINAC high voltage is automatically
turned off.
Figure 42 Resume button on left screen of Delivery phase
To resume treatment after a Soft Stop, see “Patient Realignment After a Pause or Error” on
page 8-91.
1075883-ENG A Interrupting Treatment | 8-83

Error Handling
• “Soft Stops” on page 8-84
• “E-Stops” on page 8-85
• “Resetting a Recoverable E-Stop” on page 8-86
• “Exiting Treatment After an E-Stop” on page 8-87
During treatment delivery, the following types of errors can occur:
• a Soft Stop (a non-emergency treatment interruption)
• a recoverable Emergency Stop (E-Stop)
• an unrecoverable E-Stop.
The type of error depends on what caused the problem.
Soft Stops
Soft Stops are triggered by imaging errors such as image algorithm errors or a patient out-of-
bounds error that occur in the Delivery phase. If a Soft Stop occurs, an error message with
information about the error(s) is displayed in the Messages panel of the Delivery phase (see
Figure 43).
Figure 43 Messages panel in the Delivery phase
The information includes any user action needed to resolve the error. (Another type of message
called a Delivery Inhibitor message is also displayed in the Messages panel. Delivery Inhibitor
messages report conditions that prevent you from starting treatment (the Start button on the left
screen is disabled) until the condition is resolved.)

If more than one error occurs, click the Previous or Next button in the Messages panel to view
their descriptions. When the errors are resolved, the Resume button on the left screen of the
Delivery phase is enabled. You should confirm patient alignment before resuming treatment.
See “Patient Realignment After a Pause or Error” on page 8-91.
For a list of errors that produce a Soft Stop, and a list of Delivery Inhibitor messages, see "Chapter
8: Treatment Delivery".
E-Stops
If an E-Stop occurs, the Error Handling System screen displays information about the error(s) that
led to the E-Stop (see Figure 44). If the error is recoverable, you can correct the error, click
Continue, and resume treatment. If the error is unrecoverable, you cannot continue and must
exit the treatment. For unrecoverable errors, contact Accuray Customer Support. For information
on the Error Handling System screen, see "Chapter 5: Treatment Delivery System Overview".
Figure 44 Error Handling System screen

For more information on error handling, see also:

• "Appendix A: Error Messages".
• "Chapter 7: Treatment Room Operations" for information on error handling with the
optional Xchange System and the optional RoboCouch System.
• "Chapter 9: Synchrony Fiducial Tracking" for information on error handling with
Synchrony Fiducial Tracking mode.
• "Chapter 10: Synchrony Spine Tracking (Option)" for information on error handling with
the optional Synchrony Spine Tracking.
• "Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)" for
information on error handling with the optional Synchrony Lung Tracking with Respiratory
Modeling System.
• "Chapter 12: Synchrony Respiratory Tracking System (Option)" for information on error
handling when the optional SynchronyTracking System is used.
• "Chapter 13: Synchrony Fiducial Tracking with InTempo Imaging (Option)" for information
on error handling when the optional Synchrony Fiducial Tracking with InTempo Imaging is
used.
• "Chapter 15: Lung Optimized Treatment (Option)" for information on error handling when
the optional Lung Optimized Treatment option is used.
Resetting a Recoverable E-Stop

If an E-Stop is recoverable, the Continue button in the Error Handling System screen is enabled.
 To reset a recoverable E-Stop error:
1. Resolve the error if user action is required.
2. Click the Continue button to acknowledge the error and continue with treatment.
If the reset fails, the Error Handling System screen displays any inhibiting errors that
occur.
 To resume treatment after resetting a recoverable E-Stop:
After resetting a recoverable E-Stop using the Continue button in the Error Handling System
screen, you are returned to the Delivery phase.
1. Realign the patient if necessary before proceeding.
2. When patient realignment is completed, you can resume treatment by clicking the
Resume button.
For information on resuming treatment after patient realignment, see “Patient
Realignment After a Pause or Error” on page 8-91.

Exiting Treatment After an E-Stop

You can exit treatment after a recoverable E-Stop or unrecoverable E-Stop. When you exit
treatment, a makeup fraction is automatically generated if the fraction has not been completed.
If an E-Stop is unrecoverable, the Continue button on the Error Handling System screen is
disabled, and only the Exit Treatment button is available. (In some cases outside of the
treatment delivery workflow, an Abort button is available on the Error Handling System screen
instead of the Exit Treatment button.)
 To exit treatment after an E-Stop occurs:
1. Click the Exit Treatment button on the Error Handling System screen. A message
window is displayed asking you to confirm that you want to exit the treatment application.
2. Click the OK button in the message to confirm you want to exit treatment.
• If no beam was delivered before the E-Stop occurred, after clicking OK, you are
returned to the CyberKnife System Menu (see Figure 45).
Figure 45 Message displayed when exiting treat-

ment before beam delivery
• If beam was delivered and the exit sequence followed a recoverable E-Stop, the
message also reports that a makeup fraction will be generated (see Figure 60).
Figure 46 Message displayed when exiting a partial

treatment fraction and a makeup fraction is created

To begin delivery of the makeup fraction, click Cancel to cancel exiting the
treatment application.
To return to the CyberKnife System Menu without delivering the makeup fraction,
click OK.
• If the exit sequence was the result of an unrecoverable E-Stop, CyberKnife System
communications are automatically reset.
While the reset is in progress, the message window of Figure 47 is displayed with the
Yes button disabled until the reset is successful. The text equipment power not
ready is also displayed at the bottom of the message window.
Figure 47 Delivery makeup fraction message
If the reset is successful, the Yes button is enabled. You can then click Yes to begin
delivery of the makeup fraction, or you can click No to return to the CyberKnife
System Menu.
If the reset is not successful (within a couple of minutes), the text equipment power
not ready persists and only the No button is enabled, allowing you to return to the
CyberKnife System Menu. The CyberKnife System is then automatically powered
down.

Error 623: Contact Detection Sensor

The Contact Detection Sensor is a secondary safety feature of the CyberKnife System. It is
installed on the secondary housing for fixed collimators and on the Iris Collimator (see Figure 48).

for Fixed Collimators
Extended
Figure 48 Contact Detection Sensor for Fixed Collimators
An E-Stop (Error 623) is triggered and treatment robot movement is stopped when the Contact
Detection Sensor comes into contact with an obstacle.
WARNING: Always pay close attention to the location of the treatment robot in
relationship to the patient and obstacles in the Treatment Room, even when the Contact
Detection Sensor is extended. If the treatment robot appears to be moving too close to the
patient or to any other object, push the nearest E-Stop button. Treatment robot collision
can result in serious injury or death to the patient.
NOTE: Depending on your CyberKnife System version, Error

20623 will be triggered when the Contact Detection Sensor for
fixed collimators is not pulled down completely so that it covers
the collimator retaining nut. For more information on the Contact
Detection Sensor for fixed collimators, see Chapter 6,
"Treatment Room Operations".

 To respond to a Contact Detection Sensor error (Error 623):

If an E-Stop occurs due to a Contact Detection Sensor error (Error 623) that is triggered by contact
between the treatment robot and the patient or another object:
1. Stop the treatment and attend to the patient.
2. If contact with the patient has occurred without causing injury and if the reason for the
contact can be determined and corrected, treatment can be resumed.
Otherwise:
• Move the patient safely away from the contact area. If necessary, use the Hand
Controller to move the treatment couch away from the contact area.
• After moving the treatment robot safely away from the contact area, move it to the
perch position.
• Record the accumulated dose to the patient.
• Follow the standard E-Stop recovery procedure to reset the error (see “Resetting a
Recoverable E-Stop” on page 8-86).
• Contact Accuray Customer Support as soon as possible.
3. If contact with another object has occurred:
• Move the object away from the treatment robot, if possible.
If the object cannot be moved, use the Teach Pendant to move the treatment robot
away from the contact area.
On the Teach Pendant, select low speed teach mode (T1 mode) and use Jog mode.
Select a slow speed for treatment robot travel.
For more information on moving the treatment robot manually using the Teach
Pendant, see "Chapter 4: System Startup and Shutdown".
• After moving the treatment robot safely away from the contact area, move it to the
perch position.
• Follow the standard E-Stop recovery procedure to reset the error (see “Resetting a
Recoverable E-Stop” on page 8-86).
• Contact Accuray Customer Support as soon as possible.
For information on performing a Contact Detection Sensor check, see "Chapter 2: Safety". For
information on ensuring that the Contact Detection Sensor for fixed collimators is extended
completely, see Chapter 6, "Treatment Room Operations". Report any malfunction of the Contact
Detection Sensor to Accuray Customer Support.

Patient Realignment After a Pause or Error

During treatment, if an error occurs (due to a Soft Stop or an E-Stop) or if you pause treatment by
clicking the Interlock button (see Figure 12 on page 8-20) or the Pause button, you should
confirm alignment of the patient before treatment can resume.
 To confirm patient alignment and resume treatment after a Pause, Soft Stop, or E-Stop:
Before treatment delivery can resume, new Live X-ray images may be acquired to confirm the
patient position.
1. Click the Acquire button in the Delivery phase to acquire new Live X-ray images.
2. After confirming the patient position, click the Resume button to resume treatment.
3. Follow the steps in “Treatment Delivery” on page 8-69 to restart treatment delivery and
turn on the high voltage to the LINAC.
Treatment delivery then proceeds as before.
If the Pause, Soft Stop, or E-Stop occurred when the treatment robot was not at an unblocked
node, you can also click the Move Robot to Imaging Node button to move to the closest
unblocked node for imaging. Then you can click the Acquire button to manually acquire new Live
X-ray images and perform image correlation. After successful image correlation, you can then click
the Resume button to proceed with treatment delivery.
 To resume treatment after a Soft Stop:

1. Click the Resume button in the Patient Alignment and Resume Treatment window.
The Beam Data window and Treatment Monitoring window are displayed. The value of
the Image Interval parameter (or the value of the Max Image Age parameter if the
optional Synchrony Fiducial Tracking with InTempo Imaging is in use) is checked to
determine if new Live X-ray images are required. New images are also required if the
Discard displayed corrections checkbox is selected.
2. If the HV ON countdown timer reached 0 seconds and the high voltage to the LINAC
was turned off, you are prompted to turn it on before the next beam is delivered.
Turn the high voltage on as described in “Turning on the High Voltage” on page 8-72.
Treatment delivery then proceeds as before.
1075883-ENG A Patient Realignment After a Pause or Error | 8-91

Makeup Fractions
A makeup fraction is automatically created when a fraction of a patient treatment plan or a QA plan
is terminated before the total dose is delivered. For example, a makeup fraction is created when
an unrecoverable error occurs or treatment delivery is exited (see “Exiting Treatment After an E-
Stop” on page 8-87).
A makeup fraction consists of all paths of the terminated fraction that were not executed. If needed,
the makeup fraction also includes a makeup path similar to the path in which the termination
occurred. The makeup path contains the same set of nodes as the terminated path, except that
nodes where dose has been delivered have a zero dose and the node where the termination
occurred contains only the dose remaining.
If treatment is exited and you immediately begin delivery of the makeup fraction from the current
position of the treatment robot (without first moving the perch position):
• If treatment was exited at a blocked node, only the Move Robot to Imaging Node
button will be enabled in the Delivery phase. Click the Move Robot to Imaging
Node button to move the treatment robot to the closest unblocked node position for
image acquisition. After successful image correlation, you can click the Resume button.
The treatment robot then proceeds to the next node in the treatment path where beam is
to be delivered.
NOTE: When you start delivery of a makeup fraction

immediately after exited treatment, you cannot use the Teach
Pendant to move the treatment robot.
8-92 | Makeup Fractions 1075883-ENG A

Phantom Mode
Phantom mode allows you to simulate patient treatment using a phantom to check the accuracy
and safe delivery of a patient treatment plan. To access this mode, click the Phantom button on
the CyberKnife System Menu and then log in. This button is enabled only when equipment power
is on.
Controls are the same as those in Treatment mode. In Phantom mode, however, you can only
select treatment plans created for phantoms. For information on specifying whether a treatment
plan applies to a patient or phantom, see the Data Management Manual.
A phantom treatment plan has unlimited deliverable fractions. When the last fraction in a phantom
treatment plan is completed, a new fraction is automatically created. To view the new fraction in
the Overview phase, click the Refresh button. In this way, you can continue treatment delivery
to the phantom without the need to create a new treatment plan.
For more information on Phantom mode, see "Chapter 5: Treatment Delivery System Overview".
Demonstration Mode
Demonstration mode allows you to demonstrate operation of the CyberKnife System by
performing a BB test. In this mode, no treatment radiation is delivered. Live X-ray images can be
acquired in the patient alignment phase using a phantom. However, no live X-ray images are
acquired during the robot motion phase. You have the option of bypassing the X-ray imaging
system in the patient alignment phase, allowing you to start the demonstration without acquiring
initial Live X-rays. The demonstration is performed using the Teach Pendant to manually move the
treatment robot.
Controls are the same as those in Treatment mode, except that you can bypass the X-ray
imaging system and the Secondary Collimator System. For more information on controls in
Demonstration mode, see "Chapter 5: Treatment Delivery System Overview".
BB Test
The BB test is used to demonstrate operation of the CyberKnife System. It is also used to perform
a visual qualitative check of the targeting accuracy of the treatment robot.
NOTE: For more information on equipment and procedures

used during the BB test, see the Physics Essentials Guide.
1075883-ENG A Phantom Mode | 8-93

Required Phantoms
The following phantoms are required for the BB test:
• Skull phantom with external markers (also called BBs) on the surface of the phantom for
Synchrony Skull Tracking mode. The external marker (BB) on the surface of the phantom
is shown in Figure 49.
• A skull or body phantom with 3 or more fiducials and external markers (BBs) on the
surface of the phantom for Synchrony Fiducial Tracking mode.
External
Marker
Figure 49 External marker (BB)

on surface of phantom

BB Test Procedure
This section gives instructions for performing the BB test.
 For treatment planning and DRR generation, follow these steps:
1. Select the appropriate phantom for the BB test.
2. Obtain a CT scan of the phantom and load it as a phantom CT image into the iDMS Data
Management System.
For more information on the iDMS Data Management System, see the Data Management
Manual.
3. In the Accuray Precision System, select the phantom and CT scan for the BB test. Select
Synchrony Fiducial Tracking mode. Mark fiducials as necessary.
4. Choose a 5 mm fixed collimator and locate the target as the one of the external markers
(BBs) on the surface of the phantom.
5. Generate a simple isocentric plan. For more information, see the Treatment Planning
Manual.
6. Save the treatment plan as a deliverable plan.
 To load patient data for the demonstration:
For more information on loading patient data, see “Loading Patient and Treatment Data” on
page 7-2.
1. On the treatment delivery computer, click the Demonstration button on the
CyberKnife System Menu and then log in. This button is enabled only when equipment
power is on.
The Load Patient Data screen is displayed.
2. Select the phantom, the treatment plan generated for the BB test, and the fraction. Then
click the Load button.
The screens for the Overview phase are displayed.
3. Verify the patient, treatment, and fraction information and then select the three Data
Verified checkboxes in order from left to right.
After treatment files are downloaded, click the Alignment > Couch tab to go to the
Alignment > Couch phase.
 To perform patient alignment:

For more information on performing patient alignment, see “Performing Patient Alignment” on
page 8-27.
1. Use visual inspection to position the phantom close to the required position on the
treatment couch table top or headrest.
2. Exit the Treatment Room and close the Treatment Room door.
3. On the left screen of the Alignment > Couch phase, click the Acquire button to
acquire an X-ray image of the phantom. Then visually align the phantom.

4. Click the Technique tab to go to the Alignment > Technique phase. If nothing is
changed in the phase and you are satisfied with the Technique, move on to the
Alignment > Align phase. If you are not satisfied, go back to step 3.
5. Click the Align tab to go to the Alignment > Align phase. Adjust the treatment
couch position using the values in the Offsets panel.
If no offset values are displayed, visually assess the alignment of the DRR images and
the Live X-ray images.
6. Repeat the above process until the values displayed in the Offsets panel are 1 mm or
less for translations and 1 degree or less for rotations (if available).
 To perform the BB test:
1. Click the to go to the Readiness phase. An equipment readiness check is performed.
When all equipment subsystems are ready, the Warning Message Status and
Collimation System Status text fields on the left screen both display green
checkmarks. For more information on the equipment readiness check, see “Checking
Equipment Readiness” on page 8-67.
2. Click the Delivery tab to go to the Delivery phase. Then click the Start button on the
left screen of the Delivery phase.
A message is displayed in the Messages panel on the right screen that instructs you to
use the treatment robot Teach Pendant to continue the demonstration (see Figure 50).
Figure 50 Use Teach Pendant message

3. Enter the Treatment Room. Bypass the Treatment Room door E-Stop and enter the
Treatment Room.
To bypass the Treatment Room door E-Stop, remove the safety interlock key Enable
High Voltage key from the operator control panel and use it to bypass the Treatment
Room door interlock. Bypassing the Treatment Room door interlock allows you to open
the Treatment Room door without producing an E-Stop.
WARNING: Pay close attention at all times to treatment robot movement to ensure the
safety of observers. If the treatment robot appears to be moving too close to any person
or object in the Treatment Room, push the E-Stop button on the Teach Pendant to stop
movement of the treatment robot.
NOTE: In Demonstration mode, when the Teach Pendant is

used to initiate the robot motion phase of the demonstration, no
further X-ray images are taken.
On the Teach Pendant select the SIM NODE button to initiate the demonstration, and then
continue to press the SIM NODE button until the robot moves to the first node.
Figure 51 BB Test window on Teach Pendant
The treatment robot moves to the first node.

4. Verify that the laser is pointing at the external marker (BB) targeted in the treatment plan
to within 1 mm.
NOTE: The laser is only on while the beam is delivered.

5. On the Teach Pendant, select the SIM NODE button again to move to the next node in
the treatment path.
6. Verify that the treatment robot stops at the next node and that the laser is pointing at the
external marker (BB) to within 1 mm.
 Adjust the phantom position a few times during the BB test and continue:
For more information on pausing and resuming treatment, see “Interrupting Treatment” on
page 7-69. For information on patient realignment, see “Patient Realignment After a Pause or
Error” on page 7-81.
1. On the left screen of the Delivery phase, click the Interlock button at the bottom of
the screen (see Figure 12 on page 8-20).
2. Verify that a CyberKnife System E-Stop occurs and the Error Handling System window is
displayed. Verify that the treatment robot stops moving.
3. Click the Continue button. Verify that the screens of the Delivery phase are
displayed.
4. Enter the Treatment Room and adjust the phantom position by about +5 mm along the X
axis, for a coordinate system defined for a patient in the HFS position on the treatment
couch:
• X axis: Inferior(+)/Superior(-)
• Y axis: Left(+)/Right(-)
• Z axis: Anterior(+)/Posterior(-)
5. Exit the Treatment Room and close the Treatment Room door. Remove the safety
interlock key from the Treatment Room door and return it to the operator control panel.
6. Click the Pause button to activate the Acquire button, and then click Acquire.
WARNING: Ensure that no users or observers are in the Treatment Room when Live X-ray
7. Verify that Live X-ray images are acquired and new offset values are calculated and
displayed in the Offsets panel text fields. Verify that these values are different from the
previous values by approximately the amount that the phantom position was adjusted.
8. Click the Resume on the left screen of the Delivery phase.
A message window is redisplayed instructing you to use the treatment robot Teach
Pendant to continue the BB test (see Figure 51 on page 8-97).

9. Bypass the Treatment Room door E-Stop and re-enter the Treatment Room.
To bypass the Treatment Room door E-Stop, remove the safety interlock key from the
operator control panel and use it to bypass the Treatment Room door interlock.
Bypassing the Treatment Room door interlock allows you to open the Treatment Room
door without producing an E-Stop.
NOTE: In Demonstration mode, when the Teach Pendant is used to initiate the robot
10. On the treatment robot Teach Pendant select the SIM NODE button to move to the next
node in the treatment path.
11. Verify that the treatment robot moves to the next node and that the laser is pointing at the
external marker (BB) to within 1 mm.
12. Repeat the BB test with following patient position adjustments:
• ±5 mm in the X direction
• ±5 mm in the Y direction
• ±5 mm in the Z direction
• +5 mm in the X, Y, and Z directions
• -5 mm in the X, Y, and Z directions
13. When a sufficient number of nodes have been observed for pointing accuracy, select the
SIM ALL button on the Teach Pendant.
The treatment robot moves through the remaining nodes in the treatment path and then
returns to the perch position, without stopping for operator intervention.
14. At the end of the demonstration, remove the safety interlock key from the Treatment
Room door, return it to the operator control panel, and close the Treatment Room door.

Plan QA Mode
Plan QA mode allows you to select a quality assurance (QA) plan associated with a specific
patient and patient treatment plan and deliver the QA plan to a phantom. This mode provides a
method to perform quality assurance for patient-specific treatment plans.
WARNING: Plan QA should be performed prior to patient treatment delivery to verify that
the planned dose is consistent with the measured dose. Failure to perform plan QA can
result in patient mistreatment. For more information on the plan QA procedure, see the
Physics Essentials Guide.
Controls in Plan QA mode are the same as those in Treatment mode, except for the additional
QA plan information described in "Chapter 5: Treatment Delivery System Overview" and as
described below.
In Plan QA mode, you can only select QA plans for delivery. Only a single fraction is created for
a QA plan. If the fraction is partially delivered and treatment is aborted, a makeup fraction is created
that can be immediately delivered.
For information on creating a QA plan, see the Treatment Planning Manual. For information on
authorizing a QA plan and recording analysis results, see the Data Management Manual.
Plan Approval and DRR Generation

Before a QA plan can be delivered, it must be approved for delivery and Digitally Reconstructed
Radiograph (DRR) images must be generated from the patient CT image series. These procedures
are the same as for patient treatment plans.
Treatment plan approval and DRR generation are performed using the iDMS Data Management
System. For more information, see the Data Management Manual.
Loading Patient and Treatment Data for QA Plan

NOTE: Follow hospital procedures for verifying the patient and
treatment plan information.
NOTE: Do not attempt to modify a treatment file. Improperly

changed data can result in invalid QA results.
On the day of QA plan delivery, on the treatment delivery computer, power on the CyberKnife
System as described in "Chapter 4: System Startup and Shutdown".
Loading patient and treatment data includes the following steps:
• “Select the Patient, Treatment Plan, and QA Plan” on page 8-101
• “Verify Patient and Treatment Data for the QA Plan” on page 8-102

Select the Patient, Treatment Plan, and QA Plan

The first step to load patient and treatment data is to select the patient, patient treatment plan, and
QA plan.
 To select the patient, treatment plan, and QA plan:
1. On the CyberKnife System Menu, click the Plan QA button and log in as described in
"Chapter 4: System Startup and Shutdown". You may also add participants, as described
in "Chapter 5: Treatment Delivery System Overview".
After a successful login, the Load Patient Data screen is displayed (for an example for
Treatment mode, see “Select the Patient, Plan, and Fraction” on page 8-6). This
screen lists patients with approved treatment plans, along with QA plans associated with
the treatment plans. It may take a moment for data to be retrieved from the data server of
the iDMS Data Management System.

populated with the names of approved treatment plans for that patient that also have
associated QA plans. Patient treatment plans and QA plans are not listed until DRR
images have been generated on the iDMS Data Management System.
3. To refresh the Patient list with patients that have newly approved treatment plans, and
the Plan list and QA Plan list with plans that have newly generated DRR images, click
the Refresh button. It may take a few moments for the lists to be updated.
4. Click to select a patient treatment plan from the Plan list. After a moment, the QA Plan
list is populated with the names of QA plans for that treatment plan.
5. Click to select a QA plan from the QA Plan list.
Under the lists, the Patient, Plan, and QA Plan sections display information about the
selected patient, treatment plan, and QA plan as you select them.
In the QA Plan section, the name and Medical ID of the phantom used to create the QA
plan is displayed. The same phantom should be used for QA plan delivery.
For more information on the text fields of the Load Patient Data screen, see "Chapter 5:
Treatment Delivery System Overview".
6. Click the Load button to begin downloading patient and treatment data from the iDMS
Data Management System to the treatment delivery computer.
After you click the Load button and patient and treatment data is downloaded, you are ready to
verify that the data is correct in the Overview phase.

Verify Patient and Treatment Data for the QA Plan

In the Overview phase, you verify that patient and treatment data are correct. The left screen of
the Overview phase displays patient and treatment information (for an example for Treatment
mode, see “Verify Patient and Treatment Data” on page 8-8). You must verify that this information
is correct before you can proceed.
NOTE: Carefully verify that this phantom is in fact the one

specified in the QA plan and that the QA plan is the correct one
to use. Otherwise, the plan QA procedure will not yield accurate
results.
When this window appears, the first Data Verified checkbox is active. You must verify that
patient, treatment plan and QA plan, and treatment fraction information in the three columns on the
left screen are correct.
 To verify that patient and treatment information for the QA plan is correct:
1. If the patient information is correct, click the first Data Verified checkbox. The second
Data Verified checkbox in the treatment information section becomes active.
If information is not correct, click the Interlock button at the bottom of the left screen,
followed by the Exit Treatment button on the Error Handling System screen. After
clicking OK, you will return to the CyberKnife System Menu.
2. If the treatment plan and QA plan information is correct, click the second Data Verified
checkbox. The third Data Verified checkbox in the treatment fraction information
section becomes active.
3. If the treatment fraction information is correct, click the third Data Verified checkbox.
For more information on the Overview phase, see "Chapter 5: Treatment Delivery System
Overview".
Treatment files, including treatment paths, DRR images, and other treatment data for the QA plan,
are downloaded from the treatment delivery computer to the Target Locating System (TLS)
computer. The initial alignment position for the treatment couch is also downloaded to the
treatment couch Hand Controller.
After treatment files have been successfully downloaded, click the Alignment > Couch tab to
go to the Alignment > Couch phase (see “Visually Aligning the Patient” on page 8-15).
Procedures for initial positioning of the phantom and phantom alignment are the same as those
described in “Initial Patient Positioning” on page 8-10 and “Performing Patient Alignment” on
page 8-27.

Treatment Delivery of a QA Plan

After aligning the phantom, you are ready to begin delivering the QA plan to the phantom.
Treatment delivery procedures for a QA plan are the same as those for a patient treatment plan,
except as described below.
If delivery of a QA plan is interrupted by a Soft Stop or a recoverable E-Stop, the treatment path
that was interrupted can be resumed. If delivery is interrupted by an unrecoverable E-Stop,
treatment must be aborted.
Only a single fraction is created for a QA plan. Makeup fractions are created when a QA plan is
partially delivered and aborted that can be delivered immediately.
QA plans are delivered using either Synchrony Skull Tracking or Synchrony Fiducial Tracking
mode, regardless of the tracking mode specified in the patient treatment plan. Fiducials outside the
live field of view are disabled. If all fiducials are outside the live field of view, an unrecoverable error
occurs and replanning is required.


Chapter 9: Synchrony Fiducial
Tracking
Introduction
This chapter describes how to use Synchrony Fiducial Tracking mode with the CyberKnife
Treatment Delivery System.
• “Overview of the Synchrony Fiducial Tracking System Algorithm” on page 9-2
• “Workflow for Synchrony Fiducial Tracking Mode” on page 9-4
• “Verifying Patient and Treatment Data” on page 9-5
This chapter assumes you are familiar with “Chapter 8: Treatment Delivery”.
NOTE: For information on using the optional InTempo Adaptive

Imaging System with Synchrony Fiducial Tracking mode, see
“Chapter 13: Synchrony Tracking with InTempo Imaging
(Option)”.

Overview of the Synchrony Fiducial Tracking

System Algorithm
The Synchrony Fiducial Tracking System uses a fiducial extraction algorithm that analyzes both
the DRR and Live X-ray images to determine fiducial locations.
In fiducial tracking mode, the DRR and Live X-ray images are enhanced to minimize background
and noise information. The region around reference fiducials in the DRR images is then extracted
and correlated with the corresponding Live X-ray images.
Candidate fiducial locations are identified using the correlation images, the relative position of
fiducials in the two Live X-ray images, and the expected position of fiducials relative to each other.
The fiducial extraction algorithm also computes an uncertainty value that provides a measure of
the likelihood of error in the extracted fiducial configuration.
Tracking accuracy is impacted by the relative distance of the isocenter to the tumor target, which
is recommended to be less than 5.0 cm.
Rigid Body Error

For a fiducial configuration consisting of two or more fiducials, the distance between each pair of
fiducials in the Live X-ray images is calculated and compared with the respective distances as
determined in the CT volume. The difference between these distances is called the Rigid Body
Error. These distances are shown in Figure 1 for an example configuration of 3 fiducials.
2 3 2 3
(a) CT volume (b) Live X-ray image
Figure 1 Example configuration of 3 fiducials in which

Fiducial 1 has migrated in the Live X-ray images relative to
its location in the CT volume
9-2 | Overview of the Synchrony Fiducial Tracking System Algorithm 1075883-ENG A

Treatment Delivery Manual Chapter 9: Synchrony Fiducial Tracking
For a configuration of 3 fiducials, there are 3 Rigid Body Error values, one for each pair of fiducials.
In this example, the Rigid Body Error value for each fiducial pair is determined from the following
quantities:
• F1-2|CT: distance between Fiducial 1 and 2 in the CT volume
and
• F1-2|Live: distance between Fiducial 1 and 2 in the Live X-ray images
The Rigid Body Error, RBE, for each pair of fiducials is the difference between the corresponding
distances in the CT volume and the Live X-ray images:
RBE1-2 = | F1-2|CT - F1-2|Live |
RBE1-3 = | F1-3|CT - F1-3|Live |
RBE2-3 = | F2-3|CT - F2-3|Live |
The Rigid Body (mm) threshold sets the maximum allowed value of the Rigid Body Error for each
pair of fiducials. If the value for any one pair of fiducials exceeds this threshold, an error occurs and
treatment is interrupted.
For information on responding to a Rigid Body Error and adjusting the threshold, see “Responding
to a Rigid Body Error” on page 9-23.
1075883-ENG A Overview of the Synchrony Fiducial Tracking System Algorithm | 9-3

Workflow for Synchrony Fiducial Tracking

Mode
Figure 2 shows the workflow for patient alignment and treatment delivery using fiducial tracking
mode.
Figure 2 Workflow for Synchrony Fiducial Tracking

mode
Figure 3 shows the workflow for patient alignment and treatment delivery when the Synchrony
Fiducial Tracking System is used with Respiratory Modeling. For information on using the
Synchrony tracking System, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
Figure 3 Workflow for Synchrony Fiducial Tracking

with Respiratory Modeling
Aligning the patient in Synchrony Fiducial Tracking mode requires ensuring that the fiducial
extraction algorithm has correctly located the fiducials. The patient position is then adjusted until
proper alignment is reached. In the Alignment phase, you perform the following steps:
• Visually aligning the patient in the Alignment > Couch phase.
• Optimizing the X-ray technique in the Alignment > Technique phase.
• Performing patient alignment in the Alignment > Align phase.
For more information on the general workflow for patient alignment and treatment delivery, see
9-4 | Workflow for Synchrony Fiducial Tracking Mode 1075883-ENG A

Verifying Patient and Treatment Data

In the Overview phase, you load patient treatment files and verify that patient and treatment data
are correct. After treatment files for the patient have been downloaded to the treatment delivery
computer, you move to the Alignment > Couch phase to begin patient alignment procedures.
For more information on the Overview phase, see “Chapter 8: Treatment Delivery”.

Live X-ray and DRR images before proceeding to the next phase.
Figure 4 shows the Alignment > Couch phase (left screen) for Synchrony Fiducial Tracking
mode after the Live X-ray and DRR images have been visually aligned using Couch Mode. Table 1
on page 9-11 describes the image panel controls to aid image analysis and visual alignment. For
more information on this phase, see “Chapter 8: Treatment Delivery”.

chrony Fiducial Tracking mode after visual alignment using
Couch Mode
1075883-ENG A Verifying Patient and Treatment Data | 9-5


The goal of the Alignment > Technique phase for fiducial tracking mode is to find the optimal
X-ray technique. This X-ray technique will be the default for future treatment fractions unless it is
changed. You start by analyzing the existing image from the Alignment > Couch phase.
For additional information on the Alignment > Technique phase, see “Chapter 8: Treatment
Delivery”.
correctly.
X-ray parameters should be set to achieve Live X-ray images that look similar to the DRR images.
For fiducial tracking treatments, set X-ray parameters so that fiducials can be clearly seen against
the background. For more information on setting X-ray parameters and acquiring Live X-ray
images, see “Chapter 8: Treatment Delivery”.
Figure 5 shows the Alignment > Technique phase (left screen) for fiducial tracking mode
after image acquisition.

Figure 5 Alignment > Technique phase (left screen)

for Synchrony Fiducial Tracking mode after image
acquisition
If you are satisfied with the X-ray technique, you can proceed to the Alignment > Align phase.
Otherwise, you can change the X-ray technique as needed until you are satisfied with the image
quality, as described below. For more information on this phase, see “Chapter 8: Treatment
Delivery”.

To visually identify the fiducials clearly against the background, you can attempt to improve the
quality of the Live X-ray images by modifying X-ray parameters. If there is too little detail in the Live
X-ray images, you can try increasing the kV, mA, and ms settings to increase the exposure. If
the image is too dark, try decreasing the kV, mA, and ms settings to decrease the exposure.
If the fiducials appear blurred, try decreasing the ms setting and increasing the mA setting to
compensate. Decreasing ms may lessen the effect of tumor motion during imaging while
increasing mA may improve image quality. For fiducial location, it is best to maximize the contrast
between the fiducials and the surrounding tissue.
After modifying X-ray parameters, you acquire new Live X-ray images by clicking the Acquire
button.


The goal of the Alignment > Align phase for Synchrony Fiducial Tracking mode is to make
sure the patient is aligned within acceptable bounds for treatment delivery, or for Respiratory
Modeling if the Synchrony tracking System is used.
Figure 6 shows the Alignment > Align phase (left screen) for Synchrony Fiducial Tracking
mode after image correlation. For more information on this phase, see “Chapter 8: Treatment
Delivery”.
Figure 6 Alignment > Align phase (left screen) for

Synchrony Fiducial Tracking mode after image cor-
relation
correlated with the DRR images. The fiducial extraction algorithm attempts to locate the fiducials
in the images. Once located, fiducials are marked in the Live X-ray images with a green circle
marker. The locations of the reference fiducials are marked with yellow diamond markers in the
DRR images.

If fiducial extraction was successful and candidates are found for all fiducials, the Offsets panel
displays suggested treatment couch movements to position the patient in correct alignment.
ray images to ensure that the fiducials to be used for tracking are correctly identified.
• “Moving the Couch” on page 9-26: You move the treatment couch as needed and acquire
new Live X-ray images.
For additional information on the Alignment > Align phase, see “Chapter 8: Treatment
Delivery”.

• “Ensuring Fiducial Identification and Tracking” on page 9-10
• “Enable or Disable Fiducials Used For Tracking” on page 9-22
• “Responding to a Rigid Body Error” on page 9-23
• “Analyzing the Image History” on page 9-25

The calculated offset values indicate treatment couch movement needed to align features in the
Live X-ray and DRR images. Images are automatically shifted by the translational offsets to show
the alignment that would result if the couch is moved by these amounts.
• Offsets are within tolerances required for treatment delivery, and you can verify that
fiducials have been correctly identified and are in the correct configuration.
button. See “Moving the Couch” on page 9-26.

and an out-of-bounds error has occurred. An orange box around a tracking algorithm
slider bar indicates that a threshold violation has occurred.
 You can use image analysis tools in Table 1 on page 9-11 to make sure you can
visually identify the fiducials to be used for tracking. Check that fiducials are aligned
in the Live X-ray and DRR images.
Algorithm Parameters” on page 9-16.
NOTE: Depending on the tracking mode, offsets may not be

calculated for certain values and dashes are displayed instead.
For example, no rotational offsets are calculated for fiducial
tracking mode when fewer than three fiducials are selected for
tracking.
Ensuring Fiducial Identification and Tracking

• “Using Image Panel Controls” on page 9-10
• “Using Offset Mode to Shift ROIs Manually” on page 9-15
WARNING: Visually ensure that the fiducials are correctly identified.
WARNING: Misidentifying image features that appear similar to anatomical structures

used for tracking may result in mistreatment. Carefully review images to correctly identify
anatomical structures used for tracking.
For more information on procedures to help visually identify fiducials, see “Chapter 8: Treatment
Delivery”.
Using Image Panel Controls

Table 1 describes image panel controls to aid image analysis as you verify that fiducials are
correctly identified.

Control Description

image.
You can also use Offset Mode when the Pointer is turned on. For more
information, see “Using Offset Mode to Shift ROIs Manually” on page 9-15.
Respiratory Model one at a time in respiratory sequence. This makes tumor


Control Description
clicking and dragging in either the Live X-ray image or DRR image. See “Moving
the Couch” on page 9-26. Depending on the treatment phase, the following icons
are displayed:
unshifted position.
They affect the image display only.
(Synchrony Fiducial Tracking mode only) You may need to modify the Window/
Level settings for the Live X-ray images to see the fiducials.

Control Description
DRR images. Can be used with other image panel controls.
Fiducial ROI: (Synchrony Fiducial Tracking mode only) Displays a square yellow
box in the Live X-ray image for each Region of Interest (ROI) where the fiducial
extraction algorithm searches for fiducial candidates. Each box is centered on a
fiducial candidate.
adjusted. For more information, see “Adjusting the Tracking Range (mm)” on
page 9-20.
Fiducial Markers: (Synchrony Fiducial Tracking mode only) Displays markers in

the Live X-ray and DRR images to identify fiducial locations:
Live X-ray image in Offset Mode. For more information, see “Chapter 9:
Synchrony Fiducial Tracking”.
DRR images.
out automatically.

Control Description
image is required.
r Turn on/off Fiducial ROI. (Synchrony Fiducial Tracking mode)
m Turn on/off Fiducial Markers. (Synchrony Fiducial Tracking

mode)

Using Offset Mode to Shift ROIs Manually

In the case that the fiducials are not found correctly by the fiducial extraction algorithm, it is
necessary for you to assist the algorithm by shifting the fiducial ROIs manually.
You can use Offset Mode to move all ROIs simultaneously. Offset Mode is useful when you can
visually identify fiducials that the fiducial extraction algorithm cannot identify: In Offset Mode, you
click and drag the mouse in one of the Live X-ray images to move all reference fiducial ROIs
simultaneously and overlay them on features you have visually identified as fiducials.
1. Turn on the Pointer and Fiducial Markers in the image panel (see Table 1 on page 9-11).
You can also click the Fiducial ROI icon to simultaneously display ROI boxes if you
choose.
2. Use the Blend Tool to adjust the blending of the Live X-ray image so that it is 100%. (It is
100% by default to start with for fiducial tracking mode).
This step removes the display of yellow diamond markers for reference fiducials in the
DRR image. Only green circle markers will be displayed to indicate the reference fiducial
locations projected onto the Live X-ray image.
3. Move the cursor over one of the green circle markers in the Live X-ray image. The circles
turn red.
4. Click in the Live X-ray image to grab the reference group of circle markers. Drag the
group of circles to overlay them on fiducials you have visually identified in the Live X-ray
image. The circles turn red as you drag them. Depending on the direction you drag them,
the reference group of circles in the other image may also move.
5. Let go of the reference group of circle markers. Both Live X-ray images are automatically
correlated. The translational offsets determined by moving the reference configuration of
fiducials are input to the fiducial extraction algorithm. The fiducial extraction algorithm
uses the new location of the circle markers to search for fiducials.
After the correlation is performed, green circle markers indicate the new location of
candidate fiducials in the Live X-ray image. Updated offset values are displayed.

6. Verify that the fiducials have been located correctly. Evaluate the updated offsets (see
“Evaluating Calculated Offsets” on page 9-9). You can then move the treatment couch as
needed (see “Moving the Couch” on page 9-26).
collisions.



You can monitor values of several parameters calculated by the fiducial extraction algorithm.
Values are updated when images are acquired or correlated. The calculated values are displayed
on the Acquisition Details tab of the Image History table (right screen), as shown in
Figure 7.
Figure 7 Calculated algorithm parameters for Syn-

chrony Fiducial Tracking mode on the Acquisition
Details tab (right screen)
Some of these calculated values are also displayed to the left of slider bars (left screen), where
you can adjust their thresholds (see Figure 8 on page 9-17). If a parameter value exceeds its
threshold, a threshold violation occurs, and an orange box is displayed around the slider bar. When
a threshold violation occurs the first time you are in the Alignment > Align phase during a
treatment fraction, you cannot move to the next phase until the threshold violation is resolved.

Figure 8 Slider bars for adjusting algorithm parameters and

thresholds in the Alignment > Align phase (left screen)
Calculated parameters are described below.

• “dxAB (mm)” on page 9-17
• “Rigid Body Error (mm)” on page 9-18
• “Uncertainty (%)” on page 9-18
• “Fiducial Spacing” on page 9-18
• “Collinearity” on page 9-19
dxAB (mm)
The dxAB (mm) parameter gives the relative distance along the Inferior/Superior axis between a
candidate fiducial in the two projections (for Camera A and Camera B of the X-ray imaging system).
If this distance exceeds the threshold value, the fiducial extraction algorithm does not consider the
candidate fiducial in each projection to be the same fiducial and a dxAB error occurs. The X-axis
(Inferior/Superior axis) is used because this axis is common to both projections.
The default value of the dxAB threshold parameter is 2.5 mm. The default value is designed to
eliminate false identification of fiducials. However, in some cases, for example, with abnormally
long fiducials (> 5 mm) or fiducials in close proximity to another bright object in the projected
image, the displacement estimates in the Inferior/Superior direction obtained from each X-ray
image detector may differ by more than this limit. In such cases, first re-adjust the offset in order
to correctly overlap with the actual fiducials, as visually identified in the live image. Then decrease
the Tracking Range to help identify and correctly lock on to the fiducials. If the error persists, then
increase the threshold value.

continue.
WARNING: If you increase the value of the dxAB (mm) threshold, it is possible for the
fiducial extraction algorithm to incorrectly identify the fiducial configuration without
generating an error. You must therefore visually verify that the fiducial configuration has
been correctly identified.

Rigid Body Error (mm)

For information on this parameter, see “Rigid Body Error” on page 9-2 and “Responding to a Rigid
Body Error” on page 9-23.
Uncertainty (%)
The Uncertainty (%) parameter gives the detection uncertainty value for the fiducial extraction
algorithm. The fiducial extraction algorithm computes an uncertainty value that is a measure of the
incorrectness of the extracted fiducial configuration.
If the detection uncertainty value computed by the fiducial extraction algorithm is greater than the
Uncertainty threshold parameter, an Uncertainty error occurs (see “Error Handling” on page 9-30).
The default value of the Uncertainty (%) threshold parameter is 40%. If an Uncertainty error occurs,
you can consider increasing the Uncertainty (%) threshold if you are confident that the fiducials
found using a higher value are correctly identified. For more information, see “Adjusting Algorithm
Parameters” on page 9-20.

continue.
WARNING: If you increase the value of the Uncertainty (%) threshold, it is possible for the
fiducial extraction algorithm to incorrectly identify a feature as a fiducial without
generating an error. You must therefore visually verify that each fiducial has been
correctly identified and that fiducials are in the correct configuration.
Fiducial Spacing
The Spacing (mm) parameter gives the lowest calculated distance between fiducials. This distance
is also called the Fiducial Spacing.
The Spacing threshold parameter sets the minimum distance between fiducials required for
accurate estimation of rotations. The default value of the Spacing threshold parameter is 18.0 mm.
When the calculated Spacing value is less than the threshold, a Spacing error occurs, and text is
displayed at the bottom of the left screen to indicate that the threshold failed.
If fewer than 3 pairs of fiducials have Spacing values that exceed the threshold, the fiducial
extraction algorithm will calculate and display rotations, but rotational corrections will not be
applied. If fewer than 3 fiducials are selected to be used for tracking, you cannot adjust the Spacing
threshold parameter.

You can force the computation of rotations by reducing the Spacing threshold parameter. However,
you should note that the accuracy of rotational corrections increases when the fiducials are further
apart from each other.

continue.
WARNING: If you lower the value of the Fiducial Spacing Threshold parameter, it is
possible for the fiducial extraction algorithm to compute rotations inaccurately, resulting
in larger targeting errors.
Collinearity
The Collinearity (deg) parameter gives the largest calculated angle between lines joining any group
of 3 fiducials. This parameter is a measure of the closeness of a triplet of fiducials to a straight line.
The Collinearity value is determined by either the smallest calculated angle θ or 180 - θ between
lines joining any group of 3 fiducials, whichever value is lower.
The Collinearity threshold parameter sets the minimum angle required for accurate estimation of
rotations. The default value of the Collinearity threshold parameter is 15.0°. When the calculated
Collinearity value is less than the threshold, a Collinearity error occurs, and text is displayed at the
bottom of the left screen to indicate that the fiducial angle threshold failed.
If at least one fiducial triplet exceeds the Collinearity threshold, the fiducial extraction algorithm
calculates rotations, and rotational corrections are applied. Otherwise, only translational
corrections are applied. If fewer than 3 fiducials are selected to be used for tracking, you cannot
adjust the Collinearity threshold parameter.
You can force the computation of rotations by reducing the Collinearity threshold parameter.
However, you should note that the accuracy of rotational corrections is reduced when the fiducial
configuration is more collinear. However, the accuracy of rotations is not guaranteed for such
fiducial configurations.

continue.
WARNING: If you lower the value of the Collinearity threshold parameter, it is possible for
the fiducial extraction algorithm to compute rotations inaccurately, resulting in larger
targeting errors.


The default settings for algorithm parameters and thresholds are adequate for most cases and are
recommended for use. If the fiducial extraction algorithm fails or a threshold violation occurs,
adjusting some of these values may allow successful tracking. If you make a threshold value more
lenient than the default value, a warning appears requiring confirmation to continue.
• “Adjusting the Tracking Range (mm)” on page 9-20
• “Adjusting Algorithm Parameter Thresholds” on page 9-20
Adjusting the Tracking Range (mm)

The Tracking Range (mm) parameter sets the height and width of a square region enclosing a
reference fiducial. The fiducial extraction algorithm searches within this region in the Live X-ray
images to identify fiducials.
The default value of the Tracking Range parameter is 10.0 mm. You can adjust this parameter to
ensure that fiducials are within the tracking range. For example, you can decrease this parameter
to exclude a structure that is incorrectly identified as a fiducial. You can increase this parameter if
the fiducial extraction algorithm is not able to locate a fiducial that is outside the default tracking
range. If the value is too large and ROIs overlap, the tracking algorithm may not be able to identify
the correct fiducial.
 To adjust the Tracking Range (mm) parameter:
• Click and drag the adjustable cursor on the slider bar to adjust the value (see Figure 8 on
page 9-17). Alternatively, enter a new value in the textbox to the right of the slider bar and
press <Enter>. If you make a threshold value more lenient than the default value, a
warning appears requiring confirmation to continue.
adjustable cursor on the slider bar to the vertical line. The vertical line indicates the
default value.
Images are automatically correlated when the Tracking Range (mm) parameter is changed.
Adjusting Algorithm Parameter Thresholds

Slider bars on the left screen allow you to monitor and change the values of the following algorithm
parameter thresholds (see Figure 9):
• Uncertainty (%) threshold
• Rigid Body (mm) threshold


Value of Rigid Cursor Threshold Value
Body Error
Figure 9 Rigid Body Error slider bar

• The current value of the Rigid Body Error parameter is displayed to the left of the slider
bar. The border between the red and green portions of the slider bar also indicates the
current value.
value.

continue.
fiducial extraction algorithm to incorrectly identify a feature as a fiducial without
generating an error. You must therefore visually verify that each fiducial has been
correctly identified and that fiducials are in the correct configuration.
WARNING: If you increase the value of the dxAB (mm) threshold, it is possible for the
fiducial extraction algorithm to incorrectly identify the fiducial configuration without
generating an error. You must therefore visually verify that the fiducial configuration has

WARNING: If you increase the value of the Rigid Body Error threshold, it is possible for
the fiducial extraction algorithm to result in larger targeting errors leading to
mistreatment.
Enable or Disable Fiducials Used For Tracking
WARNING: If fewer than 3 fiducials are enabled for tracking, the tracking algorithm will
not estimate rotational corrections. Only translational corrections will be applied during
beam delivery. Tracking with fewer than 3 fiducials significantly reduces the usefulness of
the Rigid Body Error value as an indicator of tracking reliability.
WARNING: Use extreme caution when considering whether to track the target using only
1 fiducial. If only 1 fiducial is enabled for tracking, the tracking algorithm will not estimate
rotational corrections and the Rigid Body Error value will no longer be available as an
indicator of tracking reliability. Tracking with only 1 fiducial increases the risk of beam
mis-targeting.
The Fiducials checkboxes on the left screen (see Figure 6 on page 9-8) allow you to turn tracking
on or off for individual fiducials:
• When the checkbox for a fiducial is selected, the fiducial extraction algorithm uses that
fiducial to track target movement. The corresponding diamond marker for that fiducial in
the DRR images is yellow.
• When a checkbox is deselected, the corresponding fiducial is not used for tracking. The
diamond marker is removed.
• Images are automatically correlated when you select or deselect a checkbox.
Up to 8 fiducial checkboxes can be displayed. The corresponding fiducials are numbered in the
images.
The following examples are cases where you could consider disabling a fiducial so that it is not
used for tracking:
• The fiducial is incorrectly identified.
• The fiducial produces Rigid Body Errors due to migration. For more information on
disabling fiducials in response to a Rigid Body Error, see “Responding to a Rigid Body
Error” on page 9-23.
• The fiducial has a high uncertainty level due to poor image quality in the Live X-ray
images, migration, obstruction by an object in the ROI, or close proximity to another
fiducial.

Once the new Live X-ray image acquisition or image correlation is complete, you should again
attempt to visually verify that the fiducials have been correctly located. If they have not, repeat the
above procedures and try again.
Responding to a Rigid Body Error

A Rigid Body Error is indicated when the red error bar on the Rigid Body (mm) slider bar
extends beyond the adjustable threshold cursor, and an orange box is displayed around the slider
bar (see Figure 9 on page 9-21). The default value of the Rigid Body parameter threshold is
1.5 mm.
In addition, a solid red or yellow square next to a fiducial checkbox under the slider bars indicates
that the fiducial is contributing to the Rigid Body Error. A solid red square identifies the fiducial that
is contributing the most to the error. It is possible for more than one solid yellow square to be
displayed, indicating that more than one fiducial is contributing to the error. Only one solid red
square is displayed, indicating the single fiducial that has the largest impact.
In the event that a fiducial produces a Rigid Body Error due to migration, you can consider
increasing the Rigid Body parameter threshold or disabling the fiducial so that it is not used for
tracking. Once you have specified the Rigid Body Error value that you are willing to accept by
adjusting the threshold, you can disable the fiducial(s) that contribute error above that value.

continue.
WARNING: If you increase the value of the Rigid Body parameter threshold, it is possible
for the fiducial extraction algorithm to result in larger targeting errors leading to
mistreatment.
When you disable the fiducial with a solid red square so that it is not used for tracking, its
contribution to the error is removed. When you disable a fiducial, a new image correlation is
performed automatically. A solid red square is then displayed for the next fiducial that is
contributing the most to the error.
After each image acquisition or correlation, the Algorithm Details tab in the Image History
table (right screen) displays the value of several fiducial tracking algorithm parameters. For the
Rigid Body Error parameter, the calculated value for each pair of fiducials is displayed. You can
refer to these values as an aid to determine which fiducials, if any, to disable for tracking in
response to a Rigid Body Error.
WARNING: If fewer than 3 fiducials are enabled for tracking, the tracking algorithm will
not estimate rotational corrections. Only translational corrections will be applied during
beam delivery. Tracking with fewer than 3 fiducials significantly reduces the usefulness of
the Rigid Body Error value as in indicator of tracking reliability.

WARNING: Use extreme caution when considering whether to track the target using only
1 fiducial. If only 1 fiducial is enabled for tracking, the tracking algorithm will not estimate
rotational corrections and the Rigid Body Error value will no longer be available as an
indicator of tracking reliability. Tracking with only 1 fiducial increases the risk of beam
mis-targeting.
NOTE: If you track with fewer than 3 fiducials, some imaging

parameters are not calculated.
Figure 10 shows an example of the Rigid Body (mm) section of the Algorithm Details tab
for a case with 4 fiducials enabled for tracking.
Figure 10 Example of Algorithm Details tab for a case with

4 fiducials. The Rigid Body Error value for each pair of fidu-
cials is displayed.
If the Rigid Body Error values shown in Figure 10 are listed in descending order, the fiducial pair
that is contributing the most to the error will be at the top of the list:
RBE1-3 1.9
RBE2-3 1.7
RBE1-4 1.6
RBE1-2 1.5
RBE2-4 1.3

To determine which fiducial in the pair is contributing the most, evaluate how the error changes if
one of these fiducials is removed. If Fiducial 1 is removed, the next highest Rigid Body Error value
is 1.7. If Fiducial 3 is removed, the next highest Rigid Body Error is 1.6. Therefore, Fiducial 3 has
the most significant contribution to the Rigid Body Error.
A solid red square in the Fiducial Tracking control area indicates that Fiducial 3 is contributing the
most, as shown in Figure 11. A solid yellow square indicates that Fiducial 1 has the next largest
impact. The current value of the Rigid Body Error, 1.9 mm, is displayed under the slider bar.
Figure 11 In this example, a solid red square indicates that

Fiducial 3 is contributing the most to the Rigid Body Error
If Fiducial 3 is disabled for tracking, Fiducial 1 will become the fiducial that contributes the most to
the error (Fiducial 1 contributes to the next highest value in the list). A solid red square is then
displayed for Fiducial 1, as shown in Figure 12.
Figure 12 In this example, when Fiducial 3 is disabled for

tracking, a solid red square indicates that Fiducial 1 is now
contributing the most to the error
Analyzing the Image History

The Image History table in the Alignment > Align phase lets you view details for all
images acquired in all treatment phases for this treatment session. Select a tab to view:
• Acquisition Details: Displays acquisition time, X-ray technique, and other data.
• Images: Displays the Live X-ray images and the X-ray technique. Select controls at the
bottom of the image to aid image analysis (see Table 1 on page 9-11).
• Location/Uncertainty: Displays a log of data calculated by the tracking algorithm,
including Fiducial Location (mm) and Fiducial Uncertainty (%) for each fiducial.
• Algorithm Details: Displays a log of data calculated by the tracking algorithm,
including Collinearity (deg), Fiducial Spacing (mm), and Rigid Body (mm).
For more information on the Image History table, see “Chapter 8: Treatment Delivery”.

Moving the Couch

Once you verify that each fiducial has been correctly located and that the fiducials are in the correct
configuration, you can proceed with adjusting the patient position until proper alignment is reached.
Calculated offset values automatically fill the Couch Position (mm) and Couch Rotation
(deg) textboxes. To reduce offsets, you move the treatment couch using the Move Couch
button.
movement relative to its current position. Values above the textboxes show the absolute rotational
position of the couch.
Depending on tracking mode, values are displayed for translations only or for both translations and
rotations. When 2 or fewer fiducials are used for tracking, only translational values are calculated.
maximum allowed rotational displacements. This checkbox is enabled by default.
In the Alignment > Align phase, high initial translational offsets can lead to false rotational
values. If calculated offset values for translation and rotation are high, disable rotational movement
initially, so that only translational adjustments of the treatment couch are made. Then acquire
another image to obtain updated offsets.
again to unlock it.
change and approach zero as the desired couch position is achieved. Slider bars for adjusting
algorithm parameters thresholds turn gray when the couch is moved, since previously calculated
parameter values are no longer relevant.
collisions.
You can also use Couch Mode to shift the Live X-ray and DRR images so that anatomical or other
features match. To do this, select the Couch Mode icon (Table 1 on page 9-11). Then click and
drag in the Live X-ray image. Do this separately for each image panel.
As the relative position of the images is adjusted, the target translational values in the Couch
Position (mm) textboxes are updated. (Rotational values are not updated in Couch Mode.)
Then click the Move Couch button to move the couch to the target position.
After moving the couch, you acquire a Live X-ray image and then analyze imaging results to verify
that each fiducial has been correctly located and that the fiducials are in the correct configuration.
If the fiducials are not correctly identified, reattempt the procedures described in the previous
section “Analyzing Imaging Results” on page 9-9.

When the patient is within required translational and rotational tolerances, you can proceed with
treatment by moving to the Readiness phase. For more information on required tolerances, see

In the Readiness phase, you review, resolve when applicable, and confirm any messages
displayed in the Delivery Warning Messages table, perform a Patient Safety Zone Check in
the Proximity Detection Status section, and make sure the collimator is set up correctly in
the Collimator and Laser Alignment Check section of the screen. For more information
on these procedures, see “Chapter 8: Treatment Delivery”.
When the Warning Message Status and Collimation System Status are both Ready,
you are ready to start treatment delivery.

Treatment Delivery
• “Starting Treatment Delivery” on page 9-29
• “Treatment Monitoring Graph” on page 9-29
The left screen of the Delivery phase for Synchrony Fiducial Tracking mode is shown in
Figure 13. Controls allow you to monitor and verify patient alignment and tracking results during
treatment delivery.

Fiducial Tracking mode
For more information on treatment delivery procedures, see “Chapter 8: Treatment Delivery”.

Starting Treatment Delivery

If the Start button is enabled, the CyberKnife System is ready to start treatment.
WARNING: Visually verify that the fiducials are correctly identified throughout treatment.
WARNING: After X-ray image acquisition at each node, visually verify the patient position
and verify the positions of the located fiducials. If at any time it appears that the patient or
fiducials are not correctly located in the Live X-ray images, pause treatment by clicking
the Interlock button on the left screen of the Delivery phase or push the nearest E-Stop
button.
After pausing treatment, follow the procedures described in “Analyzing Imaging Results” on
page 9-9 until fiducial location is successful and shows that the patient is within alignment bounds.
For more information on interrupting treatment, see “Chapter 8: Treatment Delivery”.
Treatment Monitoring Graph

The Treatment Monitoring graph for fiducial tracking mode includes a Fiducial graph display
(Figure 14). This display shows the computed values of the following parameters as a function of
time:
• Uncertainty (%): The computed value of the Uncertainty parameter (as a
percentage).
• dxAB (mm): The computed value of the dxAB parameter (in millimeters).
• Rigid Body: The computed value of the Rigid Body Error parameter (in millimeters).
Figure 14 Treatment Monitoring graph for Synchrony Fiducial Tracking mode

Error Handling
The fiducial extraction algorithm may fail for the following reasons:
• dxAB Error
• Rigid Body Error
• Uncertainty Error
• Spacing Error
• Collinearity Error
During patient alignment in the Alignment > Align phase, when the calculated value of a
fiducial extraction algorithm parameter exceeds the value of its threshold, a threshold violation
occurs. An orange box is then displayed around the slider bar for that parameter threshold.
If this occurs the first time you are in the Alignment > Align phase during a treatment fraction,
you cannot proceed to the next phase until the threshold violation is resolved. After the first time
(for example, if you return to the Alignment > Align phase to realign the patient), if a threshold
violation occurs, you can proceed to the next phase. However, you will not be able to start
treatment delivery until the threshold violation is resolved.
If a threshold violation occurs while treatment is in progress in the Delivery phase, a correlation
error occurs (a Soft Stop). Treatment is paused and the error is described in the Messages panel.
To determine which threshold was violated, you can return to the Alignment > Align phase to
see which slider bar is surrounded by an orange box.
For information on the parameters above and their thresholds, see “Monitoring and Adjusting
Algorithm Parameters” on page 9-16. For information on responding to a Rigid Body Error, see
“Responding to a Rigid Body Error” on page 9-23. For information on resuming treatment after a
Soft Stop, see Chapter 7, “Treatment Delivery”.
Patient Realignment
If treatment is interrupted due to a Soft Stop or E-Stop, or if you click the Interlock button or the
Pause button, you should confirm alignment of the patient before resuming treatment. For
information on patient realignment after a treatment interruption, see Chapter 7, “Treatment
Delivery”.

Chapter 10: Synchrony Spine
Tracking (Option)
Introduction
This chapter describes how to use Synchrony Spine Tracking Supine and Synchrony Spine
Tracking Prone with Respiratory Modeling. When content is relevant to both tracking modes, the
generic term "Synchrony Spine Tracking" is used.
• “Overview of Synchrony Spine Tracking” on page 10-2
• “Requirements for Visual Evaluation” on page 10-3
• “Workflow for Synchrony Spine Tracking” on page 10-4
• “Synchrony Spine Tracking Prone with Respiratory Modeling” on page 10-33
Synchrony Spine Tracking enables tracking of skeletal structures in the spine region for accurate
patient positioning and radiation beam delivery using the CyberKnife System. It provides the
capability to deliver radiation treatments in all regions of the spine without the need for implanting
fiducials. Synchrony Spine Tracking is capable of accurately and automatically tracking a wide
range of skeletal structures, including all cervical, thoracic, lumbar and sacral areas.
NOTE: For information on using the optional Synchrony Spine

Tracking with InTempo Imaging system see “Chapter 13:

Overview of Synchrony Spine Tracking

Synchrony Spine Tracking works by computing the displacement of skeletal structures within the
patient body. The skeletal structures to be tracked are predetermined during treatment planning.
During treatment planning in the Accuray Precision System, the user defines the following
reference locations:
• An imaging center, also called the align center, is chosen in the patient CT image series.
The imaging center should be close to the target and in a region with sufficient skeletal
features for tracking.
NOTE: The imaging center for Synchrony Spine Tracking

corresponds to the alignment center used by Synchrony Lung
Tracking with Respiratory Modeling.
• A region of interest (ROI) containing an 81-node grid is defined when the treatment plan
is created. During treatment delivery, Synchrony Spine Tracking computes target
displacement by monitoring the displacement of nodes of the ROI in the Live X-ray
images relative to the nodes in the DRR images. The ROI size defined during treatment
planning is used as the default ROI size during treatment delivery.
Synchrony Spine Tracking computes patient displacement in 6 degrees of freedom: 3 translations
and 3 global rotations.
During patient alignment, the computed displacements are used to adjust the patient position.
During treatment delivery, the treatment robot adjusts the position of the LINAC to correct for
translational and rotational displacement of the target. For more information on selecting the
imaging center and adjusting the ROI size during treatment planning, see the Treatment Planning
Manual.
Accuracy of Synchrony Spine Tracking

The tracking accuracy and stability of Synchrony Spine Tracking is verified and validated using
phantom experiments as well as clinical patient data at Accuray. These studies indicate that
Synchrony Spine Tracking can track with an accuracy of better than 0.5 mm for radial translation
error, and 0.5 degree for radial rotation error. This accuracy is applicable over the tracking range
of the CyberKnife System of ±10 mm. Synchrony Spine Tracking is capable of tracking over a much
larger range with a slightly reduced amount of accuracy, enabling you to quickly position the patient
to within the tracking range of the CyberKnife System, for the start of treatment delivery.
The tracking accuracy should be kept in mind when selecting the CT center as a reference point.
Because of errors in estimating patient rotation, the targeting error increases as a function of the
distance of the tumor from the CT center. With an estimated 0.5 degree of radial rotation error for
Synchrony Spine Tracking, every 1 cm distance of the tumor from the CT center, contributes to a
targeting error of about 0.1 mm. It is recommended that the tumor should be no more than 5 cm
from the CT center. In addition, any non-rigid motion of the tumor with respect to the CT center
should be taken into consideration, since the motion is not estimated by the tracking algorithm.
10-2 | Overview of Synchrony Spine Tracking 1075883-ENG A

Treatment Delivery Manual Chapter 10: Synchrony Spine Tracking (Option)
Requirements for Visual Evaluation

Visual evaluation is essential for safe treatment delivery usingSynchrony Spine Tracking . Visual
evaluation ensures that the Synchrony Spine Tracking algorithm tracks skeletal structures
correctly.
During treatment planning, the DRR images generated by the Accuray Precision System should
be inspected to ensure that they are suitable for tracking using Synchrony Spine Tracking . DRR
images that clearly show skeletal structures (or other radiopaque structures) against the
background indicate that the target can be tracked using Synchrony Spine Tracking . For
information on generating DRR images during treatment planning, see the Treatment Planning
Manual.
Visual inspection of tracking results during treatment delivery is also required, as described in
“Visual Inspection During Treatment DeliverySynchrony Spine Tracking relies on the nodes in the
center columns of the ROI to estimate the patient roll rotations (rotation about the Inferior/Superior
axis).” on page 10-29.
The Treatment Delivery System user interface provides tools to verify that Synchrony Spine
Tracking is able to register skeletal structures in the Live X-ray images with corresponding features
in the DRR images. For information, see “Performing Patient Alignment” on page 10-11 and
NOTE: Visual evaluation during treatment delivery ensures that

the Synchrony Spine Tracking algorithm is producing results that
are correct at a coarse level. However, visual evaluation alone is
not adequate for verifying submillimeter accuracy.
1075883-ENG A Requirements for Visual Evaluation | 10-3

Workflow for Synchrony Spine Tracking

Figure 1 shows the workflow for patient alignment and treatment delivery using Synchrony Spine
Tracking Supine.
Figure 1 Workflow for Synchrony Spine Tracking

Supine
Figure 2 shows the workflow for patient alignment and treatment delivery for Synchrony Spine
Tracking Prone with Respiratory Modeling. For information on Synchrony Spine Tracking Prone
with Respiratory Modeling, see “Synchrony Spine Tracking Prone with Respiratory Modeling” on
page 10-33. For information on using Synchrony Spine Tracking with Respiratory Modeling, see
Figure 2 Workflow for Synchrony Spine Tracking

Prone with Respiratory Modeling
In the Alignment phase, you perform the following steps:

• Visually aligning the patient in the Alignment > Couch phase.
• Optimizing the X-ray technique in the Alignment > Technique phase.
• Performing patient alignment in the Alignment > Align phase.
10-4 | Workflow for Synchrony Spine Tracking 1075883-ENG A


• “Generating DRR Images” on page 10-5
• “Downloading Treatment Files” on page 10-6
Generating DRR Images

In the Synchrony Spine Tracking System, roll angles of the patient are computed by comparing the
Live X-ray images with multiple DRR images. The DRR images are generated using the iDMS Data
Management System as described in “Chapter 8: Treatment Delivery”.
The number and type of DRR image pairs generated for use with Synchrony Spine Tracking
depends on whether spine segmentation was performed during treatment planning:
• Synchrony Spine Tracking (without spine segmentation):
 Multiple pairs of unsegmented (full content) spine DRR images with optimally
distributed orientations, to simulate different roll angles of the patient.
 1 pair of unsegmented (full content) spine DRR images for automatic contrast
adjustment and visual inspection of tracking results during treatment delivery.
• Synchrony Spine Tracking (with spine segmentation):
 Multiple pairs of segmented spine DRR images with optimally distributed orientations,
to simulate different roll angles of the patient.
 1 pair of unsegmented (full content) spine DRR images for automatic contrast
adjustment and visual inspection of tracking results during treatment delivery.

Downloading Treatment Files

During treatment file downloading, the Treatment Delivery System performs the following actions:
• The multiple pairs of DRR images generated on the iDMS Data Management System are
transmitted to the TLS computer for use by the Synchrony Spine Tracking algorithm. The
separate pair of unsegmented (full content) DRR images is also transmitted.
• The Synchrony Spine Tracking algorithm is initialized.
When downloading is complete and you have verified that patient and treatment data are correct,
you can move to the Alignment > Couch phase.
For more information on downloading treatment files, see “Chapter 8: Treatment Delivery” For
more information on the Treatment Delivery screen, see “Chapter 5: Treatment Delivery System
Overview”.
10-6 | Verifying Patient and Treatment Data 1075883-ENG A


Figure 3 shows the Alignment > Couch phase (left screen) for Synchrony Spine Tracking after
the Live X-ray and DRR images have been visually aligned using Couch Mode. The unsegmented
(full content) DRR images are displayed. Table 1 on page 10-14 describes the image panel
controls to aid image analysis and visual alignment. For more information on this phase, see

chrony Spine Tracking after visual alignment using Couch
Mode


The goal of the Alignment > Technique phase for Synchrony Spine Tracking is to find the
optimal X-ray technique. This X-ray technique will be the default for future treatment fractions
unless it is changed. Start by analyzing the existing image from the Alignment > Couch phase.
correctly.
Figure 4 shows the Alignment > Technique phase (left screen) for Synchrony Spine Tracking
after image acquisition. Table 1 on page 10-14 describes the image panel controls to aid image
analysis in this phase, including DRR display modes.
Figure 4 Alignment > Technique phase (left screen) for Syn-

chrony Spine Tracking after image acquisition

The Region of Interest (ROI) Width is represented by a yellow box in the Raw Image (far left in
Figure 4). The ROI Width (mm) value is also displayed in the Image History table on the right
screen (see Figure 5). A histogram display below each Raw Image represents the distribution of
pixel intensities in the ROI. The Image History table also displays the calculated False Nodes
value for each image.
Figure 5 Image History table for Synchrony Spine Tracking

in the Alignment > Technique phase (right screen)
The goal is to determine the optimal X-ray technique for XRS A and XRS B independently, by
evaluating image quality, histogram displays, and False Nodes values of images on the left screen
and in the Image History table.
Increasing the X-ray technique generally pushes the histogram peak to the left. Decreasing the X-
ray technique generally pushes the peak to the right. The ideal distribution is spread out (indicating
good contrast) and not shifted towards the extreme left or right.
If you are satisfied with the X-ray technique, you can proceed to the Alignment > Align phase.
Otherwise, you can change the X-ray technique as needed until you are satisfied with the image
quality, as described below. For more information on the ROI Width and the False Nodes
parameters, see “Monitoring and Adjusting Algorithm Parameters” on page 10-20. For more
information on the Alignment > Technique phase, see “Chapter 8: Treatment Delivery”.


The Live X-ray images should have the same image quality as the DRR images with skeletal
features visible. X-ray parameters should be set appropriately to clearly show skeletal features in
different spinal regions. The general recommendations for setting X-ray parameters for Synchrony
Spine Tracking is lower X-ray energy for C-spine and the upper part of T-spine, and higher X-ray
energy for the lower part of T-spine and L-spine.
For some cases, for example, patients with a large body, larger values of kV (kilovolts), mA
(current), and ms (exposure time in milliseconds) may be needed for more X-ray penetration of
soft tissues.


The goal of the Alignment > Align phase for Synchrony Spine Tracking is to make sure the
patient is aligned within acceptable bounds for treatment delivery. For more information on
Synchrony Spine Tracking Prone with Respiratory Modeling, see “Synchrony Spine Tracking
Prone with Respiratory Modeling” on page 10-33.
Figure 6 shows the Alignment > Align phase (left screen) for Synchrony Spine Tracking after
image correlation. For more information on this phase, see “Chapter 8: Treatment Delivery”.
Figure 6 Alignment > Align phase (left screen) for

Synchrony Spine Tracking after image correlation
correlated with the DRR images.


ray images to verify that there are sufficient skeletal features in the images and that
anatomy in the Live X-ray and DRR images matches.
• “Moving the Couch” on page 10-27: You move the treatment couch as needed and
acquire new Live X-ray images.
in the Alignment > Align phase (for treatments that do not use Respiratory Modeling)
and the Alignment > Respiratory phase (Respiratory treatments).
If your CyberKnife System includes the optional Synchrony Lung Tracking with Respiratory
Modeling, the Alignment > Align phase (left screen) displays the Skip Spine checkbox. For
more information on this checkbox, see “Chapter 11: Synchrony Lung Tracking with Respiratory
Modeling (Options)”.
For additional information on the Alignment > Align phase, see “Chapter 8: Treatment
Delivery”.

• “Using Image Panel Controls for Image Analysis” on page 10-13

The calculated offset values indicate treatment couch movement needed to align features in the
Live X-ray and DRR images. Images are automatically shifted by the translational offsets to show
the alignment that would result if the couch is moved by these amounts.
• Offsets are within tolerances required for treatment delivery, and you can verify that there
are sufficient skeletal features in the images and that anatomy in the Live X-ray and DRR
images matches.

and an out-of-bounds error has occurred. An orange box around a tracking algorithm
slider bar indicates that a threshold violation has occurred.
 You can use image analysis tools in Table 1 on page 10-14 to make sure the Region
of Interest (ROI) includes sufficient skeletal structures. Check that anatomy is aligned
in the Live X-ray and DRR images.
Algorithm Parameters” on page 10-20.

Using Image Panel Controls for Image Analysis

• “Display Modes for DRR Images” on page 10-17
• “Display Align Center” on page 10-18
• “Display Skeletal Mesh” on page 10-18
 Table 1 describes image panel controls and DRR display modes to aid image
analysis.
NOTE: Not all image controls are available for all treatment
modes.

Control Description

image.
Respiratory model one at a time in respiratory sequence. This makes tumor


Control Description
clicking and dragging in either the Live X-ray image or DRR image. See “Moving
the Couch” on page 10-27. Depending on the treatment phase, the following icons
are displayed:
unshifted position.

Control Description
Align Center: (Synchrony Spine Tracking only) Displays a marker that

corresponds to the align center selected during treatment planning. See “Display
Align Center” on page 10-18.
Region of Interest: (Synchrony Spine Tracking in Technique phase only)

Displays the Region of Interest (ROI) Width as a yellow box in the Raw Image.
The histogram display is based on the ROI.
Skeletal Mesh: (Synchrony Spine Tracking in Align and Respiratory phases only)
Displays the skeletal mesh used for tracking. See “Display Skeletal Mesh” on
page 10-18.
DRR images.
out automatically.
Full Content DRR: (Synchrony Spine Tracking only) Displays the unsegmented
(full content) DRR images. See “Display Modes for DRR Images” on page 10-17.
Segmented DRR: (Synchrony Spine Tracking only) Displays the segmented DRR
images, in which all image content except the spine is removed. See “Display
Modes for DRR Images” on page 10-17.
image is required.

r Turn on/off Skeletal Mesh. (Synchrony Spine Tracking)
m Turn on/off Align Center. (Synchrony Spine Tracking)
Display Modes for DRR Images

You can switch between two display modes for the DRR images in each row (corresponding to
Camera B and Camera A of the X-ray imaging system):
• Full Content DRR display mode: Click the Full Content DRR icon to display the
unsegmented (full content) DRR images.
• Segmented DRR display mode: Click the Segmented DRR icon to remove all image
content except the spine from the DRR images. A segmented view of the DRR images is
available only if spine segmentation was performed during treatment planning. The
segmented pair of DRR images with 0 degrees rotation are displayed (see “Generating
DRR Images” on page 10-5).
NOTE: These display modes affect the image display only. They
do not affect the results of the Synchrony Spine Tracking
algorithm.

Display Align Center

The Align Center icon displays markers in the DRR images and Live X-ray images that correspond
to the imaging center selected during treatment planning (see Figure 7). You can visually inspect
Synchrony Spine Tracking results from the alignment of markers in the images.
NOTE: The location of the imaging center cannot be changed

during treatment delivery.
Synchrony Spine Tracking relies on skeletal structures in the ROI for accurate tracking. Users
should inspect the ROIs for both Camera B and Camera A of the X-ray imaging system to verify
that each ROI includes sufficient skeletal structures for tracking.
Figure 7 Align Center markers displayed in Syn-

chrony Spine Tracking
Display Skeletal Mesh

When the Skeletal Mesh icon is selected, skeletal meshes in the DRR images and the Live X-ray
images are displayed (see Figure 8). The ROI is also displayed as a dark blue box in both the DRR
and Live X-ray images. The Skeletal Mesh icon is selected by default.

Figure 8 Skeletal Meshes displayed in Synchrony

Spine Tracking
The skeletal meshes correspond to the 81-node grid that is predefined during treatment planning.
The skeletal meshes are displayed in different colors depending on the agreement between nodes
in the DRR and Live X-ray images:
• Green: The skeletal mesh in a DRR image is displayed in green.
• Dark blue: A node in a Live X-ray image is displayed in dark blue if there is good
agreement between that node and the corresponding node in the DRR image. Grid lines
projecting from that node are also displayed in dark blue.
• Orange: A node in a Live X-ray image is displayed in orange if it is a false node. Grid
lines projecting from a false node are also displayed in orange.
To identify nodes in the Live X-ray images, Synchrony Spine Tracking looks for internal anatomy
that corresponds to the region surrounding each node in the DRR images. If the estimated
translation of a node in the skeletal mesh is inconsistent with nodes in the surrounding grid, the
node is identified as a false node. The smaller the number of false nodes, the more reliable the
translational corrections from the Synchrony Spine Tracking algorithm.
In Couch Mode (see Table 1 on page 10-14), when you click the Offsets icon, the skeletal meshes
in the DRR images and the Live X-ray images for both projections (Camera A and Camera B of the
X-ray imaging system) are automatically aligned.
The Offsets icon uses only translations to perform alignment. When large rotations exist, the
rotations of the skeletal mesh in the Live X-ray images can clearly be seen. You can visually
inspect the tracking accuracy from the alignment of the mesh nodes in the area close to the image
center.



You can monitor values of several parameters calculated by the Synchrony Spine Tracking
algorithm. Values are updated when images are acquired or correlated. The calculated values are
displayed on the Acquisition Details tab of the Image History table (right screen), as
shown in Figure 9.
Figure 9 Calculated algorithm parameters for Synchrony

Spine Tracking on the Acquisition Details tab
adjust their thresholds (see Figure 10 on page 10-20). If a parameter value exceeds its threshold,
a threshold violation occurs, and an orange box is displayed around the slider bar. When a
threshold violation occurs the first time you are in the Alignment > Align phase during a
treatment fraction, you cannot move to the next phase until the threshold violation is resolved.
Figure 10 Slider bars for adjusting algorithm parameters

and thresholds in the Alignment > Align phase (left screen)


• “drAB (deg)” on page 10-21
• “False Nodes (%)” on page 10-22
dxAB (mm)
center in the two projections (for Camera A and Camera B of the X-ray imaging system. This
difference is called dxAB. The Synchrony Spine Tracking algorithm calculates the dxAB value for
every image acquisition. When the dxAB value exceeds the dxAB threshold value, a dxAB error
occurs (see “Error Handling” on page 10-31). The Inferior/Superior axis is used because this axis
is common to both projections.
The default value of the dxAB threshold parameter is 2.5 mm. The value of the dxAB threshold
parameter should be small. However, in the presence of large rotations this setting could be
somewhat larger (up to 4 mm). If you change this threshold value during patient alignment, you
should return to the default value when patient alignment is completed.

continue.
parameter can cause the Synchrony Spine Tracking algorithm to produce incorrect
drAB (deg)
The drAB (deg) parameter gives the absolute difference between projected roll angles in the two
projections (for Camera A and Camera B of the X-ray imaging system). This difference is called
drAB. When the drAB value calculated by the Synchrony Spine Tracking algorithm is below the
threshold, the estimate of roll by the tracking algorithm is considered to be reliable. If the drAB
value exceeds the drAB threshold value, a drAB error occurs (see “Error Handling” on page 10-31).

The default value of the drAB threshold parameter is 2.0°. The value of the drAB threshold
parameter should be small. In general, if you change this parameter value during patient alignment,
you should return to the default value when patient alignment is completed. In some cases, for
example, poor image quality or degraded bony anatomy, it may be necessary to use a larger
threshold value than the default.

continue.
WARNING: If you increase the value of the drAB threshold parameter, you must perform
visual inspection after tracking results are displayed. Increasing the value of this
parameter may cause the Synchrony Spine Tracking algorithm to produce unreliable
estimates of the patient roll, which in turn can lead to misdirected radiation beams. Use
caution before changing this parameter value.
False Nodes (%)

The False Nodes (%) parameter gives the percentage of rejected node candidates in the ROI.
False nodes are nodes that are falsely identified in the Live X-ray image due to lack of skeletal
structure, noise, hardware, and so on. A node is identified as a false node if no correlation is found
between the Live X-ray and DRR images. The higher the value of the False Nodes threshold
parameter, the more rejected nodes are allowed. Consequently, the confidence in tracking results
is lower. When the percentage of false nodes determined by the Synchrony Spine Tracking
algorithm exceeds the False Nodes threshold value, a False Nodes error occurs (see “Error
Handling” on page 9-30).
The default value of the False Nodes threshold parameter is 50.0%. For most cases, the actual
percentage of false nodes is considerably less. However, in some lumbar cases or in some cases
of the lower parts of the thoracic spine, the value of this threshold may need to be increased. You
can also consider increasing the value (up to 65%) for small instrument implants and noisy images.

continue.
WARNING: If you increase the value of the False Nodes threshold parameter, you must
perform visual inspection after tracking results are displayed. Increasing the value of this
parameter may cause the Synchrony Spine Tracking algorithm to produce incorrect
Use caution before increasing this parameter value.


recommended for use. If the Synchrony Spine Tracking algorithm fails or a threshold violation
occurs, adjusting some of these values may allow successful tracking. If you make a threshold
value more lenient than the default value, a warning appears requiring confirmation to continue.
• “Adjusting the Tracking Range (mm)” on page 10-23
• “Adjusting the ROI Width (mm)” on page 10-23
Adjusting the Tracking Range (mm)

The Tracking Range (mm) parameter specifies the range of patient translations in all directions that
the Synchrony Spine Tracking algorithm is able to track. The Tracking Range value applies to
translations of each of the 81 nodes in the skeletal mesh.
The default value of the Tracking Range parameter is 20.0 mm. It can often help to increase the
tracking range during initial alignment. Once the patient is aligned, a smaller tracking range may
be helpful.
• Click and drag the adjustable cursor on the slider bar to adjust the value (see Figure 10
on page 10-20). Alternatively, enter a new value in the textbox to the right of the slider bar
and press <Enter>.
default value.
Images are automatically correlated when the Tracking Range (mm) parameter is changed.
Adjusting the ROI Width (mm)

The ROI Width (mm) parameter sets the width of the Region of Interest (ROI) used for tracking.
The default value of the ROI Width parameter is specified during treatment planning as follows:
• The position of the ROI is determined by the user with the selection of the align center
during treatment planning.
• The ROI size is also selected during treatment planning. The ROI width is larger than the
ROI height by a ratio of 3:2 (the width is the narrower dimension).
The ROI is displayed in the DRR images when the Display Skeletal Mesh checkbox is
selected (see “Display Skeletal Mesh” on page 10-18).

From Planning Default Value Adjustable Current

Checkbox From Cursor Value
Planning
Figure 11 False Nodes slider bar
The ROI Width (mm) slider bar includes the following controls:
• The current value is displayed to the right of the slider bar.
• The slider bar cursor allows you to adjust the value of the parameter. Drag the cursor to
change the value. You can also enter a value directly in the textbox under the slider bar.
• When the From Planning checkbox is selected, the default value of the ROI Width
parameter specified in the treatment plan is used.
 To change the ROI Width (mm) parameter from the default value:
1. Clear (deselect) the From Planning checkbox.
The textbox to the right of the slider bar is enabled with the default value 40.0 mm.
2. Click and drag the slider bar cursor to adjust the value. Alternatively, enter a new value in
the textbox under the slider bar and press <Enter>.
3. When the ROI Width value is changed, a blue box representing the ROI in the DRR
image dynamically changes size.
Images are automatically correlated when the ROI Width (mm) parameter is changed.
 To return to the default ROI Width value specified in the treatment plan:
1. Select the From Planning checkbox. The ROI Width value from the treatment plan
is displayed and the textbox is disabled.
The ROI Width should be adjusted during treatment planning based on the region of the spine
being tracked. For example, you may consider increasing the value of this parameter for the lumbar
and lower thoracic region because vertebrae are larger, and also increasing it for small instrument
implants and decayed skeletal structures. For information on how to size the ROI appropriately,
see the Treatment Planning Manual.
NOTE: The location of the imaging center cannot be changed

during treatment delivery.
In most cases the ROI Width specified during treatment planning should be used. The ROI Width
can be adjusted during treatment delivery to include more detailed spine structure that may not
have been seen in the DRR images generated during treatment planning.


• False Nodes (%) threshold
• drAB (deg) threshold
Current Default Adjustable Current

Calculated Value of Threshold Threshold
Value Threshold Cursor Value
Figure 12 False Nodes slider bar

value.
value.

continue.


Moving the Couch

Once you verify that there are sufficient skeletal features in the images and that anatomy in the
Live X-ray and DRR images matches, you can proceed with adjusting the patient position until
proper alignment is reached.
For more information on moving the treatment couch using the Move Couch button or Move
Couch mode, see “Chapter 8: Treatment Delivery”.
collisions.
When the patient is within required translational and rotational tolerances, you can proceed with
treatment by moving to the Readiness phase. For more information on required tolerances, see

In the Readiness phase, you review, resolve when applicable, and confirm any messages
displayed in the Delivery Warning Messages table, perform a Patient Safety Zone Check in
the Proximity Detection Status section, and make sure the collimator is set up correctly in
the Collimator and Laser Alignment Check section of the screen. For more information
on these procedures, see “Chapter 8: Treatment Delivery”.
When the Warning Message Status and Collimation System Status are both Ready,
you are ready to start treatment delivery.
For information on the optional Physician Setup Approval workflow, see “Physician Setup
Approval of Patient Alignment” on page 8-54.

Treatment Delivery
• “Visual Inspection During Treatment DeliverySynchrony Spine Tracking relies on the
nodes in the center columns of the ROI to estimate the patient roll rotations (rotation
about the Inferior/Superior axis).” on page 10-29
The Delivery phase (left screen) for Synchrony Spine Tracking is shown in Figure 13. Controls
on this screen and the right screen allow you to monitor and verify patient alignment and tracking
results during treatment delivery using Synchrony Spine Tracking .

Spine Tracking

For additional information on using Synchrony Spine Tracking Prone with Respiratory Modeling,
see “Synchrony Spine Tracking Prone with Respiratory Modeling” on page 10-33.
For more information on treatment delivery procedures, see “Chapter 8: Treatment Delivery”. For
information on treatment planning for treatment using Synchrony Spine Tracking , see the
Treatment Planning Manual.
Visual Inspection During Treatment DeliverySynchrony
WARNING: During treatment delivery, after acquisition of Live X-ray images at each node,
visually verify the patient position and verify that there are sufficient skeletal features in
the images. Make sure that anatomy in the Live X-ray and DRR images matches. For more
information on visually identifying features to be tracked, see “Chapter 8: Treatment
Delivery”.
WARNING: Lack of skeletal features in the Region of Interest (ROI) can result in incorrect
Inspect the ROIs in the Live X-ray images for both Camera A and Camera B to verify that
the ROI includes sufficient skeletal structures.
Spine Tracking relies on the nodes in the center columns of the ROI to estimate the patient roll
rotations (rotation about the Inferior/Superior axis).
WARNING: Lack of features in the center columns of the ROI can cause the Synchrony
Spine Tracking algorithm to produce incorrect estimates of the patient roll rotation, which
in turn can lead to misdirected radiation beams. Inspect the ROIs in the Live X-ray images
from both Camera A and Camera B to verify that the nodes in the center columns of each
ROI include sufficient features.


The Treatment Monitoring graph for Synchrony Spine Tracking includes an Spine graph display
(Figure 14). This display shows the computed values of the following parameters as a function of
time:
• False Nodes A (%): The percentage of false nodes in Live X-ray image A.
• False Nodes B (%): The percentage of false nodes in Live X-ray image B.
• dxAB (mm): The computed dxAB value (in millimeters).
• drAB (deg): The computed drAB value (in degrees).
Figure 14 Treatment Monitoring graph for Synchrony Spine

Tracking

Error Handling
The Synchrony Spine Tracking algorithm may fail for the following reasons:
• “False Nodes Error” on page 10-31
• “dxAB Error” on page 10-32
• “drAB Error” on page 10-32
During patient alignment in the Alignment > Align phase, when the calculated value of a
Synchrony Spine Tracking parameter exceeds the value of its threshold, one of the above
threshold violations occurs. An orange box is then displayed around the slider bar for that
parameter threshold.
For information on resuming treatment after a Soft Stop, see Chapter 7, “Treatment Delivery”.
False Nodes Error

A False Nodes Error most commonly occurs if the Live X-ray images are mismatched with the DRR
images during the Delivery phase. In this case, an error message is displayed in the Messages
window. If a False Nodes Error occurs, you should first check patient alignment. Patient alignment
must be achieved prior to tracking skeletal structures.

continue.

dxAB Error
A dxAB Error due to overly large dxAB values may be caused by large yaw rotations during the
Delivery phase. In this case, an error message is displayed in the Messages window.
To resolve this error, first check patient alignment. The treatment couch yaw position may need to
be adjusted. Then consider increasing the value of the dxAB threshold parameter. After the patient
is aligned, return to the default value of this parameter.

continue.
WARNING: If you change the value of the dxAB threshold parameter, you must perform
visual inspection after tracking results are displayed. Changing the value of this
drAB Error
A drAB Error due to overly large drAB values may be caused by image noise, low contrast, or a
deformed spine region during the Delivery phase. In this case, an error message is displayed in
the Messages window.
To resolve this error, first check patient alignment. Next consider adjusting X-ray parameters to
improve X-ray image quality. Then for very low contrast images, consider increasing the value of
the drAB threshold parameter to resolve the Soft Stop generated by the error. After the patient is
successfully aligned, return to the default value of this parameter.
If the previous solutions do not resolve the error, then after visually confirming tracking accuracy,
try increasing the drAB threshold value and disable (clear) the Robot Rotation Corrections
Enabled checkbox in the Readiness phase. Perform visual inspection to monitor and confirm
tracking results in both projections (Camera A and Camera B).

continue.

Synchrony Spine Tracking Prone with

This section provides information on using Synchrony Spine Tracking Prone with Respiratory
Modeling for treatment delivery. It describes differences between treatment delivery using
Synchrony Spine Tracking Prone with Respiratory Modeling and Synchrony Spine Tracking
without respiratory modeling.
• “CT Acquisition” on page 10-33
• “Placement of the Synchrony Respiratory External LED Markers” on page 10-34
• “Synchrony Spine Tracking Algorithm Parameters” on page 10-34
• “Rotational Corrections and Rotational Bounds Checking” on page 10-34
• “Respiratory Correlation Error” on page 10-35
CT Acquisition
For Synchrony Spine Tracking Prone with Respiratory Modeling treatments, it is essential to have
the patient in the same position for treatment as they were during pretreatment CT scanning,
including all immobilization devices. A reproducible patient position is the primary requirement
during patient preparation for the CT scan. Bring all immobilization devices created for the patient
to the CT scanner to replicate the patient position.
It is very important that the CT scan be taken during natural (not forced) inhalation or exhalation,
and that the same immobilization applied to the patient is used for both CT scanning and treatment
delivery. If any compression device is placed on the patient, it is essential that it be present for both
CT scanning and treatment delivery.
The size of any immobilization device placed between the hard surface of the treatment couch
table top and the patient should be minimized to reduce the distance from the couch surface to
highest point of the patient. Using an immobilization device that is thicker than the couch cushions
provided by Accuray increases the risk that the patient will be positioned outside the Patient Safety
Zone. For more information on the Patient Safety Zone, see “Chapter 2: Safety”.
of the PDP model increases the risk of collision with the treatment robot and can cause
serious injury or harm to the patient.
Follow the guidelines for patient preparation for pretreatment scanning described in “Chapter 6:
Patient Preparation”, and “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
1075883-ENG A Synchrony Spine Tracking Prone with Respiratory Modeling | 10-33

Placement of the Synchrony Respiratory External

LED Markers
For Synchrony Spine Tracking Prone with Respiratory Modeling, when attaching the 3 Tracking
Markers to the Synchrony Respiratory Vest, place them as close to the target as possible. This may
not be the location of maximum motion.
Note that with Synchrony Fiducial Tracking with Respiratory Modeling or Synchrony Lung Tracking
with Respiratory Modeling, the Tracking Markers are placed at the location of maximum motion.
With Synchrony Spine Tracking Prone with Respiratory Modeling, however, it is important that the
motion of the Tracking Markers and the target are closely correlated and have a linear relationship.
The Respiratory Model type is restricted to Linear when using Synchrony Spine Tracking Prone
with Respiratory Modeling.
Synchrony Spine Tracking Algorithm Parameters

For Synchrony Spine Tracking Prone with Respiratory Modeling, the following parameters are set
by default:
• The Skip Respiratory checkbox is deselected (cleared) so that respiratory modeling
is enabled by default.
• The Robot Rotation Corrections Enabled checkbox is deselected in the
Readiness phase. Only translational corrections will be made by the treatment robot
during treatment delivery. For more information on displacement corrections, see
• The default values for roll, pitch, and yaw in the Rotational Bounds Checking
textboxes are set to 2.5 degrees.
If you disable respiratory modeling by selecting the Skip Respiratory checkbox, then the
Robot Rotation Corrections Enabled checkbox is selected by default and rotational
corrections will be made during treatment delivery.
NOTE: If you exit treatment delivery and return to the CyberKnife

System Menu, respiratory modeling will be re-enabled the next
time you return to the treatment delivery screen.
Rotational Corrections and Rotational Bounds

Checking
For Synchrony Spine Tracking Prone with Respiratory Modeling, by default respiratory modeling
is enabled (Skip Respiratory checkbox is deselected). In this case, rotational corrections will
not be made by the treatment robot during treatment delivery (the Robot Rotation
Corrections Enabled checkbox is deselected in the Readiness phase). Only translational
respiratory corrections will be made.
10-34 | Synchrony Spine Tracking Prone with Respiratory Modeling 1075883-ENG A

Because spine rotations are not corrected for by default for Synchrony Spine Tracking Prone with
Respiratory Modeling treatments, the default settings for Rotational Bounds Checking that
trigger a Soft Stop are reduced to 2.5 degrees for all three rotations (roll, pitch, and yaw). You can
override these limits down to 0.1 degrees or up to 5 degrees for each rotation.
When target motion is not clinically relevant as determined by a clinician, it may be advantageous
to disable respiratory modeling. For Synchrony Spine Tracking Prone, when respiratory modeling
is disabled, rotational corrections are enabled by default and can be corrected for during treatment
delivery. To disable respiratory modeling, select the Skip Respiratory checkbox. The Robot
Rotation Corrections Enabled checkbox is then automatically selected in the Readiness
phase. The settings for Rotational Bounds Checking will be determined by the treatment
couch, among other factors. For more information, see “Chapter 8: Treatment Delivery”.
Respiratory Correlation Error

For treatments using Synchrony Spine Tracking Prone with Respiratory Modeling, the threshold
for triggering a Soft Stop due to an excessive correlation error value is reduced to 2.5 mm (from 5
mm).
The user can lower the correlation error threshold value so that a Soft Stop is triggered at less than
the default value of 2.5 mm.
For Synchrony Spine Tracking Prone with Respiratory Modeling, the threshold can be decreased
from 2.5 mm to 1.5 mm. Note that for Synchrony Spine Tracking Prone with Respiratory Modeling
treatments, you are likely to be treating anatomies that are more sensitive to accurate dose
placement. It is therefore important to carefully consider the clinical implications of the correlation
error.
1075883-ENG A Synchrony Spine Tracking Prone with Respiratory Modeling | 10-35

10-36 | Synchrony Spine Tracking Prone with Respiratory Modeling 1075883-ENG A

Chapter 11: Synchrony Lung
Tracking with Respiratory
Modeling (Options)
Introduction
This chapter describes how to use the Synchrony Lung Tracking with Respiratory Modeling with
the CyberKnife System. This chapter covers the following topics:
• “Overview of the Synchrony Lung Tracking with Respiratory Modeling” on page 11-2
• “Requirements for Visual Evaluation” on page 11-5
• “Workflow for Synchrony Lung Tracking with Respiratory Modeling” on page 11-6
The Synchrony Lung Tracking with Respiratory Modeling enables radiation beam delivery in the
lung with for accurate tracking without the need for implanting fiducials. It is used in combination
with Synchrony Spine Tracking to perform patient alignment. During treatment delivery, the
Synchrony Lung Tracking with Respiratory Modeling may be used with the Synchrony tracking
System to track movement of the tumor due to patient breathing patterns.
This chapter assumes you are familiar with the following chapters:
• “Chapter 8: Treatment Delivery” on page 8-1
• “Chapter 10: Synchrony Spine Tracking (Option)” on page 10-1
• “Chapter 12: Synchrony Respiratory Tracking System (Option)” on page
12-1

Overview of the Synchrony Lung Tracking with

This section describes the Synchrony Lung Tracking with Respiratory Modeling algorithm and its
intended use in the CyberKnife System. It covers the following topics:
• “Synchrony Lung Tracking with Respiratory Modeling Algorithm” on page 11-2
• “Quality Metrics” on page 11-3
• “Tumor Region DRR Images” on page 11-4
• “Preferred Projection” on page 11-4
• “Treatment Planning Overview” on page 11-4
The Synchrony Lung Tracking with Respiratory Modeling can accurately track lung tumors that
meet the following conditions, without the use of fiducials in the lung:
• Tumor diameter larger than 15 mm in all directions.
• Tumor location in the peripheral region of the lung.
The ability of the Synchrony Lung Tracking with Respiratory Modeling to accurately track lung
tumors depends on whether they are visible in both projection images.
The workflow described in “Chapter 14: Simulation Application Overview
(Option)” on page 14-1 will allow the user to verify that the algorithm is able to visualize the
lung tumor.
Treatment using the Synchrony Lung Tracking with Respiratory Modeling includes a treatment
planning phase and a treatment delivery phase.
NOTE: When the preferred projection method is enabled, the

Synchrony Lung Tracking with Respiratory Modeling algorithm
does not calculate a value for the dxAB parameter for the
correlation.
Synchrony Lung Tracking with Respiratory

Modeling Algorithm
The Synchrony Lung Tracking with Respiratory Modeling algorithm searches for and locates the
target in the Live X-ray images of the patient during treatment. Target localization is performed by
image registration between the DRR images and the Live X-ray images. Specifically, the image
intensity pattern of the tumor region in the DRR images is matched to the most similar region in the
Live X-ray images. A matching window for the tumor is defined based on the 2D tumor outline in
each image. The matching window is the smallest rectangle that encompasses the entire tumor.
Since typical tumor shapes are not rectangular, the matching window will also include some of the
surrounding region.
11-2 | Overview of the Synchrony Lung Tracking with Respiratory Modeling 1075883-ENG A
Treatment Delivery Manual Chapter 11: Synchrony Lung Tracking with Respiratory Modeling
The registration process is performed independently for each projection (corresponding to

Camera A and Camera B of the X-ray imaging system), resulting in target location information for
both projections. Registration is performed by moving the matching window throughout a user-
defined search area (see “Adjusting Tracking Range X (mm) and Tracking Range Y (mm)” on
page 11-30). The region of the search area with maximum similarity to the corresponding DRR
image is considered to be the target. To assess the quality of the registration, the Synchrony Lung
Tracking with Respiratory Modeling algorithm uses quality metrics (see “Quality Metrics” on
page 11-3).
The Synchrony Lung Tracking with Respiratory Modeling algorithm computes three translational
components of the target patient displacement. The rotational components are provided by the roll
displacements estimated by Synchrony Spine Tracking during patient alignment and are assumed
to be constant throughout the treatment. Successful initial patient alignment using Synchrony
Spine Tracking is therefore necessary. The treatment robot continually adjusts the position of the
LINAC to correct for translational offsets of the target and applies the constant rotational correction.
The Synchrony Lung Tracking with Respiratory Modeling is used in conjunction with the
Respiratory system to track and compensate for patient respiratory motion. Treatment delivery
uses the Synchrony Lung Tracking with Respiratory Modeling for target localization and the
Synchrony tracking System for compensating for respiratory motion.
Quality Metrics
The Synchrony Lung Tracking with Respiratory Modeling algorithm operates by locating an
intensity pattern in the Live X-ray images that is similar to that in the DRR images. It is possible
that more than one such pattern exists in the search area. The algorithm takes into account several
factors to assess the registration quality:
• The maximum of the similarity measure between the Live X-ray and DRR images.
• The number of other local maxima found within the Tracking Range (for information on
the Tracking Range parameters, see “Adjusting Tracking Range X (mm) and Tracking
Range Y (mm)” on page 11-30).
• The tumor size and the tumor location relative to the prediction made by the Synchrony
tracking System. For more information on the Synchrony tracking System, see “Chapter
These factors are combined to calculate the detection uncertainty. The threshold for detection
uncertainty is user-defined (see “Uncertainty (%)” on page 11-29). If the detection uncertainty is
higher than the threshold, treatment delivery is interrupted by a Soft Stop.
WARNING: It is very important to visually inspect tracking results during treatment

delivery. Otherwise, mistargeting can result. It is possible for intensity patterns similar to
that of the target to exist at locations other than the target position.
The Synchrony Lung Tracking with Respiratory Modeling algorithm also calculates a dxAB value
as a quality metric. For information on this parameter, see “dxAB (mm)” on page 11-29.
1075883-ENG A Overview of the Synchrony Lung Tracking with Respiratory Modeling | 11-3
Tumor Region DRR Images

Tumor region DRR images remove all structures that are not in the neighborhood of the tumor. In
this way, visibility of the tumor in the DRR images is improved and the Synchrony Lung Tracking
with Respiratory Modeling algorithm is prevented from locking onto a structure that appears to be
near the tumor in the DRR images but is actually located far from it, with a different motion pattern.
Preferred Projection
In some cases, the tumor is more clearly visible or better identified on one Live X-ray image than
the other. Depending on tumor location, the tumor in one projection may partially or completely
overlap with the spine, chest wall, heart, diaphragm, or other anatomic structures. In these cases,
the Preferred Projection feature of the Synchrony Lung Tracking with Respiratory Modeling
algorithm can improve the accuracy and robustness of target localization (see “Enabling Preferred
Projection” on page 11-31).
When the preferred projection method is enabled, the Synchrony Lung Tracking with Respiratory
Modeling uses the shared Inferior/Superior direction in the two Live X-ray images to combine the
similarity measures from both images when attempting to find the target. In this way, poor target
visibility in one image can be overcome by combining the similarity measure from that image with
the well-defined similarity maximum in the image where the target is clearly visible.
NOTE: When the preferred projection method is enabled, the

Synchrony Lung Tracking with Respiratory Modeling algorithm
does not calculate a value for the dxAB parameter for the
correlation.
WARNING: For image correlations when the preferred projection method is invoked, the
dxAB value can no longer be used as an indication of tracking reliability. It is possible for
a tracking failure to occur without producing a dxAB error.
Treatment Planning Overview

During treatment planning using the Accuray Precision System, spine segmentation must be
performed to isolate spinal structures. The location of the tumor to be treated is identified and tumor
segmentation is performed to generate 2D tumor contours.
Tumor segmentation is used to generate tumor region DRR images. Tumor region DRR images
include the tumor contour and a 20 mm dilated region around it. During treatment planning, tumor
contours in the DRR images define the size and center of rectangular matching windows that are
used during treatment delivery for correlation of the Live X-ray images with the DRR images. If the
matching windows specified during treatment planning do not fit within the 20 mm dilated region,
the region is expanded further until the matching windows are fully enclosed.
11-4 | Overview of the Synchrony Lung Tracking with Respiratory Modeling 1075883-ENG A
In the Accuray Precision System, sample DRR images are generated and should be inspected to
determine whether the case is suitable for Synchrony Lung Tracking with Respiratory Modeling. If
the case is confirmed to be suitable, the treatment plan is saved. Prior to treatment delivery,
multiple DRR images are generated using the iDMS Data Management System. The DRR images
are used during patient alignment with Synchrony Spine Tracking and during treatment using the
Synchrony Lung Tracking with Respiratory Modeling.
For more information on the DRR images that are generated, see “Generating DRR Images” on
page 11-8. For more information on treatment planning using the Synchrony Lung Tracking with
Respiratory Modeling, see the Treatment Planning Manual.

Visual evaluation to verify that the lung tumor is tracked correctly by the Synchrony Lung Tracking
with Respiratory Modeling algorithm is essential to safe treatment delivery.
The Treatment Delivery System user interface provides tools to verify that Synchrony Spine
Tracking and the Synchrony Lung Tracking with Respiratory Modeling are able to register skeletal
structures and lung tumors in the Live X-ray images with those in the DRR images. For more
information, see “Analyzing Imaging Results” on page 11-21.
NOTE: Visual inspection during treatment delivery ensures that

the Synchrony Lung Tracking with Respiratory Modeling
algorithm is tracking correctly. However, visual inspection alone
is not adequate for verifying submillimeter accuracy.
1075883-ENG A Requirements for Visual Evaluation | 11-5

Workflow for Synchrony Lung Tracking with

Figure 1 shows the workflow for patient alignment and treatment delivery using Synchrony Lung
Tracking with Respiratory Modeling mode
Figure 1 Workflow for Synchrony Lung Tracking

with Respiratory Modeling
Two treatment couch positions are used during treatment delivery with the Synchrony Lung
Tracking with Respiratory Modeling:
• Spine position: The alignment center defined during treatment planning in the Align step
of the Accuray Precision System. This position is used for alignment by Synchrony Spine
Tracking.
• Lung position: The treatment center automatically determined during treatment planning
during tumor segmentation. This is the spine position plus the alignment-to-treatment
offset from planning. This position is used for tracking by the Synchrony Lung Tracking
The alignment center is typically different from the treatment center. The alignment center is used
during an initial spine alignment procedure using Synchrony Spine Tracking. The spine alignment
is performed in the Alignment > Align phase. This procedure determines the rotational
alignment corrections that will be used during treatment delivery with the Synchrony Lung Tracking
After spine alignment is completed, you transition from Synchrony Spine Tracking to the Synchrony
Lung Tracking with Respiratory Modeling. This transition occurs when you move to the
Alignment > Lung phase. You then move the treatment couch to the treatment center.
WARNING: It is strongly recommended that Synchrony Spine Tracking be used for initial
patient alignment (by performing spine alignment in the Alignment > Align phase)
before treatment is delivered using the Synchrony Lung Tracking with Respiratory
Modeling. Otherwise, rotational misalignment during patient positioning will not be
compensated for.
11-6 | Workflow for Synchrony Lung Tracking with Respiratory Modeling 1075883-ENG A
Treatment delivery using the Synchrony Lung Tracking with Respiratory Modeling includes the
following general steps:
1. Load patient and treatment plan data in the Overview phase, as described in “Chapter
2. Find the optimal X-ray technique for spine alignment using Synchrony Spine Tracking in
the first Alignment > Technique phase, as described in “Chapter 10: Synchrony
Spine Tracking (Option)”.
3. Position the patient on the treatment couch and move the patient to the alignment center
for initial spine alignment using Synchrony Spine Tracking in the Alignment > Align
phase, as described in “Chapter 10: Synchrony Spine Tracking (Option)”.
4. Use Synchrony Spine Tracking to align the patient translationally and rotationally at the
spine position, as described in “Chapter 10: Synchrony Spine Tracking (Option)”. After
this step, the treatment couch is at Synchrony Spine Tracking alignment center.
5. Switch from Synchrony Spine Tracking alignment center (the spine position) to the
Synchrony Lung Tracking with Respiratory Modeling treatment center (the lung position)
in the Alignment > Lung phase.
This step involves treatment couch movement. The difference between the alignment
center and the treatment center includes the alignment-to-treatment offset defined from
treatment planning plus any additional offset the user applied during the current or
previous treatment fractions. For more information, see “Transition to the Synchrony
Lung Tracking with Respiratory Modeling” on page 11-13.
6. Find the optimal X-ray technique for treatment delivery using the Synchrony Lung
Tracking with Respiratory Modeling in the second Alignment > Technique phase.
7. Use the Synchrony Lung Tracking with Respiratory Modeling to translationally align the
patient sufficiently for tracking, in the Alignment > Respiratory phase
If the Synchrony tracking System is used, establish a Respiratory correlation model for
patient respiratory motion.
NOTE: The user decides whether to enable or disable the

Synchrony tracking System during Synchrony Lung Tracking
with Respiratory Modeling treatment delivery. As an example, if
the motion of the target due to respiration is considered to be
insignificant, the Synchrony tracking System may be disabled.
8. Start treatment delivery in the Delivery phase.
“Chapter 8: Treatment Delivery”. For information on using the Synchrony tracking System, see
1075883-ENG A Workflow for Synchrony Lung Tracking with Respiratory Modeling | 11-7


DRR images for use with the Synchrony Lung Tracking with Respiratory Modeling are generated
using the iDMS Data Management System as described in “Chapter 8: Treatment Delivery”. Roll
angles of the patient are computed during initial alignment using Synchrony Spine Tracking by
comparing the Live X-ray images with multiple DRR images.
The following number and types of DRR image pairs are generated:
• Multiple pairs of segmented spine DRR images with optimally distributed orientations, to
simulate different roll angles of the patient. These DRR images are used during patient
alignment with Synchrony Spine Tracking.
• 1 pair of unsegmented (full content) spine DRR images for automatic contrast adjustment
and visual inspection of image correlation results during patient alignment using
Synchrony Spine Tracking. These DRR images correspond to the imaging center (also
called the alignment center), which is chosen during treatment planning.
• 1 pair of full content DRR images that correspond to the treatment center for the target
tumor, which is chosen during treatment planning. This pair of DRR images is used for
automatic contrast adjustment and visual inspection of tracking results during treatment
delivery using the Synchrony Lung Tracking with Respiratory Modeling.
• 1 pair of segmented DRR images in which the spine and other skeletal structures are
removed. This pair of DRR images is used for image correlation with the Live X-ray
images during treatment delivery.
• 1 pair of tumor region DRR images in which all structures that are not in the neighborhood
of the tumor are removed. For more information on tumor region DRR images, see
“Tumor Region DRR Images” on page 11-4.
11-8 | Verifying Patient and Treatment Data 1075883-ENG A


transmitted to the TLS computer for use by Synchrony Spine Tracking algorithm. The
separate pairs of unsegmented (full content) DRR images, soft tissue-only DRR images,
and tumor region DRR images are also transmitted.
• Synchrony Spine Tracking and Synchrony Lung Tracking with Respiratory Modeling
algorithms are initialized.
For more information on downloading treatment files, see “Chapter 8: Treatment Delivery”.

Figure 2 shows the Alignment > Couch phase (left screen) for Synchrony Spine Tracking after
the Live X-ray and DRR images have been visually aligned using Couch Mode. The unsegmented
(full content) DRR images for Synchrony Spine Tracking are displayed. Table 3 on page 11-23
describes the image panel controls to aid image analysis and visual alignment. For more
information on this phase, see “Chapter 8: Treatment Delivery”.

Figure 2 Alignment > Couch phase (left screen) for Synchrony Lung Tracking with Respi-
ratory Modeling after visual alignment using Couch Mode

The goal of the first Alignment > Technique phase for Synchrony Lung Tracking with
Respiratory Modeling is to find the optimal X-ray technique for spine alignment. This X-ray
technique will be the default for future treatment fractions unless it is changed. Start by analyzing
the existing image from the Alignment > Couch phase.
For more information on optimizing the X-ray technique for spine alignment using Synchrony Spine
Tracking, see “Chapter 10: Synchrony Spine Tracking (Option)”.


The goal of patient alignment is to make sure the patient is aligned within acceptable bounds for
treatment using the Synchrony Lung Tracking with Respiratory Modeling. Patient alignment
involves the following general steps:
1. Initial spine alignment at the spine position using Synchrony Spine Tracking in the
Alignment > Align phase. For Synchrony Lung Tracking with Respiratory Modeling
mode, the goal of this procedure is to determine the rotational offsets that will be used in
the Align > Lung phase and during treatment delivery.
2. Moving the treatment couch from the spine position to the lung position in the Align >
Lung phase. This step transitions from Synchrony Spine Tracking to the Synchrony
Lung Tracking with Respiratory Modeling. The goal of this step is to verify that the move
is successful, with rigid structures aligned in the Live X-ray and DRR images.
3. Finding the optimal X-ray technique for treatment delivery using the Synchrony Lung
Tracking with Respiratory Modeling in the second Alignment > Technique phase.
4. Alignment for treatment using Synchrony Lung Tracking with Respiratory Modeling and
establishment of a Respiratory correlation model using the Synchrony tracking System, in
the Alignment > Respiratory phase.
5. Optional remote approval of alignment with the TxView application. For information on the
TxView remote approval workflow, see “Requesting Remote Approval of Patient
Alignment (TxView Option)” on page 8-53.
6. Optional Physician Setup Approval of Patient Alignment workflow, For more information,
see “Physician Setup Approval of Patient Alignment” on page 8-54.
• “Initial Alignment Using Synchrony Spine Tracking” on page 11-12
• “Transition to the Synchrony Lung Tracking with Respiratory Modeling” on page 11-13
• “Alignment for Treatment Using the Synchrony Lung Tracking with Respiratory Modeling”
on page 11-20

Initial Alignment Using Synchrony Spine Tracking

Initial alignment using Synchrony Spine Tracking is performed in the Alignment > Align phase
as described in “Chapter 10: Synchrony Spine Tracking (Option)”. The goal of this step for
Synchrony Lung Tracking with Respiratory Modeling treatments is to determine the rotational
offsets that will be used in the Align > Lung phase and during treatment delivery in the
Delivery phase.
Figure 3 shows the Alignment > Align phase (left screen) for a Synchrony Lung Tracking with
Respiratory Modeling treatment. The unsegmented (full content) DRR images for Synchrony Spine
Tracking at the alignment center are displayed. The screen is similar to the screen for a Synchrony
Spine Tracking Supine or Synchrony Spine Tracking treatment, with the addition of the Skip
Spine checkbox below Image A.
Figure 3 Alignment > Align phase (left screen) for a Syn-

chrony Lung Tracking with Respiratory Modeling Tracking
treatment after image correlation

For Synchrony Lung Tracking with Respiratory Modeling treatments, selecting the Skip Spine
checkbox allows you to skip spine alignment and proceed directly to the Alignment > Lung
phase. This checkbox is deselected by default. You should not skip spine alignment if it is possible
to track using Synchrony Spine Tracking algorithm. If you do decide to skip spine alignment, you
should align to the best of your visual ability before proceeding.
WARNING: It is strongly recommended that Synchrony Spine Tracking be used for initial
patient alignment (by performing spine alignment in the Alignment > Align phase)
before treatment is delivered using the Synchrony Lung Tracking with Respiratory
Modeling. Otherwise, rotational misalignment during patient positioning will not be
compensated for.
After aligning the patient properly within acceptable bounds, you are ready to move to the
Alignment > Lung phase.
Transition to the Synchrony Lung Tracking with

Once alignment has been accomplished using Synchrony Spine Tracking, you click the Lung tab
to transition to alignment using the Synchrony Lung Tracking with Respiratory Modeling in the
WARNING: Do not reposition the patient or adjust treatment couch rotation after
switching to the Synchrony Lung Tracking with Respiratory Modeling System. If it is
necessary to perform either of these actions, return to the Alignment > Align phase
and repeat Synchrony Spine Tracking alignment procedure, as described in “Chapter 10:
Synchrony Spine Tracking (Option)”.
The goal of this step is to move the treatment couch from the spine position to the lung position.
You then take an image and make sure that rigid structures are aligned in the Live X-ray and DRR
images.
NOTE: Do not attempt to manually align the tumor in the

Figure 4 shows the Alignment > Lung phase (left screen) before moving to the lung position.
The full content DRR images corresponding to the treatment center for the Synchrony Lung
Tracking with Respiratory Modeling are displayed.

Figure 4 Alignment > Lung phase (left screen)

before moving to Lung position
Table 1 shows the treatment couch position display in the Alignment > Lung phase (below
Image A). The display includes a position indicator which shows the treatment couch at one of 4
positions:
• At the spine position: The spine align center from treatment planning plus the final offsets
from the Alignment > Align phase.
NOTE: If spine alignment is not performed (that is, the Skip

Spine checkbox was selected), the spine position is the
treatment couch position when leaving the Alignment >
Align phase.
• At the lung position: This is the spine position plus the shift to the lung align center from
treatment planning.
• Between the spine and lung position: The treatment couch is paused between or moving
between these two positions.
• Near but not at the lung position.
NOTE: The treatment couch position display is a graphical

display that only indicates one of the above 4 positions. It does
not show the actual physical location of the lung tumor and does
not represent actual targeting of the lung tumor.

The display also includes 2 buttons for moving the treatment couch, as described in Table 2.
Table 1 Treatment couch position display
Position Indicator Description
Treatment couch is at the spine

position (alignment center).
In this state, the Move Couch to
Lung button is enabled.
Treatment couch is at the lung

position (treatment position).
Spine button is enabled.
Treatment couch is currently

paused between or moving
between the spine and lung
positions.
When paused, both the Move
Couch to Spine and Move
Couch to Lung buttons are
enabled. During movement, all
controls are disabled except the
Interlock button.
Treatment couch is near but not at

the lung position.
In this state, both the Move
enabled.

Table 2 Buttons associated with the treatment couch position display
Move Couch Moves the treatment couch to the lung position (treatment
to Lung position).
Move Couch Moves the treatment couch to the spine position

to Spine (alignment center).

system of the CyberKnife System. Visually observe all movement of the couch to prevent
potential collisions.
 To move to the lung position:

1. Click the Move Couch to Lung button. Then wait until the couch has moved to the
lung position.
2. Click the Acquire button to acquire a Live X-ray image. For more information on
acquiring Live X-ray images, see “Chapter 8: Treatment Delivery”.
3. Analyze imaging results to verify that rigid structures are aligned in the Live X-ray and
DRR images. Verify that there are no unexpected features or obstructions in the images.
For more information, see “Analyzing Imaging Results” on page 11-21.
If treatment couch motion is interrupted during the transition between Synchrony Spine Tracking
and the Synchrony Lung Tracking with Respiratory Modeling, for example, if an E-Stop button is
pressed, you can use the treatment couch position display to move to the spine or lung position,
as described below.

 To move to the spine or lung position after treatment couch motion is interrupted:
• In the Alignment > Lung phase, click the Move Couch to Spine button to move
to the spine position (alignment center). Or, click the Move Couch to Lung position to
move to the lung position (treatment center).
If it is necessary, you can add an offset to the alignment-to-treatment offset from planning, as
described below.
 To add an offset to the lung position from planning:
1. Enter target translational values in the Couch Position (mm) textboxes.
Arrows above the textboxes point in the positive direction. Values indicate target
treatment couch movement relative to its current position.
2. Click the Move Couch button to move the treatment couch. (The couch rotations from
spine alignment are locked in the Alignment > Lung phase.)
The additional offset is automatically saved and will be applied during treatment delivery
for the current fraction and future fractions. (The Apply additional relative offset
checkbox is selected by default.)
3. To remove the additional offset that you generated in Step 2, or to remove the additional
offset that was saved and applied for previous fractions, deselect the Apply
additional relative offset checkbox. Then click the Move Couch to Lung
button.
This step returns the couch to the lung position (the treatment position from planning).
The lung position will then be used for the current fraction and future fractions.
After moving the treatment couch to the lung position, taking an image, and verifying that rigid
structures in the Live X-ray and DRR images are aligned, you are ready to move to the second

After aligning the patient properly at the lung position, you click the Technique tab to proceed to
the Alignment > Technique phase for lung, where you refine the X-ray technique that will be
used for treatment.
The goal of the second Alignment > Technique phase for Synchrony Lung Tracking with
Respiratory Modeling treatments is to find the optimal X-ray technique. This X-ray technique will
be the default for future treatment fractions unless it is changed. You start by analyzing the existing
image from the Alignment > Lung phase.

correctly.
Figure 5 shows the Alignment > Technique phase (left screen) for the Synchrony Lung
Tracking with Respiratory Modeling after image acquisition. A histogram display below each Raw
Image represents the distribution of pixel intensities in the entire image. Table 3 on page 11-23
describes the image panel controls to aid image analysis in this phase, including DRR display
modes.
Figure 5 Alignment > Technique phase (left screen) for Syn-

chrony Lung Tracking with Respiratory Modeling after
image acquisition
Figure 6 shows the Alignment > Technique phase (right screen) for the Synchrony Lung
Tracking with Respiratory Modeling after image acquisition. The image history displays the
technique used to acquire the selected image as well as a histogram representing the distribution
of pixel intensities in the selected image,

Figure 6 Image History table for Synchrony Lung Tracking

with Respiratory Modeling System in the Alignment > Tech-
nique phase (right screen)
evaluating image quality and histogram displays of images on the left screen and in the Image
History table.
If you have selected a satisfactory X-ray technique, you can proceed to the
Alignment > Respiratory phase. Otherwise, you can change the X-ray technique as needed
until you are satisfied with the image quality, as described below. For more information on the
Alignment > Technique phase, see “Chapter 8: Treatment Delivery”.

The Live X-ray images should have the same image quality as the DRR images. You can modify
the X-ray parameters to improve the quality of the image. If there is too little detail in the Live X-ray
images, you can try increasing the kV, mA, and ms settings to increase the exposure. If the
image is too dark, try decreasing the kV, mA, and ms settings to decrease the exposure. For
locating the tumor, it is best to maximize the contrast between the tumor and the surrounding
tissue.

Alignment for Treatment Using the Synchrony

Lung Tracking with Respiratory Modeling
The goal of the Alignment > Respiratory phase for Synchrony Lung Tracking with
Respiratory Modeling treatments is to translationally align the patient sufficiently for tracking and
to build a Respiratory correlation model for patient respiratory motion.
Figure 7 shows the Alignment > Respiratory phase (left screen) for Synchrony Lung
Tracking with Respiratory Modeling mode after image acquisition. For more information on the
Figure 7 Alignment > Respiratory phase (left screen) for

Synchrony Lung Tracking with Respiratory Modeling after
image correlation
The Alignment > Respiratory phase has the following steps, described in the sections
below:
• “Analyzing Imaging Results” on page 11-21: You start by evaluating image correlation
results to determine if you need to move the treatment couch. You also review the Live X-
ray images to verify that the tumor has been correctly located and that anatomy in the
Live X-ray and DRR images matches.
• “Alignment for Treatment Using the Synchrony Lung Tracking with Respiratory Modeling”
on page 11-20: You build a Respiratory correlation model for respiratory motion.


• “Evaluating Image Correlation Results” on page 11-21
Evaluating Image Correlation Results

The Live X-ray images are correlated with the reference DRR images to determine patient offsets.
Because the Synchrony Lung Tracking with Respiratory Modeling algorithm does not estimate
rotational offsets, only translational offsets are displayed and updated in the Respiratory
Model (mm) table (see Figure 7).
If the tumor was successfully detected in the Live X-ray image, a graphic overlay of the tumor
outline appears over the detected location of the tumor (see Table 3 on page 11-23).
For the Synchrony Lung Tracking with Respiratory Modeling, rotational offsets are not calculated
during treatment. The rotational corrections obtained from initial Synchrony Spine Tracking
alignment are used to perform rotation adjustments of the LINAC during treatment delivery. These
Alignment Rotational Correction (deg) values are displayed in the Respiratory
Model (mm) table.
If the calculated offsets are within tolerances required for treatment delivery, and you can verify
that the tumor has been correctly located in the Live X-ray images and that anatomy in the Live X-
ray and DRR images matches, you are ready to proceed with building a Respiratory Model. See
“Alignment for Treatment Using the Synchrony Lung Tracking with Respiratory Modeling” on
page 11-20". To reduce offsets, you can move the treatment couch using the Move Couch
button. For more information on moving the couch, see “Chapter 8: Treatment Delivery”.
NOTE: Any motion of the treatment couch will invalidate the

Respiratory correlation model and require that a new model be
established prior to treatment delivery.
If the Synchrony Lung Tracking with Respiratory Modeling algorithm cannot locate the tumor, the
displayed tumor outline in the Live X-ray images will not be aligned with the actual tumor. An out-
of-bounds error may also occur, indicated by an orange box around the row in the Respiratory
Model (mm) table that is not within required tolerances. Also tracking algorithm threshold
violations may occur, indicated by an orange box around the row in the table and around the slider
bar for a threshold parameter.
In this situation, you can attempt one or more of the following:
• Make the following adjustments as appropriate:
 Use Offset Mode to drag the tumor outlines in the Live X-ray images and determine
translational offsets. For more information, see “Using Offset Mode” on page 11-27.

 You can increase the Tracking Range X and Tracking Range Y parameters. For
more information, see “Adjusting Tracking Range X (mm) and Tracking Range Y
(mm)” on page 11-30.
• You can also consider increasing the value of the Uncertainty threshold parameter if you
are confident that the tumor found using a higher value is correctly identified. For more
information, see “Uncertainty (%)” on page 11-29.

continue.
Synchrony Lung Tracking with Respiratory Modeling algorithm to incorrectly identify the
tumor without generating an error. You must therefore visually verify that the tumor has
been correctly identified throughout the treatment.
• If the tumor is visible in one projection but blocked (for example, by radiopaque structures
such as the spine or heart) in the other projection, or if a large dxAB value and large
detection Uncertainty are calculated for one of the projections, you can consider enabling
the preferred projection method. For more information, see “Enabling Preferred
Projection” on page 11-31.
For more information on image analysis tools to verify that the tumor is correctly located by the
tracking algorithm, see Table 3 on page 11-23. For information on calculated algorithm
parameters, parameter thresholds, and algorithm input parameters, see “Correlation Error (mm)”
on page 11-30.

Table 3 describes image panel controls and DRR display modes to aid image analysis.

Control Description

image.
(Synchrony Lung Tracking with Respiratory Modeling mode) You can also use
Offset Mode when the Pointer is turned on. For more information, see “Using


Control Description
clicking and dragging in either the Live X-ray image or DRR image. For more
information, see “Chapter 8: Treatment Delivery”. Depending on the treatment
phase, the following icons are displayed:
unshifted position.

Control Description
Tumor Outline: (Synchrony Lung Tracking with Respiratory Modeling mode;

lower right of image panel) Displays a graphic overlay of the tumor outline (Target
Tracking Volume, TTV) in the DRR images and Live X-ray images that
corresponds to the tumor contour specified during treatment planning:
Live X-ray image in Offset Mode. For more information, see “Using Offset
Mode” on page 11-27.
The Tumor Outline is turned on by default.
DRR images.
out automatically.
Full Content DRR: (Synchrony Lung Tracking with Respiratory Modeling mode)
Displays the unsegmented (full content) DRR images. For more information, see
“Display Modes for DRR Images” on page 11-26.

mode) Displays the segmented DRR images, in which the spine and other bony
structures are removed and remaining DRR image content is displayed. For more
information, see “Display Modes for DRR Images” on page 11-26.

Control Description
Tumor Region DRR: (Synchrony Lung Tracking with Respiratory Modeling mode;
upper right corner of image panel) Displays the tumor region DRR images, in
which all image content that is not in the immediate region of the tumor is
removed. For more information, see “Display Modes for DRR Images” on
page 11-26.
image is required.
t Turn on/off Tumor Outline (Target Tracking Volume, TTV).

(Synchrony Lung Tracking with Respiratory Modeling mode)

You can switch between 3 display modes for the DRR images in the image panels (see Table 3):

• Full Content DRR display mode

• Spine Removed DRR display mode
• Tumor Region DRR display mode
do not affect the results of the Synchrony Lung Tracking with
Respiratory Modeling algorithm.
You can select different display modes for each image (corresponding to Camera B and Camera A
of the X-ray imaging system).
NOTE: Use Full Content DRR display mode for visual

evaluation of tracking results. You can switch back and forth
between display modes.
Using Offset Mode

If the Synchrony Lung Tracking with Respiratory Modeling algorithm cannot locate the tumor, the
displayed tumor outline in the Live X-ray images will not be aligned with the actual tumor. In this
situation, you can use Offset Mode to assist the tracking algorithm by shifting the tumor outline
manually. You can click and drag the mouse in one of the Live X-ray images to move the tumor
outline and overlay it on the feature you have visually identified as the actual tumor. The
translational offsets determined by manually shifting the tumor outline are used as inputs to the
Synchrony Lung Tracking with Respiratory Modeling algorithm.
1. Turn on the Pointer and Tumor Outline in the image panel (see Table 3 on page 11-23).
2. Move the cursor over the blue tumor outline in one of the Live X-ray images. The outline
turns red.
3. Click in the Live X-ray image to grab the tumor outline. Drag the tumor outline in the Live
X-ray image to overlay it on the feature you have visually identified as the actual tumor.
The outline remains red as you drag it. Depending on the movement, the tumor outline in
the opposing image may also move.
4. Let go of the tumor outline. It turns green while both Live X-ray images are automatically
correlated. The Synchrony Lung Tracking with Respiratory Modeling algorithm uses the
new location of the tumor outline to search for the tumor.
Upon completion of the automatic correlation, a blue outline indicates the new location of
the tumor in the Live X-ray image. Updated offset values are displayed.

5. Verify that the tumor has been located correctly. Evaluate the updated offsets (see
“Evaluating Image Correlation Results” on page 11-21). You can then move the treatment
couch using the Couch Position (mm) and Couch Rotation (deg) textboxes

and the Move Couch button as needed. For more information on moving the couch,
see “Chapter 8: Treatment Delivery”.
collisions.

• “Correlation Error (mm)” on page 11-30

You can monitor values of several parameters calculated by the Synchrony Lung Tracking with
Respiratory Modeling algorithm. Values are updated when images are acquired or correlated. The
calculated values are displayed on the Acquisition Details tab of the Image History table
(right screen), as shown in Figure 8.
Figure 8 Calculated algorithm parameters for Synchrony

Lung Tracking with Respiratory Modeling mode on the
Acquisition Details tab
adjust their thresholds (see Figure 9). If a parameter value exceeds its threshold, a threshold
violation occurs, and an orange box is displayed around the slider bar. When a threshold violation
occurs the first time you are in the Alignment > Respiratory phase during a treatment
fraction, you cannot move to the next phase until the threshold violation is resolved.

Figure 9 Controls for adjusting algorithm parameters and

thresholds in the Alignment > Respiratory phase (left
screen)

• “Uncertainty (%)” on page 11-29
dxAB (mm)
center in the two projections (for Camera A and Camera B of the X-ray imaging system). This
difference is called dxAB. The Inferior/Superior axis is used because this axis is common to both
projections.
The Synchrony Lung Tracking with Respiratory Modeling algorithm calculates the dxAB value for
every image acquisition, except for image correlations when the preferred projection method is
invoked (see “Enabling Preferred Projection” on page 11-31). When the dxAB value exceeds the
dxAB threshold value, a dxAB Error occurs, except when the Preferred Projection checkbox
is selected (see “Error Handling” on page 11-37).

continue.
parameter can cause the Synchrony Lung Tracking with Respiratory Modeling algorithm
to produce incorrect estimates of the patient position, which in turn can lead to
misdirected radiation beams. Use caution before changing this parameter value.
The default value of the dxAB threshold parameter is 2.5 mm.

Uncertainty (%)
The Uncertainty (%) parameter gives the calculated detection uncertainty value for the Synchrony
Lung Tracking with Respiratory Modeling algorithm. For more information on the detection
uncertainty, see “Quality Metrics” on page 11-3.

If the detection uncertainty value calculated by the Synchrony Lung Tracking with Respiratory
Modeling algorithm is greater than the Uncertainty threshold parameter, an Uncertainty error
occurs (see “Error Handling” on page 11-37).
you can consider increasing the Uncertainty (%) threshold if you are confident that the tracking
algorithm correctly located the target. For more information, see “Correlation Error (mm)” on
page 11-30.

continue.
been correctly identified throughout the treatment.
Correlation Error (mm)
The Correlation Error indicates how well a particular model point agrees with the current
Respiratory Model. The user can lower the correlation error threshold value so that a Soft Stop is
triggered at less than the default value of 5 mm. For more information on Respiratory Correlation
Error, see “Chapter 12: Synchrony Respiratory Tracking System (Option)” on page 12-1.

recommended for use. If the Synchrony Lung Tracking with Respiratory Modeling algorithm fails
or a threshold violation occurs, adjusting some of these parameters may allow successful tracking.
If you make a threshold value more lenient than the default value, a warning appears requiring
confirmation to continue.
• “Adjusting Tracking Range X (mm) and Tracking Range Y (mm)” on page 11-30
• “Enabling Preferred Projection” on page 11-31
Adjusting Tracking Range X (mm) and Tracking Range Y (mm)
There are two Tracking Range parameters:
• Tracking Range X (mm)
• Tracking Range Y (mm)

The Tracking Range parameters define the search area within which the Synchrony Lung Tracking
with Respiratory Modeling algorithm searches for the target. During image registration, a matching
window is moved throughout this search area to search for the desired intensity pattern. For more
information on the search area and the matching window, see “Synchrony Lung Tracking with
Respiratory Modeling Algorithm” on page 11-2.
The default Tracking Range X and Tracking Range Y values are 12.0 mm. The Tracking Range is
the distance from the center of the Live X-ray images that the tracking algorithm will search for the
target. Depending on target location and/or motion, users may find it helpful to increase and/or
decrease this value during treatment.
In most cases, the default value will be sufficient.
page 11-29). Alternatively, enter a new value in the textbox to the right of the slider bar
and press <Enter>.
default value.
Images are automatically correlated when a Tracking Range parameter is changed.
Enabling Preferred Projection
The Preferred Projection checkbox (see Figure 9 on page 11-29) allows you to enable or
disable the preferred projection method for locating the target. This checkbox is disabled by
default. When you select this checkbox, an image correlation is performed automatically. For more
information on preferred projection, see “Preferred Projection” on page 11-4.

• Correlation Error (mm) threshold


Value Cursor Threshold Value
Figure 10 dxAB slider bar

value.
value.

continue.
Respiratory Alignment and Building a Respiratory Model

If the Synchrony tracking System will be used to track respiratory motion, you must also build a
Respiratory correlation model before starting treatment delivery. The Respiratory Correlation Error
for all model points is updated dynamically when an image is added, removed, or recorrelated in
the model.
The Skip Respiratory checkbox (Figure 7 on page 11-20) is deselected (cleared) by default so
that the Synchrony tracking System is enabled.
Selecting the Skip Respiratory checkbox disables use of the Synchrony tracking System for
treatment delivery and changes the appearance of the left screen of the Respiratory phase. The
Respiratory Model (mm) table is replaced by the Offsets panel displayed in the
Alignment > Align phase. Offset values for only the most recent image are displayed, and
dashes are displayed for the calculated rotations.
For information on building a Respiratory correlation model and using the Synchrony tracking
System during treatment delivery, see “Chapter 12: Synchrony Respiratory Tracking System
(Option)”.

Treatment Delivery
• “Visual Inspection During Treatment Delivery” on page 11-35
The Delivery phase (left screen) for the Synchrony Lung Tracking with Respiratory Modeling is
shown in Figure 11. Controls on this screen and the right screen allow you to monitor and verify
patient alignment and tracking results, as well as the Respiratory Model, during treatment delivery
using the Synchrony Lung Tracking with Respiratory Modeling.
Figure 11 Delivery phase (left screen) for the Syn-

chrony Lung Tracking with Respiratory Modeling

Because the Synchrony Lung Tracking with Respiratory Modeling algorithm does not estimate
rotational offsets, only translational offsets are displayed and updated on the Left screen in the
Calculated column during treatment delivery automation (treatments that do not use Respiratory
Modeling only). Dashes are displayed for the calculated rotational offsets. In the Applied column,
the rotational offsets that are displayed and used to perform rotation adjustments of the LINAC
during treatment are the rotational corrections obtained from initial Synchrony Spine Tracking
alignment.
information on the Synchrony tracking System, see “Chapter 12: Synchrony Respiratory Tracking
System (Option)”. For information on treatment planning for treatment using the Synchrony Lung
Tracking with Respiratory Modeling, see the Treatment Planning Manual.
Visual Inspection During Treatment Delivery
WARNING: Visually compare the DRR and Live X-ray images to ensure that features are
similar in both. For example, if you attempt Synchrony Lung Tracking with Respiratory
Modeling treatment delivery at the alignment center position instead of the treatment
center position, the images will not be similar.
WARNING: For image correlations when the preferred projection method is used, the
WARNING: During treatment delivery, after acquisition of Live X-ray images, visually
verify the patient position and verify that tumor is visible in the images. Make sure that
anatomy in the Live X-ray and DRR images matches. For more information on visually
identifying features to be tracked, see “Chapter 8: Treatment Delivery”.


The Treatment Monitoring graph for the Synchrony Lung Tracking with Respiratory Modeling
includes a Lung graph display (Figure 12). This display shows the computed values of the following
parameters as a function of time:
• Uncertainty A (%): The detection uncertainty level in Live X-ray image A (a
percentage).
• Uncertainty B (%): The detection uncertainty level in Live X-ray image B (a
percentage).
• dxAB (mm): The computed dxAB value (in millimeters).
The graphs also display a pointer (green for Projection A or light blue for Projection B) to identify
the preferred projection, if the Preferred Projection checkbox is selected in the Alignment
> Respiratory phase and the Synchrony Lung Tracking with Respiratory Modeling algorithm
has chosen the preferred projection method for target location.
NOTE: When the preferred projection method is used for image

correlation, the Synchrony Lung Tracking with Respiratory
Modeling graph does not display values for that particular dxAB
data point.
Figure 12 Treatment Monitoring graphs for the

Synchrony Lung Tracking with Respiratory Model-
ing

Error Handling
The Synchrony Lung Tracking with Respiratory Modeling algorithm may fail for the following
reasons:
• “Uncertainty Error” on page 11-37
• “dxAB Error” on page 11-38
During patient alignment in the Alignment > Align phase, when the calculated value of an
Synchrony Lung Tracking with Respiratory Modeling algorithm parameter exceeds the value of its
threshold, one of the above threshold violations occurs. An orange box is then displayed around
the slider bar for that parameter threshold.
For information on resuming treatment after a Soft Stop, see Chapter 7, “Treatment Delivery”.
Uncertainty Error
An Uncertainty Error occurs when the computed value of the Uncertainty parameter exceeds the
value of the Uncertainty threshold parameter during the Delivery phase. For more information
about the detection uncertainty, see “Uncertainty (%)” on page 11-29.

continue.

dxAB Error
A dxAB error occurs when the calculated value of dxAB exceeds the value of the dxAB threshold
parameter during the Delivery phase. When this error occurs, a message is displayed in the
Messages window. To address a dxAB error, consider reducing the tracking range and/or using
Offset Mode, and enabling the preferred projection method. For more information on dxAB, see
“dxAB (mm)” on page 11-29.
NOTE: Values for the dxAB parameter are not calculated for
image correlations when the preferred projection method is
invoked.

continue.

Patient Realignment
The same as for patient alignment, patient realignment has two phases:
• Realignment using Synchrony Spine Tracking.
• Realignment using the Synchrony Lung Tracking with Respiratory Modeling.
An example case when this is necessary is when the patient moves during treatment and global
patient rotational alignment needs to be recalculated.
If Synchrony Lung Tracking with Respiratory modeling is being used and treatment delivery is
interrupted by a Soft Stop, an E-Stop/Interlock, or a Pause, if the Respiratory correlation model is
still valid, you can click the Start/Resume button to resume treatment.

Alternatively, you can choose to return to Synchrony Spine Tracking alignment.

 To return to Synchrony Spine Tracking alignment:
1. Move back to the Alignment > Lung phase and click the Move to Spine button.
2. Then move to the Alignment > Align phase and perform spine alignment. See “Initial
Alignment Using Synchrony Spine Tracking” on page 11-12.
NOTE: If the treatment couch is moved to the alignment center

for Synchrony Spine Tracking alignment, the Respiratory
correlation model will become invalid. In this case, a new
Respiratory Model must be established before you can resume
treatment delivery using the Synchrony Lung Tracking with
Respiratory Modeling.
For more information on using resuming treatment after treatment interruption, see “Chapter 8:


Chapter 12: Synchrony
Respiratory Tracking System
(Option)
Introduction
The Synchrony Respiratory Tracking System is an option to the CyberKnife Treatment Delivery
System and is intended to enable dynamic image-guided stereotactic radiosurgery and precision
radiotherapy of lesions, tumors and conditions that move with respiration.
This chapter describes how to use the Synchrony Respiratory Tracking System with the
CyberKnife System. It covers the following topics:
• “Synchrony Respiratory Tracking System Components” on page 12-2
• “Synchrony Respiratory Tracking Interface Module” on page 12-2
• “Patient Preparation for Pretreatment Scanning” on page 12-51
• “Patient Setup for Treatment” on page 12-54
• “Patient Alignment and Tracking” on page 12-57
• “Building a Respiratory Correlation Model” on page 12-60
The Synchrony Respiratory Tracking System tracks and compensates for the motion of targets in
areas affected by respiration. These may include targets in the lung, liver, pancreas, and kidneys,
among others. The Synchrony Respiratory Tracking System compensates for the respiratory
motion of the target by correlating target motion with the respiratory motion of the patient and
synchronizing beam delivery with target motion. The treatment robot adjusts and compensates for
these movements to ensure more accurate treatment.
NOTE: For information on using Synchrony Spine Tracking

Prone with Respiratory Modeling, see “Chapter 10: Synchrony
Figure 1 Synchrony Respiratory Tracking System

Synchrony Respiratory Tracking System

Components
• The Synchrony Respiratory Tracking System includes the following hardware
components:“Synchrony Respiratory Tracking Interface Module” on page 12-2
• “Synchrony Respiratory Camera Array” on page 12-7
• “Synchrony Respiratory Vest” on page 12-8
These Synchrony Respiratory Tracking components are described below.
Synchrony Respiratory Tracking Interface Module

This section contains the following information:
• “Wireless Interface Module” on page 12-2
• “Charging Cradle” on page 12-3
• “Non-wireless Interface Module” on page 12-6
Wireless Interface Module

The CyberKnife System with the optional RoboCouch Patient Positioning System includes a
wireless Synchrony Respiratory Tracking interface module (see example in Figure 2).
Wireless
Synchrony
RoboCouch Respiratory
Hand Tracking
Controller Interface
Charging
Cradle
Figure 2 Wireless Synchrony Respiratory Tracking

interface module in charging Cradle
12-2 | Synchrony Respiratory Tracking System Components 1075883-ENG A

Treatment Delivery Manual Chapter 12: Synchrony Respiratory Tracking System (Option)
The wireless Synchrony Respiratory Tracking interface module provides a communication

interface between an infrared (IR) transmitter mounted underneath the RoboCouch table top and
the treatment delivery computer.
The wireless Synchrony Respiratory Tracking interface module controls the Synchrony
Respiratory External LED Markers of the Synchrony Respiratory Vest. The Tracking Marker
Harness connector plugs into the Synchrony Respiratory Tracking interface module. Signals from
the IR transmitter control the blinking rate of the Synchrony Respiratory External LED Markers.
The wireless Synchrony Respiratory Tracking interface module mounts on a bracket underneath
the headrest of the RoboCouch table top (see Figure 3). When you slide the Synchrony
Respiratory Tracking interface module into the bracket, the interface module clicks into place. To
remove the Synchrony Respiratory Tracking interface module, slide it out of the bracket.
Figure 3 Mounted Synchrony Respiratory Tracking

interface module (wireless module shown)
For more information on the RoboCouch Patient Positioning System, see “Chapter 7: Treatment
Room Operations”.
Charging Cradle
The charging Cradle is a wall-mounted unit for storing and charging the wireless Synchrony
Respiratory Tracking interface module, and also for storing the RoboCouch Hand Controller. An
LED indicator on the front of the Cradle is lit when there is power to the Cradle.
 To charge the wireless Synchrony Respiratory Tracking interface module:
• Place it in the Cradle in the recess provided.
1075883-ENG A Synchrony Respiratory Tracking System Components | 12-3

Battery Indicator
When the wireless Synchrony Respiratory Tracking interface module is fully charged, it has
approximately 8 hours of battery life. A battery indicator on the front of the interface module
indicates when battery power is low. The interface module also includes an adapter plug for
auxiliary power. The auxiliary power supply replaces battery power but does not charge the battery.
NOTE: The auxiliary power supply does not recharge the

Synchrony Respiratory Tracking interface module battery.

The battery indicator has different states depending on whether the Synchrony Respiratory
Tracking interface module is sitting in the charging Cradle or whether an infrared communication
link has been established with the treatment delivery computer. If the interface module is sitting in
the Cradle, the battery indicator has the following states:
• Blinking yellow: Battery power is low and the battery is recharging.
• Blinking green: The battery is recharging but has not reached its full charge.
• Solid green: The battery is fully charged.
NOTE: When the battery is fully charged, you can continue to

store the Synchrony Respiratory Tracking interface module in
the charging Cradle. However, because a small battery drain
occurs while the interface module is stored in the Cradle, the
battery indicator may switch from solid green to blinking green.
This is a temporary state and is normal.
During treatment, when the wireless Synchrony Respiratory Tracking interface module is mounted
in the bracket underneath the RoboCouch headrest, the battery indicator is lit only if the battery
charge is nearing a low charge condition. When the battery indicator is in a blinking yellow state,
the battery has a residual charge of 1 - 2 hours and requires recharging soon.
NOTE: If it is not possible to recharge the battery within the

treatment time, the auxiliary power supply can be used.
Communication Indicator
The wireless Synchrony Respiratory Tracking interface module includes a green LED
communication indicator that is lit when there is communication between the IR transmitter and the
interface module. If there is no communication link, the communication indicator will either be off,
indicating no communication, or will blink erratically, indicating a poor communication link. The
position of the Synchrony Respiratory Tracking interface module underneath the RoboCouch
headrest is designed to provide a good communication link. If you observe no communication or a
poor communication link, check the system or call Accuray Customer Support.
NOTE: In order to use the Synchrony Respiratory Tracking

System for treatment delivery, the LED communication indicator
must be solid green.

Non-wireless Interface Module

The CyberKnife System with the standard treatment couch (see ).
Non-wireless Synchrony Respiratory Tracking interface module (Standard Treatment

Couch)The non-wireless Synchrony Respiratory Tracking interface module is powered and
communicates with the treatment delivery computer via a cable. The Tracking Marker Harness
connector plugs into the Synchrony Respiratory Tracking interface module. Signals from the
treatment delivery computer control the blinking rate of the LEDs.
For the standard treatment couch, the removable Synchrony Respiratory Tracking interface
module mounts underneath the headrest of the table top of the standard treatment couch.

Synchrony Respiratory Camera Array

The Synchrony Respiratory Camera Array is mounted to the ceiling near the foot of the treatment
couch.
Cameras
Figure 4 Synchrony Camera Array
The Synchrony Respiratory Camera Array includes 3 LED detectors that detect motion of the
Synchrony Respiratory External LED Markers on the Synchrony Respiratory Vest.
As the Synchrony External LED Markers move with patient breathing, signals from the Synchrony
Respiratory Tracking Camera Array are used to determine breathing waveforms. The breathing
waveforms are displayed on the treatment delivery computer.

Synchrony Respiratory Vest

NOTE: The Synchrony Respiratory Vest is for single-patient use
only.
The patient wears the Synchrony Respiratory Vest during pretreatment scanning and during
Synchrony Respiratory Tracking treatment. The Synchrony Respiratory Vest is shown in Figure 5.
The 3 Synchrony Respiratory External LED Markers attach to the vest during Synchrony
Respiratory Tracking treatment and move with patient breathing.
Fiber Optic Cables
Cable Management
Velcro Tabs
Velcro Strips
(Supine and Prone)
Tracking Markers
Drawstrings
Full Length Zipper

and Personalized
Name Tag (On Back
of Vest)
Figure 5 Synchrony Respiratory Vest
The Synchrony Respiratory Vest is available in 3 sizes (see Table 1 on page 12-9).
NOTE: The general size guidelines below may not apply to all
patients. Patient body shape may also affect vest size selection.
In such cases, it may be necessary to select a vest that is one
size larger or one size smaller.

Table 1 General size guidelines
Small Vest Height: <5’5" (1.68 m)
Weight: <130 lb (59 kg)
Medium Vest Height: 5’5" - 6’0" (1.68 - 1.83 m)
Weight: 130 - 180 lb (59 - 81.6 kg)
Large Vest Height: >6’0" (1.83 m)
Weight: >180 lb (81.6 kg)
Synchrony Respiratory External LED Marker Visibility

Indicator
Standard Couch: For CyberKnife Systems with a Standard couch and therefore a non-wireless
Synchrony Respiratory interface module, the appearance of a Synchrony Respiratory External
LED Marker depends on whether it is visible to the Synchrony Respiratory Tracking Camera or not.
When a LED Marker is visible to the Synchrony Respiratory Tracking Camera:
• The LED blinks rapidly. The blinking is clearly visible.
When a LED Marker is NOT visible to the Synchrony Respiratory Tracking Camera:
• The LED is solidly on and no blinking is visible
RoboCouch with wall-mounted Hand Controller: For Cyberknife Systems with a RoboCouch
with the wall-mounted Hand Controller and therefore a wireless Synchrony Respiratory Tracking
interface module, the appearance of the Synchrony Respiratory External LED Marker does not
change whether they are visible to the Synchrony Respiratory Tracking Camera or not.

Synchrony Respiratory Tracking User Interface

• “Overview Phase” on page 12-10
• “Respiratory Phase” on page 12-12
• “Readiness Phase” on page 12-39
• “Left and Right Screens of the Delivery Phase” on page 12-41
User interface controls and displays for the Synchrony Respiratory Tracking System appear in the
Overview phase, the Alignment > Respiratory phase, the Readiness phase, and the
Delivery phase.
Overview Phase
When the Synchrony Respiratory Tracking System is used, the right screen of the Overview
phase includes Synchrony Respiratory Tracking controls and displays (See Figure 6). These
displays allow you to monitor the signals from the Synchrony Respiratory External LED Markers
and also to monitor the Respiratory Model if you have returned to the Overview phase from a
later phase in which you have built a Respiratory Model.
Figure 6 Overview phase (right screen) with the Synchrony

12-10 | Synchrony Respiratory Tracking User Interface 1075883-ENG A

The following Synchrony Respiratory Modeling controls and displays are available:
• Markers control area: 3 Marker checkboxes allow you to enable or disable Tracking
Markers. A solid green square to the left of a checkbox indicates that a Tracking Marker is
currently visible to the Synchrony Respiratory Camera Array. A solid yellow square
indicates that it is currently not visible. A status bar above each checkbox shows the
visibility history of each Tracking Marker for the last 120 seconds. For more information,
see “Markers Control Area” on page 12-36.
• Summary Info section: A Respiratory Phase indicator shows which of the 4
Respiratory Model points required to proceed with treatment delivery (the Peak and
Valley model points, and the Center inhale and exhale model points) have been acquired.
For more information, see “Respiratory Phase Indicator” on page 12-16".
• Model Information section: Values for Coverage (%), Average Standard Error (mm),
Maximum Standard Error (mm); the number of Model Points; and the Model State are
displayed for the current Respiratory Model. For more information on these Respiratory
Model details, see “Respiratory Model Table” on page 12-13 and “Respiratory Details
Tab” on page 12-31.
• Tracking Markers graph: Waveforms representing breathing patterns for each Tracking
Marker enabled for tracking are displayed. Model points are shown as dots on the
waveforms. If at least 2 model points have been acquired, Amplitude indicators are also
displayed showing the respiratory range of motion covered by the current Respiratory
Model.
Controls allow you to pause and resume monitoring of Tracking Marker motion. You can
also pan the graph and change the time scale. For more information, see “Tracking
Markers Graph” on page 12-37".
• Comet graphs: If at least 2 model points have been acquired, 2 Comet graphs provide a
virtual see-through view of the patient from the coronal and sagittal perspectives,
indicated by a human body icon. These views give a qualitative picture of how well the
model points fit the current Respiratory Model. For more information, see “Comet Graphs”
on page 12-30.
1075883-ENG A Synchrony Respiratory Tracking User Interface | 12-11

Respiratory Phase
• “Respiratory Model Table” on page 12-13
• “Image Display Area” on page 12-17
• “Algorithm Parameters and Thresholds” on page 12-22
• “Manual Setup Controls” on page 12-22
• “Automatic Setup Controls (Option)” on page 12-24
• “Rotational Bounds Checking Enabled Checkbox” on page 12-25
• “Skip Respiratory Checkbox” on page 12-25
• “Reset Respiratory Model Button” on page 12-26
• “Image History Table” on page 12-28
• “Breathing Waveform Snippet” on page 12-29
• “Comet Graphs” on page 12-30
• “Respiratory Details Tab” on page 12-31
• “Acquisition Details Tab” on page 12-35
• “Images Tab” on page 12-35
• “Markers Control Area” on page 12-36
• “Tracking Markers Graph” on page 12-37
This section describes the controls and displays in the Alignment > Respiratory phase for
building and monitoring a Respiratory Model.

Respiratory Model Table

The Respiratory Model (mm) table (on the left screen, between the two Live X-ray image
panels) displays Offset values and other information for all acquired images in the current
Respiratory Model (see Figure 7). You use this information as you analyze the Respiratory Model.
When you first switch to the Respiratory phase, the Respiratory Model (mm) table is
empty and no Live X-ray images are displayed until you begin building a Respiratory Model.
The Respiratory Correlation Error for all model points is updated dynamically when an image is
added, removed, or recorrelated in the model.
Figure 7 Respiratory Model (mm) table for Synchrony Fidu-

cial Tracking System with Respiratory Modeling mode (left
screen of Respiratory phase)

The table has 15 rows, corresponding to all 15 model points. Model points are listed in the phase
order they would appear in a single respiratory cycle. (They are not listed in the order they were
acquired.) This is useful when you use Movie Mode to improve the visibility of tumor motion by
cycling through all the images in respiratory phase order. Movie Mode helps you verify that the
tracking algorithm has correctly identified and is correctly tracking the target. For more information
on Movie Mode, see Table 2 on page 12-17.
The currently selected row is highlighted in yellow and the corresponding image is displayed. A red
X indicates that an image is marked as blocked.
Rows in the Respiratory Model (mm) table display the following information:
• Respiratory Correlation Error (column 1): This value (in millimeters) indicates how well a
particular model point agrees with the current Respiratory Model.
The Respiratory Correlation Error for all model points is updated when an image is
• Offsets (columns 2 to 4): Calculated Offset values (in millimeters) between the Live X-ray
and DRR images, for each image acquisition in the Respiratory Model.
Arrows for translations point in the positive direction. The human body icon matches the
patient orientation in the treatment plan.
Calculated Offset values in the Respiratory Model (mm) table indicate couch movement that
would be needed to align features in the Live X-ray and DRR images. In the Respiratory phase,
images are not automatically shifted by the Offset amounts.
An orange box around a row indicates:
• an offset is not within required tolerances (an out-of-bounds error), or
• a tracking algorithm threshold violation has occurred.
Rows with an orange box around them are considered candidates for the Respiratory Model but
are not included in the model. If the error or threshold violation is resolved, the model point is then
automatically added to the Respiratory Model.

For example, no rotational offsets are calculated for Synchrony
Fiducial Tracking with Respiratory Modeling mode when fewer
than three fiducials are selected for tracking.
Selecting a row in the Respiratory Model (mm) table highlights the corresponding row in the
Image History table. For more information, see “Image History Table” on page 12-28.

Rotation Corrections
The Respiratory Model (mm) table displays rotational corrections which depend on the
tracking mode:
• Average Rotation Correction (deg): (Synchrony Fiducial Tracking with
Respiratory Modeling and Synchrony Spine Tracking Prone with Respiratory Modeling)
The average of the rotational values for images in the current Respiratory Model (see
Figure 7 on page 12-13).
• Alignment Rotation Correction (deg): (Synchrony Lung Tracking with
Respiratory Modeling mode) The rotational values for the last image acquired in the
Alignment > Spine phase (see Figure 8). If spine alignment was skipped, dashes are
displayed.
Figure 8 Respiratory Model (mm) table for Synchrony Lung

Tracking with Respiratory Modeling mode (left screen of
Respiratory phase)

Respiratory Phase Indicator

The Respiratory Phase indicator shows 4 of the 8 phases of the respiratory cycle (see Figure 9).
A green dot indicates that a model point has been acquired for that phase.
No Model Peak Model Peak and Peak/Valley and

Points Point Valley Model Center Inhale/Exhale
Points Model Points
Figure 9 Respiratory Phase indicator on left screen

of Respiratory phase
At a minimum, the 4 model points corresponding to the Peak and Valley and Center Inhale and
Center Exhale are required to proceed to the Readiness phase, as well as a Valid (Optimal or
Sub-Optimal) Model State.
Model Information
The Model Information section displays the following information:
• Avg Std Err (mm): The average standard error over all enabled Tracking Markers of
the Respiratory Model.
• Max Std Err (mm): The maximum standard error for all enabled Tracking Markers of
the Respiratory Model.
The standard error of the Respiratory correlation model is a good indicator of the overall
difference between the Respiratory Model curve and the individual model points that
represent each correlation image. Standard Error, estd, is defined in Equation (1):
e
2
i (1)
i
e std = ------------
n
where:
ei is the difference between the model curve and the model point, and n is the number of
model points.

• Model Information Menu Button: clicking this will display more detailed
information about the model state.
• Model State: Optimal, Sub-Optimal, or Invalid.
For information on the different model states, see “Building a Respiratory Correlation
Model” on page 12-60.
Image Display Area

The left screen of the Alignment > Respiratory phase displays the Enhanced Live X-ray
image in a teal color scale overlaid on the DRR image in grayscale for Camera B and Camera A
of the imaging system. The X-ray technique from the previous Alignment phase is used.
Table 2 describes image panel controls to aid image analysis as you verify that the features to be
tracked are correctly identified. These controls can help you to visually locate the same feature in
the DRR and Live X-ray images. Table 3 on page 12-21 lists keyboard and mouse shortcuts
available for some of these controls.
NOTE: Depending on the tracking mode, not all controls may be

available.
Control Description

image.
(Synchrony Fiducial Tracking with Respiratory Modeling, Synchrony Lung
Tracking with Respiratory Modeling, and Lung 1 View Tracking with Respiratory
Modeling) You can also use Offset Mode when the Pointer is turned on. For more
motion more visible and helps you verify that tumor motion is being tracked
correctly.

Control Description

They affect the image display only. For more information, see “Chapter 8:
(Synchrony Fiducial Tracking mode with Respiratory Modeling only) You may need
to modify the Window/Level settings for the Live X-ray images to see the fiducials.
ITTV Outline: (Lung 1 View Tracking with Respiratory Modeling only) If the
The ITTV Outline is turned off by default. See “Chapter 15: Lung Optimized
Treatment (Option)”.

Control Description
Tumor Outline: (Synchrony Lung Tracking with Respiratory Modeling and

Synchrony Lung 1 View Tracking with Respiratory Modeling only; lower right of
image panel) Displays a graphic overlay of the tumor outline (Target Tracking
Volume, TTV) in the DRR images and Live X-ray images that corresponds to the
tumor contour specified during treatment planning: With Lung 1-View Respiratory
tracking, the tumor outline is only displayed in the Live X-ray image that is used for
tracking.
The Tumor Outline is turned on by default. See “Chapter 11: Synchrony Lung
Tracking with Respiratory Modeling (Options)”, and “Chapter 15: Lung Optimized
DRR images. Can be used with other image panel controls. For more information,
Fiducial ROI: (Synchrony Fiducial Tracking with Respiratory Modeling mode only)
Displays a square yellow box in the Live X-ray image for each Region of Interest
(ROI) where the fiducial extraction algorithm searches for fiducial candidates.
Each box is centered on a fiducial candidate.
adjusted. For more information, see “Chapter 9: Synchrony Fiducial Tracking”.
Fiducial Markers: (Synchrony Fiducial Tracking with Respiratory Modeling mode

only) Displays markers in the Live X-ray and DRR images to identify fiducial
locations:
Live X-ray image in Offset Mode. For more information, see “Chapter 9:
Synchrony Fiducial Tracking”.

Control Description
Align Center: (Synchrony Spine Tracking Prone with Respiratory Modeling only)
Displays a marker that corresponds to the align center selected during treatment
planning. See “Chapter 10: Synchrony Spine Tracking (Option)”.
Skeletal Mesh: (Synchrony Spine Tracking Prone with Respiratory Modeling

only) Displays the skeletal mesh used for tracking.
See “Chapter 10: Synchrony Spine Tracking (Option)”.
DRR images.
out automatically.
Full Content DRR: (Synchrony Lung Tracking with Respiratory Modeling mode
and Lung 1 View Tracking with Respiratory Modeling mode only) Displays the
unsegmented (full content) DRR images. See “Chapter 11: Synchrony Lung
Tracking with Respiratory Modeling (Options)”, and “Chapter 15: Lung Optimized

mode and Lung 1 View Tracking with Respiratory Modeling mode only) Displays
the segmented DRR images, in which the spine and other bony structures are
removed and remaining DRR image content is displayed. See “Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling (Options)”, and “Chapter 15:
Lung Optimized Treatment (Option)”.
Tumor Region DRR: (Synchrony Lung Tracking with Respiratory Modeling mode
and Lung 1 View Tracking with Respiratory Modeling mode; upper right corner of
image panel) Displays the tumor region DRR images, in which all image content
that is not in the immediate region of the tumor is removed. See “Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling (Options)”, and “Chapter 15:
Lung Optimized Treatment (Option)”.

Control Description
image is required.
i Turn on/off ITTV Outline. (Lung 1 View Tracking with


(Synchrony Lung Tracking with Respiratory Modeling and Lung
1 View Tracking with Respiratory Modeling)
r Turn on/off Fiducial ROI. (Synchrony Fiducial Tracking with

Respiratory Modeling)
Turn on/off Skeletal Mesh. (Synchrony Spine Tracking Prone
with Respiratory Modeling)
m Turn on/off Fiducial Markers. (Synchrony Fiducial Tracking with

Turn on/off Align Center. (Synchrony Spine Tracking Prone with

Algorithm Parameters and Thresholds

You can monitor values of parameters calculated by the tracking algorithm and change their
thresholds using slider bars and checkboxes on the left screen. These controls are the same as
those in the Alignment > Align phase for the same tracking mode.
Depending on the tracking mode, you can also adjust the following algorithm input parameters:
• Synchrony Fiducial tracking with Respiratory Modeling: Tracking Range (mm),
enable/disable fiducials for tracking.
• Synchrony Spine Tracking Prone with Respiratory Modeling: Tracking Range (mm),
ROI Width (mm).
• Synchrony Lung Tracking with Respiratory Modeling: Tracking Range X (mm),
Tracking Range Y (mm), select/deselect Preferred Projection checkbox.
• Lung 1 View Tracking with Respiratory Modeling: Tracking Range X (mm), Tracking
Range Y (mm).
All images in the current Respiratory Model are automatically recorrelated when an algorithm input
parameter is changed.
For more information on algorithm parameters and the effect of adjusting thresholds, see the
following chapters:
Manual Setup Controls

The Manual Setup tab (see Figure 10) allows you to build a Respiratory Model manually using
3 methods:
• Image-by-image Phase Selection
• User-defined Respiratory Phase Selection
• No Phase Selection

Waveform Phase No Phase

Display Selection Selection
Icon Icon
Move
Couch
Button
Figure 10 Controls on the Manual Setup tab
The Phase Selection icon allows you to turn phase selection on. With phase selection, the
Synchrony Respiratory Tracking System attempts to acquire model points at targeted phases of
the respiratory cycle by automatically controlling the timing of image acquisition. The No Phase
Selection icon allows you to turn phase selection off.
The Waveform display represents a single respiratory cycle. Circles in the waveform represent
phases of the respiratory cycle that you click to select when using the User-defined Respiratory
Phase Selection method. For step-by-step instructions on building a Respiratory Model using the
Manual Setup tab, see “Using Manual Setup” on page 12-63
Move Couch Controls

Automatic patient positioning controls are available on the Manual Setup tab. When you move
the couch, the current Respiratory Model becomes invalid and you must rebuild the Respiratory
Model.
movement relative to its current position. Values above the textboxes show the absolute rotational
position of the couch.
again to unlock it.

change and approach zero as the desired couch position is achieved.

After you move the couch, you must build a new Respiratory Model.
For more information on moving the couch using the automatic patient positioning controls, see
Automatic Setup Controls (Option)

The Automatic Setup option allows you to build a Respiratory Model automatically in two
steps:
• Respiratory alignment
• Dataset acquisition
The Automatic Setup tab includes controls for performing these steps (see Figure 11).
Peak/Valley
Icon
Move Couch
Button
Figure 11 Controls on the Automatic Setup tab
Initially only the Acquire Peak and Valley Image button is enabled, allowing you to perform
Respiratory alignment. After Peak and Valley Images are acquired, the Dataset Acquisition
button is enabled. For more information on the Automatic Setup option, see “Using Automatic
Setup (Option)” on page 12-73.

Rotational Bounds Checking Enabled Checkbox

maximum allowed rotational displacements. This checkbox is enabled by default.
Skip Respiratory Checkbox

Selecting the Skip Respiratory checkbox disables Synchrony Respiratory Tracking mode to
deliver treatment that does not use Respiratory Modeling.
WARNING: Use caution before disabling Synchrony Respiratory Tracking mode. If you
disable Synchrony Respiratory Tracking mode, respiratory motion will not be modeled or
corrected for during treatment.
NOTE: For Synchrony Spine Tracking Prone with Respiratory

Modeling, the Synchrony Respiratory Tracking System is enabled by
default and the Skip Respiratory checkbox is deselected. In this
case, the Robot Rotation Corrections Enabled checkbox is
deselected in the Readiness phase. Only translational corrections
are made by the treatment robot during treatment delivery. For more
information on Synchrony Spine Tracking Prone with Respiratory
Modeling, see “Chapter 10: Synchrony Spine Tracking (Option)”.
You can disable Synchrony Respiratory Tracking mode to deliver treatment that does not use
Respiratory Modeling. When you disable Synchrony Respiratory Tracking mode, information from
the Synchrony Respiratory Tracking System is not used to correct the treatment robot position for
respiratory motion.

Modeling, if the Synchrony Respiratory Tracking System is disabled
by selecting the Skip Respiratory checkbox, then by default the
Robot Rotation Corrections Enabled checkbox is selected in
the Readiness phase and rotational corrections are made during
treatment delivery.
 To disable Synchrony Respiratory Tracking mode to deliver treatment that does not use
Respiratory Modeling:
• Click to select the Skip Respiratory checkbox on the Respiratory screen.
Selecting the Skip Respiratory checkbox changes the appearance of the left screen
of the Respiratory phase. The Respiratory Model (mm) table is replaced by the
Offsets panel displayed in the Alignment > Align phase. Offset values for only the
most recent image are displayed.
 To re-enable Synchrony Respiratory Tracking mode to deliver treatments that use
Respiratory Modeling:
• Click to deselect the Skip Respiratory checkbox on the Respiratory screen. The
existing Respiratory Model is re-used.

Reset Respiratory Model Button

The Reset Respiratory Model button in the Respiratory phase allows you to invalidate the
current Respiratory correlation model and delete all model points. (For information on removing
and adding back a single model point, see “Image History Table” on page 12-28.) You need to
reset the model if the geometric relationship between the patient, Tracking Markers, or Synchrony
Respiratory Camera Array has changed:
• If the patient is moved on the treatment couch.
• If the treatment couch is moved using the Hand Controller.
• If the Synchrony Respiratory Vest is adjusted on the patient.
• If the Synchrony Respiratory External LED Markers are moved on the vest.
• If the Synchrony Respiratory Camera Array position is adjusted.
• If high correlation errors persist.
WARNING: You must reset the Respiratory Model if you make any of the above changes.
Otherwise, targeting accuracy will be compromised.
WARNING: If you adjust the position of the Synchrony Respiratory Camera Array, you
must reset the Respiratory Model even if you have not yet established a Respiratory
Model. Otherwise, it is possible for the treatment robot to exceed displacement limits
without generating an error, and beam mistargeting can result.
NOTE: The Respiratory Model is automatically reset if the

treatment couch is moved using automatic patient positioning
controls in the Respiratory phase. For more information on
moving the treatment couch using these controls, see “Chapter
If you reset the Respiratory Model, you will need to acquire at least 8 model points to build and
validate a new Respiratory Model before treatment can continue.

 To invalidate the current Respiratory Model and delete all model points:
1. Click the Reset Respiratory Model button in the Respiratory phase (see
Figure 12).
Reset Respiratory Model

Button
Figure 12 Reset Respiratory Model button
A confirmation message is displayed asking you to confirm deletion of the Respiratory

Model (see Figure 13).
Figure 13 Confirmation message to reset Respiratory Model
2. Click the Yes button to confirm deletion of the current Respiratory Model.
The current Respiratory Model will be invalidated and all model points deleted from it. The
Respiratory Model (mm) table will be cleared. You can then build a new model.
Deleted model points will still be listed in the Image History table but can no longer be
re-used in the Respiratory Model.
WARNING: When treating using the Synchrony Respiratory Tracking System, you must
reset the Respiratory Model after any adjustment of the patient or treatment couch
position using the treatment couch Hand Controller. Then you must rebuild and validate a
new Respiratory Model. Failure to reset and reestablish the Respiratory Model can result
in inaccurate radiation delivery and harm to the patient.

Image History Table

The Image History table lets you view details for all images acquired in all treatment phases
for this treatment session. You can see additional details for each model point in the current
Respiratory Model. The Image History table also lets you turn model points on and off by
removing and adding them back to the Respiratory Model.
Click on a row to highlight it and view the following information for each model point:
• Model Point: Images in the current Respiratory Model are numbered (1 to 15).
Otherwise dashes are shown.
• Phase: Shows the phase in the respiratory cycle where the image was acquired. The
phase is only shown for images currently in the Respiratory Model.
• Age: A blue progress bar shows the age of the image (minutes:seconds) in the
Respiratory Model from 0 to 10 minutes (left-to-right). After 10 minutes, the progress bar
turns orange. Many orange progress bars means that images in the model are old.
If the most recent image is older than 10 minutes, you can proceed to the Delivery
phase, but you cannot start treatment until you acquire a new image.
• Used: A checkmark indicates the image is currently used in the Respiratory Model. A
circle indicates it is a candidate to be used in the model but is currently not used. You can
select and deselect images to be used in the model. The Respiratory Model is updated
immediately.
 To turn a model point on/off:
1. Click a checkmark to deselect an image and remove it from the Respiratory Model. The
model point is also removed from the Respiratory Model (mm) table.
Other images in the model are renumbered.
2. Click a circle to select a candidate image and add it to the model.
Click a column heading in the Image History table to sort rows. By default, model points are
listed in order of Age.
You can sort model points in respiratory phase order by clicking on the Model Point column
heading. When model points are listed in respiratory phase order, you can map model information
in the Image History table easily to information in the Respiratory Model (mm) table and
the XYZ vs R correlation graphs. Selecting a row in the Image History table corresponding to
a model point automatically selects the corresponding row in the Respiratory Model (mm)
table. For more information, see “Respiratory Model Table” on page 12-13 and “XYZ vs. R
Correlation Graphs” on page 12-32.
Use the scroll bar on the right or the Up and Down arrow keys on the keyboard to scroll through
the table.

Breathing Waveform Snippet

The graph to the left of the Image History table shows a ±5 second snippet of the breathing
waveform where the model point corresponding to the currently selected row was acquired. The
breathing waveform snippet shows a dot corresponding to the phase of the model point (see
Figure 14).
Tracking Marker data is displayed in the following colors:
• red: Tracking Marker 1
• green: Tracking Marker 2
• lavender: Tracking Marker 3
Optimal marker placement will result in a graph where all three waveforms have as high an
amplitude as possible.
Figure 14 Breathing waveform snippet on right screen of

Respiratory phase

Comet Graphs
The Comet graphs to the right of the Image History table show a virtual see-through view of
the patient from the coronal and sagittal perspectives, indicated by the human body icon (see
Figure 15 and Figure 16).
Figure 15 Moving Comet graphs on right screen of Respira-

tory phase (Linear model example)
The vertical axis represents the Inferior/Superior direction in the patient coordinate system. The
two views give a qualitative picture of how well the model points fit the current Respiratory Model:
• The moving “comet” represents average movement of the Tracking Markers in real-time
and shows where the Respiratory Model indicates the tumor is right now and where the
treatment robot would be delivering beam with the current model.
• The static points represent where images in the Respiratory Model were acquired.
• The “tail” of the comet shows the shape of the Respiratory Model. Figure 15 shows an
example for a Linear model. Figure 16 shows an example for a Dual Poly model. The
quality of the Respiratory Model is indicated by how far the static points fall from the tail.
For more information on model types, see “XYZ vs. R Correlation Graphs” on
page 12-32.

Figure 16 Moving Comet graphs on right screen of

Respiratory phase (Dual Poly model example)
 To examine the data associated with a static point:

• Click on a static point to select it. The selected point turns red.
The corresponding rows in the Respiratory Model (mm) table and the Image
History table are automatically selected.
At least 2 model points are required to display the Comet graphs.
Respiratory Details Tab

The Respiratory Details tab below the Image History table displays additional information
about the Respiratory Model (see Figure 17). Click the tab to bring it to the front.
Figure 17 Respiratory Details tab on right screen of

Respiratory phase

The Respiratory Details tab displays the following information:

• Marker checkboxes: (inactive, for display purposes only) 3 Checkboxes that apply to
the currently selected row in the Image History table. They show the status of each
Tracking Marker at the time the currently selected model point was acquired. If a
checkbox is marked selected, the Tracking Marker was enabled. If it is deselected, the
Tracking Marker was disabled. If the square next to the checkbox is green, the Tracking
Marker was visible to the Synchrony Respiratory Camera Array. If it is yellow, it was not
visible.
• Coverage (%): An average value for the enabled Tracking Markers. An indicator of
how much of the respiratory range is covered by the current Respiratory dataset. This
value does not take into account how the model points are distributed. For example, if 2
model points represent the two extremes of respiration, the coverage value would be
100%.
• Model Points: The number of model points currently in the Respiratory Model.
The Respiratory Details tab also displays XYZ vs R correlation graphs, as described in the
section below.
XYZ vs. R Correlation Graphs

The Respiratory Details tab displays three XYZ vs R correlation graphs for the current
Respiratory Model (see Figure 18). There is one correlation graph for each axis of the patient
coordinate system. The patient coordinate system is defined for a patient in the Head First Supine
(HFS) position on the treatment couch as follows:
• INF(+)/SUP(-): Inferior/Superior (X axis)
• LFT(+)/RGT(-): Left/Right (Y axis)
• ANT(+)/POS(-): Anterior/Posterior (Z axis)
Figure 18 XYZ vs. R graphs on Respiratory Details

tab (right screen of Respiratory phase)

Each correlation graph shows movement of the target (fiducial configuration or tumor) vs.
movement of each enabled Tracking Marker, for the current Respiratory Model. Each Tracking
Marker is represented by a different color:
• red: Tracking Marker 1
• green: Tracking Marker 2
• lavender: Tracking Marker 3
On each graph, a point is displayed for each model point in the Respiratory Model. The Synchrony
Respiratory Tracking System chooses one of three model types to minimize the overall correlation
error by determining the best-fit straight line, curvilinear line, or dual polynomial through these
points:
• Linear: A linear best-fit line, when target motion is linear. (See example in Figure 17.)
• Curved Poly: A curvilinear line, when the target moves back and forth along an arc.
• Dual Poly: A dual polynomial, when the target moves along an arc and uses different
paths during inspiration and expiration. (See example in Figure 17.)
The model type for each axis of the patient coordinate system is displayed below each graph. For
a Linear model, a good visual indication of a high-quality Respiratory Model is a correlation graph
with all of its points lying on the line.
NOTE: In the XYZ vs R correlation graphs, only a best-fit line is

shown, regardless of the model type (for example, see Figure 17
on page 12-31). For a Linear model, a good visual indication of
a high-quality Respiratory Model is a correlation graph with all of
its points lying on this line. The model type can also be seen in
the Comet graphs (see “Comet Graphs” on page 12-30).
The vertical axis of the correlation graphs represents the target offsets calculated by the imaging
system for each of the three principal axes of the patient coordinate system.
The horizontal axis of each correlation graph represents movement, R, of each Tracking Marker,
as described in the section “Tracking Marker Movement "R"” on page 12-34.
The following considerations are important when evaluating the correlation graphs:
• Whether all model points for a Tracking Marker lie on a line or curve. You can examine
any outlier model point by clicking the corresponding row in the Image History table
to view the Live X-ray image. Verify that the target has been correctly identified. Evaluate
any changes in the breathing pattern to determine whether to reset the Respiratory Model
and rebuild it. The model point in question can also be removed from the Respiratory
Model if needed (see “Image History Table” on page 12-28).
• Whether the slope of the line or curve is steep (more vertical in the graph). A steep slope
indicates that a small Tracking Marker motion is being used to predict large target motion.
In this case, you can evaluate placement of the Tracking Markers (see “Evaluating
Placement of Tracking Markers” on page 12-79).

Tracking Marker Movement "R"

Figure 19 shows schematically movement of a target in the patient coordinate system between
positions 1, 2, and 3. Simultaneously the three Tracking Markers move in the coordinate system
of the Synchrony Respiratory Camera Array (see “Synchrony Respiratory Camera Array” on
page 12-7). The target and Tracking Marker positions may be out of the plane of the page.
Marker 2
Camera
Coordinate
Marker 1 System
Patient
Coordinate
System
Marker 3
Target
Couch
Figure 19 Movement, R, of Tracking Marker measured in

coordinate system of Synchrony Respiratory Camera Array
The horizontal axis of each correlation graph represents the movement of each Tracking Marker
projected onto a single fixed direction in space. The projected movement is labeled R in Figure 19.
The fixed direction chosen for one Tracking Marker may be independent of the direction chosen
for another Tracking Marker.
The direction in space for each Tracking Marker is chosen as follows: Over several breathing
cycles, Over several breathing cycles, the marker positions are collected and used to determine
the direction of the marker’s major motion. This direction is used as the reference direction for that
Tracking Marker. If the reference direction is close to parallel with the Yc axis of the Synchrony
Respiratory Camera Array (see Figure 19), the camera Yc axis is used as the reference direction
instead. The Yc axis typically exhibits the most Tracking Marker motion. In general, depending on
positioning of the Synchrony Respiratory Camera Array, the Yc axis is not far from parallel with the
Z axis of the patient coordinate system (Anterior/Posterior).

Acquisition Details Tab

The Acquisition Details tab below the Image History table displays acquisition time and
data specific to the tracking mode for the currently selected row of the table (see Figure 20).
Figure 20 Acquisition Details tab in Respiratory

phase (Synchrony Fiducial Tracking with Respira-
tory Modeling mode)
• Calculated Translation (mm) and Calculated Rotation (deg): The offsets

calculated by the tracking algorithm and displayed in the Respiratory Model (mm)
panel.
• Absolute Couch Position (mm) and Absolute Couch Rotation (deg): The
absolute translational and rotational position of the couch for reference.
Fiducial tracking mode includes additional tabs:
Location/Uncertainty: Displays a log of data calculated by the tracking algorithm, including
Fiducial Location (mm) and Fiducial Uncertainty (%) for each fiducial.
Algorithm Details: Displays a log of data calculated by the tracking algorithm, including
Collinearity (deg), Fiducial Spacing (mm), and Rigid Body (mm).
Images Tab
The Images tab below the Image History table displays the Live X-ray images and the X-ray
technique corresponding to the currently selected row in the table. Select controls at the bottom of
the image to aid image analysis (see Table 2 on page 12-17).

Markers Control Area

The Markers checkboxes (on the right screen, to the left of the Tracking Markers graph) allow
you to select which Synchrony Respiratory External LED Markers are used to build a Respiratory
Model. You select or deselect a checkbox to enable or disable that Tracking Marker.
Figure 21 Markers control area on right screen of

Respiratory phase
Status bars show the visibility history of each marker for the last 120 seconds. History data fills in
from right-to-left:
•
Green: Tracking Marker is visible to the Synchrony Respiratory Camera Array.
•
Yellow: Tracking Marker is not visible to the Synchrony Respiratory Camera Array.
•
Mixed green/yellow: Tracking Marker is intermittently visible/not visible.
A solid green square to the left of a checkbox indicates that a Tracking Marker is currently visible
to the Synchrony Respiratory Camera Array. A solid yellow square indicates that it is currently not
visible.
An orange box around the Markers checkboxes indicates that a marker is not visible. The
visibility history for a Tracking Marker should be solid green. If not, you should disable that Tracking
Marker so it is not used when building a Respiratory Model. You can also evaluate the positioning
of the Tracking Markers and the Synchrony Respiratory Camera Array.
In some cases, disabling a Tracking Marker can cause one or more existing model points to be
removed from the Respiratory Model. This occurs if the remaining enabled Tracking Markers were
not enabled when those model points were acquired. Table 4 gives an example of a Respiratory
Model in which 4 model points were acquired when one or more Tracking Markers were disabled.
If Marker 1 is now disabled, Model Point 1 will be removed from the Respiratory Model. If both
Markers 1 and 2 are now disabled, Model Points 1 through 4 will be removed from the Respiratory
Model. The Coverage (%) value can also change (see “Respiratory Details Tab” on
page 12-31).

Table 4 Example of model points with disabled Tracking Markers
Model Point Marker 1 Marker 2 Marker 3

1  disabled disabled
2   disabled
3   disabled
4   disabled
5   
6   
7   
8   
 To use a Tracking Marker to build a Respiratory Model:
• Select the Marker checkbox. Data from the corresponding Tracking Marker will be used
to build a Respiratory Model.
 To disable a Tracking Marker:
• Deselect the Marker checkbox. Data from the corresponding Tracking Marker will not be
used to build a Respiratory Model.
If disabling the Tracking Marker will cause any model point(s) to be removed from the
Respiratory Model, a message will be displayed asking you to confirm the change.
Tracking Markers Graph

The Tracking Markers graph (see Figure 22) shows waveforms representing breathing
patterns for each Tracking Marker enabled for tracking. Respiratory Model points are shown as
dots on the breathing waveforms. Optimal marker placement will result in a graph where all three
waveforms have as high an amplitude as possible.
Figure 22 Tracking Markers graph (right screen of

Respiratory phase)

The graph includes the following controls:

• To pan the horizontal display, click and drag the mouse over the graph.
• To expand or reduce the time scale, rotate the mouse scroll wheel over the graph.
• To pause the graph, click the Pause icon.
• To resume monitoring in real-time, click the Play icon. The graph jumps to the current
time.
Amplitude Indicators
Three Amplitude indicators to the left of the Tracking Markers graph (see Figure 22) show how
much of the total respiratory range of motion (maximum to minimum amplitude) is covered by the
current Respiratory Model. At least 2 model points are required to see the Amplitude indicators.
Colors indicate the covered respiratory range as follows (see Figure 23):
• Orange: The orange bar represents the sampled maximum to minimum range of the
respiratory markers during patient respiration.
• Green: The superimposed green bar represents the amplitude range of the camera array
images in the current Respiratory Model relative to the orange sampled range.
There is one Amplitude indicator for each Tracking Marker (from left-to-right, for Tracking
Markers 1, 2 and 3). Each Amplitude indicator bar moves up and down as the Tracking Marker
moves.
Figure 23 Amplitude indicators showing respiratory range

covered by Respiratory Model (for Tracking Markers 1 and
3)
The Amplitude indicators show the following:

• Coverage range of the Respiratory Model. For example, if the Peak/Valley model
points are present, the indicators would be mostly green corresponding more closely with
the sampled orange tracking marker range.
• Changes in the breathing pattern leading to missing coverage. For example, if there
is an abrupt increase in the amplitude of the patient's respiration, the indicators may
temporarily show less green and more orange until new data points are acquired and the
model is refreshed.
The Amplitude indicators take into account only the top and bottom model points in the distribu-
tion of model points shown on the breathing waveform.

Readiness Phase
When the Synchrony Respiratory Tracking System is used, the left screen of the Readiness
phase includes the Image Burst Enabled checkbox (see Figure 24).
Figure 24 Image Burst Enabled checkbox in Readiness

phase (left screen) with the Synchrony Respiratory Tracking
System
Selecting this checkbox allows the Image Burst option to be used during treatment delivery
automation. The Image Burst option is disabled (the checkbox is inactive) if the Synchrony
Respiratory Tracking System is disabled. For more information on the Image Burst option during
treatment delivery, see “Left and Right Screens of the Delivery Phase” on page 12-41".
If the Skip Respiratory checkbox is selected in the Alignment > Respiratory phase, the
text Respiratory Skipped is displayed in the Readiness phase (see Figure 25). For more
information on the Skip Respiratory checkbox, see “Skip Respiratory Checkbox” on page 12-25.
Figure 25 "Respiratory Skipped" text in Readiness phase
In addition, if Respiratory is skipped in the Alignment > Respiratory phase, a Delivery

Warning Message is displayed in the Readiness phase to inform you that the Synchrony
Respiratory Tracking System has been disabled and respiratory motion will not be compensated
for during treatment delivery. You must confirm this message before you can proceed with
treatment (see Figure 26).

Figure 26 Delivery Warning Message in Readiness phase

when Respiratory is skipped

Left and Right Screens of the Delivery Phase

• “Respiratory Model Table” on page 12-44
• “Image Burst Interval Slider Bar (Option)” on page 12-45
• “Treatment Monitoring Graphs” on page 12-47
• “Markers Control Area” on page 12-48
• “Summary Info Section” on page 12-49
• “Model Information Section” on page 12-49
• “Tracking Markers Graph” on page 12-50
• “Comet Graphs” on page 12-50
When the Synchrony Respiratory Tracking System is used, the left and right screen of the
Delivery phase includes Respiratory controls and displays (See Figure 27). The controls and
displays depend on whether the Synchrony Respiratory Tracking System is enabled or disabled
(that is, whether the Skip Respiratory checkbox is deselected or selected) in the Alignment
> Respiratory phase. Figure 27 shows the left screen when the Synchrony Respiratory
Tracking System is enabled.
Figure 27 Delivery phase for Synchrony Lung Tracking with

Respiratory Modeling mode (left screen) with the Synchrony
Respiratory Tracking System enabled

In Figure 27, the Respiratory Model (mm) table displays offsets for all Respiratory Model
points. The Treatment Monitoring graphs below the image panels include graphs for Lung tracking
parameters, couch Position (mm), couch Orientation (deg), and Respiratory Model
Standard Error (mm). In this example, Image Burst is enabled.
Figure 28 shows the left screen of the Delivery phase when the Synchrony Respiratory Tracking
System is disabled.
Figure 28 Delivery phase (left screen) for Synchrony Lung

Tracking with Respiratory Modeling mode with the Syn-
chrony Respiratory Tracking System disabled
The left screen is similar to the screen in the Alignment > Align phase. The Respiratory
Model (mm) table is replaced by the Offsets panel. Offsets for only the most current image
acquisition are displayed. The Image Burst option is disabled and the Image Interval (sec)
slider bar is displayed instead.
For the Synchrony Lung Tracking with Respiratory Modeling, rotational offsets are not calculated
during treatment. The rotational corrections obtained from initial Spine alignment are used to
perform rotation adjustments of the LINAC during treatment delivery. To indicate this, dashes are
displayed for the calculated rotations in the Offsets panel.

Figure 29 shows the right screen of the Delivery phase with the Synchrony Respiratory Tracking
System. Information about the current Respiratory Model is displayed even when the Synchrony
Respiratory Tracking System is disabled.
Figure 29 Delivery phase (right screen) with the Synchrony

The sections below describe the Respiratory controls and displays available on these screens.

Respiratory Model Table

The Respiratory Model (mm) table in the Delivery phase includes the Respiratory
Correlation Error and Offset values in millimeters for all model points in the current Respiratory
The Respiratory Correlation Error for all model points is updated dynamically when an image is
Figure 30 Respiratory Model (mm) table in Delivery

phase for Synchrony Lung Tracking with Respira-
tory Modeling mode
For more information, see “Respiratory Model Table” on page 12-44.

Rotation Correction Section

The Rotation Correction (deg) section displays rotational corrections that depend on the
tracking mode and the following settings:
• Align: The rotational values for the last image acquired in the Alignment > Spine
phase (see Figure 31). If spine alignment was skipped, dashes are displayed.
• Average: The average of the rotational values for images in the current Respiratory
Model for Synchrony Fiducial Tracking with Respiratory Modeling mode and Synchrony
Spine Tracking Prone with Respiratory Modeling (see Figure 31).
• Applied: The rotational offsets sent to the treatment robot. If the Robot Rotation
Corrections Enabled checkbox is deselected in the Readiness phase, dashes are
displayed.
Figure 31 Rotation Corrections panel in Delivery

phase for Synchrony Fiducial Tracking with Respira-
tory Modeling mode
Image Burst Interval Slider Bar (Option)

The Image Burst option allows the Synchrony Respiratory Tracking System to take a burst of
images at a specified time interval during treatment delivery automation. The time interval between
bursts is adjustable. The burst of images reduces the age of model points in the Respiratory Model,
which can improve the quality of the model and reduce the likelihood of treatment interruptions.
During treatment delivery automation, if the Image Burst option is available on your CyberKnife
System and enabled, the Synchrony Respiratory Tracking System takes a rapid burst of 3 Live X-
ray images 1 second apart at a default Image Burst Interval of 60 seconds. The new images
replace the 3 oldest images. In this way, the complete Respiratory Model (15 model points) is
refreshed every 5 minutes.
The Image Burst Interval parameter can be adjusted from a minimum of 45 seconds to a maximum
of 150 seconds using the Image Burst Interval (sec) slider bar (see Figure 32). The Image
Burst option can be disabled in the Readiness phase (see “Readiness Phase” on page 12-39).
The goal of adjusting the interval slider is to correct for shifts in the tumor target and to minimize
patient exposure to imaging X-rays. If a patient, and therefore tumor target, moves more, decrease
the imaging interval to image more often. If a patient, and therefore tumor target, moves less,
increase the imaging interval because images are not required as often.

If a Respiratory Model becomes invalid, beam delivery is interrupted. When treatment resumes,
image acquisition and image correlation are automatically performed before the next beam
delivery and the Respiratory Model is refreshed. The Respiratory Model may become invalid
because of patient motion, camera shift, marker shift, excessive marker motion, if a targeted phase
is missed by newly acquired images, the model type changes from Linear or Curved Poly to Dual
Poly, or when disabled markers are re-enabled.
Figure 32 Image Burst Interval (sec) slider bar

(Image Burst enabled)
The Image Burst option can only be enabled if the Synchrony Respiratory Tracking System is
enabled. If you disable the Synchrony Respiratory Tracking System in the Alignment >
Respiratory phase, the Image Burst Interval (sec) slider bar changes to the Image
Interval (sec) slider bar, with a default Image Interval of one image every 15 seconds (see
Figure 33). Also, if you disable imaging in the Readiness phase by selecting the Disable
Imaging checkbox, the Image Burst option cannot be enabled.
Figure 33 Image Interval (sec) slider bar (Image

Burst disabled)

Treatment Monitoring Graphs

The Delivery phase displays 2 additional Treatment Monitoring graphs with the Synchrony
Respiratory Tracking System:
• XYZ vs R correlation graphs: Displayed on the right screen. For more information, see
“XYZ vs. R Correlation Graphs” on page 12-32.
Figure 34 XYZ vs. R correlation graph in Delivery

phase
• Respiratory Model Standard Error (mm) graph: This graph shows the Average
Standard Error (mm) and the Maximum Standard Error (mm) over enabled markers for
the Respiratory Model as a function of time. The Average Standard Error (mm) and
Maximum Standard Error (mm) for the current Respiratory Model are also displayed In
the Model Information.

Figure 35 Respiratory Model Standard Error (mm)

graph in Delivery phase
Markers Control Area

3 Marker checkboxes allow you to enable or disable Tracking Markers in the Delivery phase
(see Figure 36). You cannot enable or disable Tracking Markers while treatment delivery
automation is in progress. You must first click the Pause button to pause treatment, or click the
Interlock button to trigger an Interlock.
Figure 36 Markers control area in Delivery phase
A solid green square to the left of a checkbox indicates that a Synchrony Respiratory External LED
Marker is currently visible to the Synchrony Respiratory Camera Array. A sold yellow square
indicates that it is currently not visible. A status bar above each checkbox shows the visibility
history of each Tracking Marker for the last 120 seconds. For more information, see “Markers
Control Area” on page 12-36.

Summary Info Section

A Respiratory Phase indicator shows which of the 4 Respiratory Model points required to proceed
with treatment delivery (the Peak and Valley model points, and the Center inhale and exhale model
points) have been acquired.
Figure 37 Summary Info section in Delivery phase
For more information, see “Respiratory Phase Indicator” on page 12-16".
Model Information Section

Values for Coverage (%), Average Standard Error (mm), Maximum Standard Error (mm); the
number of Model Points; and the Model State are displayed for the current Respiratory Model.
Figure 38 Summary Info section in Delivery phase
For more information on these Respiratory Model details, see “Respiratory Model Table” on
page 12-13 and “Respiratory Details Tab” on page 12-31.

Tracking Markers Graph

Waveforms representing breathing patterns for each Tracking Marker enabled for tracking are
displayed.
Figure 39 Tracking Markers graph in Delivery phase
Model points are shown as dots on the waveforms. If at least 2 model points have been acquired,
Amplitude indicators are also displayed showing the respiratory range of motion covered by the
current Respiratory Model.
Controls allow you to pause and resume monitoring of Tracking Marker motion. You can also pan
the graph and change the time scale. For more information, see “Tracking Markers Graph” on
page 12-37".
Comet Graphs
If at least 2 model points have been acquired, the Comet graphs provide a virtual see-through view
of the patient from the coronal and sagittal perspectives, indicated by a human body icon.
Figure 40 Comet graphs in Delivery phase
These views give a qualitative picture of how well the model points fit the current Respiratory
Model. For more information, see “Comet Graphs” on page 12-30.

Patient Preparation for Pretreatment Scanning

This section describes how to prepare the patient for acquisition of image studies used for
treatment planning. Patients must wear the Respiratory Vest during pretreatment scanning.
• “Putting on the Synchrony Respiratory Vest” on page 12-51
• “Preparing the Patient Immobilization Device” on page 12-52
• “Pretreatment Scanning” on page 12-53
• “Treatment Planning” on page 12-53
Putting on the Synchrony Respiratory Vest

Follow the patient setup guidelines below to use the Synchrony Respiratory Vest.
 To put the Synchrony Respiratory Vest on the patient:
1. Select the appropriate size of Synchrony Respiratory Vest for the patient using the
guidelines in Table 1 on page 12-9.
2. Take the vest out of the pouch. Write the patient name on the name tag located on the
back of the vest.
3. Instruct the patient to put on the Respiratory Vest. If necessary, assist the patient to put it
on.
• Unzip the back of the vest. Detach the Velcro tab on the bottom back of the vest of
the Vest.
• Ensure the two drawstrings on the vest are in their loosest position.
• All patient undergarments should be removed from the waist up. A jog bra with no
metal inserts or fasteners is permissible if necessary for large breasted patients.
Remove all clothes from upper body.
• Slip the vest over the patient’s head.
• Slip the patient’s arms into the arm holes of the vest.
• Fasten the Velcro tab at the bottom back of the vest.
• Pull the string attached to the zipper, or pull the zipper itself, down to the bottom of
the vest.
• Detach the Velcro tab at the bottom of the vest to ensure that the zipper has been
pulled all the way to the bottom of the vest. Then refasten the Velcro tab.
• Pull the whole vest down as far as possible, and cinch the bottom drawstring for a
snug fit. This aids in preventing the Synchrony Respiratory Vest from riding up.
1075883-ENG A Patient Preparation for Pretreatment Scanning | 12-51

 To remove the Synchrony Respiratory Vest from the patient:

• Unzip the back of the vest, and then slip the vest over the patient’s head.
NOTE: Only unzip the vest to remove it. DO NOT readjust the
drawstrings.
Preparing the Patient Immobilization Device

The patient must wear the Synchrony Respiratory Vest when the patient immobilization device is
prepared.
 To create an immobilization device for Synchrony Respiratory Tracking treatment:
1. With the patient wearing the Synchrony Respiratory Vest, follow standard procedures to
prepare an immobilization device using an alpha cradle or vacuum bag. Use of the
indexing table will facilitate patient setup.
For more information on patient immobilization devices, see “Chapter 6: Patient
Preparation”.
2. With the patient lying down on the table (supine or prone), cinch the mid-thoracic
abdominal drawstrings of the Synchrony Respiratory Vest for a snug fit.
NOTE: The CyberKnife System supports treatment for patients

in supine positions for all tracking modes. Support for treatment
in prone positions depends on the tracking mode. For
information on supported prone positions, see “Chapter 8:
Treatment Delivery”. The CyberKnife System does not support
scans of patients positioned on their sides.
The snug fit prevents "tenting" of the vest to ensure that it follows the contour of the
patient’s body.
3. Instruct the patient to relax and breathe normally. It is important to evaluate the patient
immobilization device for comfort and reproducibility.
12-52 | Patient Preparation for Pretreatment Scanning 1075883-ENG A

Pretreatment Scanning
The patient must wear the Synchrony Respiratory Vest during all pretreatment scanning, including
during CT, MRI, and PET scans.
Follow standard protocol guidelines for the appropriate pretreatment scan for extracranial
applications. For more information on pretreatment scanning guidelines, see “Chapter 6: Patient
Preparation”.
 To acquire pretreatment scans for treatment planning when Synchrony Respiratory
Modeling will be used:
1. Instruct the patient to breathe normally until scan acquisition begins, at which time the
patient must hold their breath at end of normal expiration.
NOTE: Practicing the appropriate breath hold with the patient

prior to scanning is recommended. If you know the patient may
not be able to hold their breath for the entire scan, it is helpful to
check the position of the target on the scout image or
scanogram. In this way, you can identify a good place to pause
the scan if necessary.
2. If the patient cannot hold their breath for the entire scan, pause the scan to allow the
patient to breathe normally. Then ask the patient to hold their breath again at the end of
normal expiration
NOTE: Do not pause the scan during imaging of the target. If

necessary, pauses should occur above or below the target.
Ensure that one of the scan segments includes the entire target.
3. Continue to acquire the pretreatment images until the scan is completed.
4. After the pretreatment scan, remove the Synchrony Respiratory Vest (see “Putting on the
Synchrony Respiratory Vest” on page 12-51). Store the vest and the patient
immobilization device to use during treatment delivery.
NOTE: DO NOT readjust the drawstrings. The drawstrings help

maintain body shape consistently between pretreatment
scanning and treatment delivery.
Treatment Planning
The Synchrony Respiratory Tracking treatment option must be specified in the patient treatment
plan. For information on creating a treatment plan that specifies Synchrony Respiratory Modeling
treatment, see the Treatment Planning Manual.
1075883-ENG A Patient Preparation for Pretreatment Scanning | 12-53

Patient Setup for Treatment

This section describes patient setup procedures for treatment delivery using the Synchrony
Respiratory Tracking System.
• “Putting on the Synchrony Respiratory Vest” on page 12-54
• “Using the Patient Immobilization Device” on page 12-54
• “Connecting the Synchrony Respiratory External LED Markers” on page 12-54
• “Adjusting the Synchrony Respiratory Camera Array” on page 12-56
Putting on the Synchrony Respiratory Vest

Assist the patient to put on the Synchrony Respiratory Vest as described earlier (see “Putting on
the Synchrony Respiratory Vest” on page 12-54).
NOTE: DO NOT readjust the drawstrings on the Synchrony

Respiratory Vest. The drawstrings help maintain body shape
consistently between pretreatment scanning and treatment
delivery.
Using the Patient Immobilization Device

The same patient immobilization device used during pretreatment scanning should be used for
treatment delivery.
 To use the patient immobilization device:
1. Place the patient on the immobilization device on the treatment couch.
2. Position the patient in the approximate treatment position, which should reproduce as
closely as possible the patient position during pretreatment scanning.
3. Instruct the patient to relax and breathe normally.
Connecting the Synchrony Respiratory External

LED Markers
Attach the 3 Tracking Markers to the Synchrony Respiratory Vest and connect them to the
Synchrony Respiratory interface module as described below.
 To connect the Tracking Markers:
1. Evaluate the patient’s breathing to identify the location of maximum motion due to
respiration.
12-54 | Patient Setup for Treatment 1075883-ENG A

• In the supine position, this location is typically the diaphragm area, but possibly may
be the lower thoracic area (for "chest breathers") or the abdominal area (for "stomach
breathers").
• In the prone position, this location is typically in the thoracic area on the back of the
patient, but can also be in the lumbar area.
NOTE: The CyberKnife System supports Synchrony Respiratory

Modeling treatment for patients in supine positions for all tracking
modes except Synchrony Spine Tracking Prone with Respiratory
Modeling. Support for treatment in prone positions depends on
the tracking mode. For information on supported prone positions,
see “Chapter 8: Treatment Delivery”. The CyberKnife System
does not support scans of patients positioned on their sides.
2. Attach the 3 Tracking Markers to the white Velcro strips on the Synchrony Respiratory
Vest at the location of maximum body motion due to respiration (see Figure 41).
NOTE: Do not place the Tracking Markers over the tumor

location unless this is the location of maximum body motion
during respiration.

Modeling, place the Tracking Markers as close to the target as
possible. This may not be the location of maximum motion.
Figure 41 Tracking Markers attached to vest
3. Secure the cables of the Tracking Marker harness using the cable management Velcro
tabs on the vest. (See Figure 41.)
4. Connect the Tracking Marker harness connector to the Synchrony Respiratory interface
module.
1075883-ENG A Patient Setup for Treatment | 12-55

Adjusting the Synchrony Respiratory Camera

Array
Adjust the position of the Synchrony Respiratory Camera Array so that it is directly in line with the
Synchrony Respiratory External LED Markers, as described below
 To adjust the position of the Synchrony Respiratory Camera Array:
1. Lower the Synchrony Respiratory Camera Array and position it as follows:
• Directly in line with the patient (that is, not angled towards the side of the patient).
• Approximately 5 - 7 ft (2 m) from the floor.
• No closer to the patient than just above the patient’s feet, but preferably farther away.
CAUTION: Moving the Synchrony Respiratory Camera Array forward (closer to the patient) can
increase the potential for collision between it and the treatment robot.
NOTE: Keep the position of Synchrony Respiratory Camera

Array low to reduce the incidence of the treatment robot blocking
the Tracking Markers.
2. Continue to adjust the position of the Tracking Markers and the Synchrony Respiratory
Camera Array and confirm that the Synchrony Respiratory Camera Array is positioned
correctly by reviewing the breathing waveforms displayed on the treatment delivery
computer.
3. For Cyberknife Systems with a Standard couch, you can also confirm the Synchrony
Respiratory Camera Array position by adjusting it until the Tracking Marker LEDs are
visible to the LED detectors. To view the LEDs best, stand directly under the Synchrony
Respiratory Camera Array looking at the Tracking Markers.
• LED blinks rapidly when a Tracking Marker is visible to the Synchrony Respiratory
Camera Array and appears solidly on when it is not visible.
NOTE: For Cyberknife Systems with a RoboCouch with and

therefore a wireless Synchrony Respiratory interface module,
the appearance of the Tracking Marker LEDs does not change
whether they are visible to the Synchrony Respiratory Camera
Array or not.
Later, after building a Respiratory correlation model, you should evaluate the placement of the
Tracking Markers by reviewing the breathing waveforms and the correlation error values (see
“Evaluating Placement of Tracking Markers” on page 12-79).
Final evaluation of the placement of the Tracking Markers should take place after patient alignment
and identification of the target have been completed.
NOTE: If a Respiratory System is moved out of position, you may need to

readjust it, reset the Respiratory Model, and build a new one.
12-56 | Patient Setup for Treatment 1075883-ENG A

Patient Alignment and Tracking

Before you can build a Respiratory correlation model, the patient must be aligned. The target
(fiducials or tumor) must be identified and tracked by the tracking algorithm specified in the
treatment plan.
• “Manually Shifting the Region of Interest” on page 12-59
These steps are performed using the Treatment Delivery System user interface on the treatment
delivery computer.

Before performing patient alignment, you must load patient treatment files and verify that patient
and treatment data are correct.
WARNING: Verify that this patient is in fact the one to be treated and the treatment plan is
the correct one to use.
 To verify that patient and treatment information are correct:

1. Load patient data as described in “Chapter 8: Treatment Delivery”.
2. In the Overview phase, confirm that the information is correct. For treatments that use
Respiratory Modeling, the Respiratory field should display Yes.
• If the patient information is correct, click the first Data Verified checkbox. The plan
information Data Verified checkbox becomes active (see Figure 42).
Figure 42 Verification checkboxes
• If the plan information is correct, click the second Data Verified button. The
fraction information in the Data Verified checkbox becomes active.
• If the fraction information is correct, click the third Data Verified button.
• If any information is not correct, click the Error Information button (see
Figure 43) and exit the treatment application.
1075883-ENG A Patient Alignment and Tracking | 12-57

Error Information
Button
Figure 43 Error Information button
3. Go to the Alignment phase.

Set up the patient by completing the requirements for the Couch, Technique, and Align
phases.
For Synchrony Fiducial Tracking with Respiratory Modeling and Synchrony Spine Tracking Prone
with Respiratory Modeling plans, continue to the Respiratory phase. For Synchrony Lung
Tracking with Respiratory Modeling plans, go to the Lung phase, transition to the treatment
position, then go to the Technique phase, and then the Respiratory phase (see Figure 44).
Figure 44 Respiratory phase (left screen) after Peak and

Valley images acquired, before complete Respiratory Model
established
12-58 | Patient Alignment and Tracking 1075883-ENG A

Manually Shifting the Region of Interest

If a valid Respiratory Model has not yet been established, the tracking algorithm may fail to locate
the target correctly. If the target is not found or is not correctly identified, it is necessary for you to
assist the tracking algorithm by shifting the Region of Interest (ROI) manually. Use Offset Mode
available in the image panel controls (see Table 2 on page 12-17) to shift the ROIs.
WARNING: In Synchrony Fiducial Tracking with Respiratory Modeling mode, visually

verify that the fiducials are correctly identified. In Synchrony Lung Tracking with
Respiratory Modeling mode, visually verify that the tumor is correctly identified.
For information on using Offset Mode, see the following chapters:

For more information on patient alignment, see the following chapters:
• “Chapter 8: Treatment Delivery”.
• “Chapter 9: Synchrony Fiducial Tracking”.
• “Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”.
1075883-ENG A Patient Alignment and Tracking | 12-59

Building a Respiratory Correlation Model

• “Overview of Respiratory Modeling” on page 12-60
• “Using Manual Setup” on page 12-63
• “Using Automatic Setup (Option)” on page 12-73
• “Evaluating Placement of Tracking Markers” on page 12-79
Before a Synchrony Respiratory Tracking treatment can begin, you must build a Respiratory
correlation model. At least 6 Live X-ray images must be acquired and successfully correlated for
the Synchrony Respiratory Tracking System to build a valid model. The patient must be completely
aligned before you begin building a Respiratory Model.
Overview of Respiratory Modeling

Breathing waveforms representing motion of the Synchrony Respiratory External LED Markers
due to respiration are displayed in the Tracking Markers graph (see Figure 45).
End Inspiration / Expiration
Start Inspiration / Expiration
Figure 45 Example of breathing waveform in Track-

ing Markers graph
Peaks and valleys in the waveforms represent the two ends of the respiratory cycle (Start
Inspiration/Expiration and End Inspiration/Expiration). Depending on the motion of each Tracking
Marker, peaks may correspond to full inspiration in one waveform and full expiration in another
waveform. The respiratory cycle is divided into 8 non-overlapping time regions called phases.
12-60 | Building a Respiratory Correlation Model 1075883-ENG A

Each Live X-ray image acquired by the Treatment Delivery System adds a point to the Respiratory
correlation model. Each model point is classified as belonging to one of the 8 phases. For an
accurate and robust model, it is critical that the model points are distributed evenly and cover the
whole range of respiratory motion. Accomplishing this distribution requires timing X-ray image
acquisition with breathing motion.
A minimum of 6 model points (including the Peak and Valley model points and the Center Inhale
and Center Exhale model points) is required to build a complete Respiratory Model.
Acquisition of at least 12 images is recommended. A maximum of 15 images (15 model points) can
be stored in the model dataset at a time covering some or all of the 8 phases in the respiratory
cycle. As additional images are acquired, a first-in, first-out (FIFO) approach is used to update the
dataset. After a Respiratory Model is built, the Respiratory Model dataset is updated during
treatment delivery with each new X-ray image acquired.
In Figure 47, the top waveform shows model points (representing X-ray images) acquired at full
inspiration and expiration (the Peak and Valley model points). The middle waveform shows model
points acquired at the midpoint of inspiration and expiration (the Center Inhale and Center Exhale
model points) and additional model points acquired in the respiratory cycle. The bottom waveform
shows the automatic image burst of three model points when treatment delivery begins.
WARNING: When Live X-ray images are being acquired, you must verify that the target is
being identified and tracked correctly. Otherwise, inaccurate information will be added to
the Respiratory correlation model.
1075883-ENG A Building a Respiratory Correlation Model | 12-61

Figure 46 Top to bottom: model points at full respi-

ration, mid respiration, and 3-point automatic burst
With the above criteria, a Respiratory Model is categorized as one of the following Model States in
the Respiratory Model (mm) table of the Respiratory phase (see Figure 47):
Figure 47 Model Information section showing

Optimal Model State
• Optimal: Contains 8 or more model points (for Linear and Curved Poly model types), 12
or more model points (for Dual Poly model type), including 4 specific respiratory phases
(the Peak/Valley and Center Inhale/Exhale model points and the midpoints between
them). When an Optimal model is established, the Readiness tab is active and you can
proceed with treatment.

• Sub-optimal: This model state is only relevant for Linear and Curved Poly model types.
Contains 8 or more model points, including 4 specific respiratory phases (the Peak/Valley
and the Center Inhale/Exhale model points) and covers greater than 40% of the initial
respiratory marker range. When a Sub-Optimal model is established, the Readiness
tab is activated, however a Delivery Warning Message must be resolved or
acknowledged and confirmed before you can proceed with treatment. For information on
confirming delivery warning messages see, “Checking Equipment Readiness” on
page 8-67.
• Invalid: Contains fewer than 6 model points (for Linear and Curved Poly model types), or
fewer than 12 model points (for Dual Poly model type), or covers less than 40% of the
initial respiratory marker range, or is missing one of the 4 following respiratory phases
(the Peak/Valley and Center Inhale/Exhale model points and the midpoints between
them). The Readiness tab is disabled and you cannot proceed with treatment.
Detailed information about the state of the model and the actions required to achieve an Optimal
model state are displayed when clicking the Model Information Menu Button. The
Synchrony Respiratory Tracking System provides two ways to build a Respiratory Model,
described in the sections that follow:
• Manual Setup: You initiate each individual image acquisition and build a Respiratory
Model one model point at a time. See “Using Manual Setup” on page 12-63
• Automatic Setup (option): With this option, you can acquire a complete Respiratory
dataset automatically in two steps. See “Using Automatic Setup (Option)” on page 12-73
Using Manual Setup

• “Overview of Phase Selection” on page 12-64
• “Aligning the Patient at the Respiratory Center” on page 12-66
• “Image-by-Image Phase Selection” on page 12-67
• “User Defined Respiratory Phase Selection” on page 12-69
• “No Phase Selection” on page 12-70
This section describes three methods for building a Respiratory Model manually, one model point
at a time:
• Image-by-Image Phase Selection: This is the default method for Respiratory Modeling.
You click the Acquire Image button to initiate each image acquisition. Timing of image
acquisition is controlled so that model points are optimally distributed over the respiratory
cycle.
• User-defined Respiratory Phase Selection: Timing is controlled so that a single image
acquisition occurs at a phase you specify. This method only applies once to a single
image acquisition. The Synchrony Respiratory Tracking System then reverts back to
Image-by-Image Phase Selection, unless you re-invoke User-defined Respiratory Phase
Selection to specify the next phase to be acquired.

• No Phase Selection Phase selection is disabled so that timing of the next image
acquisition is not phase-driven.
Overview of Phase Selection

Phase Selection is the default method used by the Respiratory Modeling System to select the next
phase of a model point in the Respiratory Model. With Phase Selection, the Synchrony Respiratory
Tracking System controls the timing of image acquisition in order to acquire a model point at an
appropriate phase in the respiratory cycle to build an Optimal Respiratory Model. Timing is
controlled by the Synchrony Respiratory Tracking System during patient alignment or realignment.
During treatment delivery, timing is controlled by both the Synchrony Respiratory Tracking System
and the value of the Image Interval parameter.
With Phase Selection, data from a single Tracking Marker is used to control timing so that a model
point is acquired at the targeted phase. The enabled Tracking Marker with the highest percentage
visibility (green status bar) is used. If the percentage visibility of another enabled Tracking Marker
improves, that Tracking Marker may be used to control timing instead.
Data from all enabled Tracking Markers is used to build a

Respiratory Model and to track respiratory motion during
treatments that use Respiratory Modeling, even if a Tracking
Marker is not used to control timing of image acquisition with
Phase Selection.
With Image-by-Image Phase Selection, model points are acquired in the following order (see
Figure 48):
1st 2nd 3rd
Figure 48 The order used to acquire model points

with Image-by-Image Phase Selection
1. The first 2 model points are acquired at the maximum and minimum amplitudes of the
respiratory cycle (the Peak and Valley model points) to obtain good coverage at the two
extremes.
2. Next, 2 model points are acquired at the midpoints of the respiratory cycle (the Center
Inhale and Center Exhale model points).
3. Finally, the last 4 model points are acquired at amplitudes halfway between the above 2
phases and the midpoints of the respiratory cycle, to obtain good coverage on the inhale
and exhale sides.

If the Respiratory Model is missing one or more of the 8 phases, the Synchrony Respiratory
Tracking System targets the missing phases in the order given above. If the model contains the
maximum of 15 model points, the next model point replaces the oldest model point in the dataset.
If any phases are missing in the dataset, the missing phases are targeted in the order given above.
If there are no missing phases, the next model point is acquired at a random phase. The oldest
model point is discarded before the new model point is acquired.
The Synchrony Respiratory Tracking System continuously re-evaluates the existing model points,
regardless of whether a new model point has been acquired. The existing model is compared with
the actual breathing pattern determined by the current motion of the Tracking Markers. Changes
in the breathing pattern can result in changes in the phase distribution of existing model points. For
example, a model point that has been classified as a Peak may no longer be at the maximum
amplitude of respiratory motion. This re-evaluation of the existing model is used to reclassify the
phases of the model points to determine the next phase that will be triggered by Phase Selection.
NOTE: The phase labeling of existing model points as indicated

on the screen (in the image panels, the Image History table,
and the breathing waveform snippet) is not changed by the re-
evaluation. Only the underlying classification that is used to
determine the next phase is changed.
It is possible for the Synchrony Respiratory Tracking System to miss a phase it has targeted. In
this case, the new model point is still used in the model, even though one or more holes remain in
the distribution of phases. The missing phase will be retargeted in the next image acquisition.
You can enable and disable Phase Selection at any time in the Respiratory phase when using
Manual Setup.

Aligning the Patient at the Respiratory Center

The first step in building a Respiratory Model manually is to align the patient near the center of the
respiratory cycle. Centering the range of respiratory motion reduces the likelihood of treatment
interruptions due to out of bounds errors. Then you acquire the remaining Respiratory dataset
one model point at a time.
being identified and tracked correctly. Otherwise, inaccurate information may be added to
 To align the patient at the center of the respiratory cycle:

1. In the Alignment > Respiratory phase, click the Manual Setup tab (see
Figure 49).
Figure 49 Manual Setup tab
2. Use User-defined Respiratory Phase Selection to acquire both the Peak and Valley
model points (full inspiration/expiration) and either the Center Inhale or Center Exhale
model point (the midpoint of the respiratory cycle). For instructions, see “User Defined
Respiratory Phase Selection” on page 12-69.
Visually compare the Live X-ray and DRR images to ensure that features are similar in
both. Ensure that the target to be tracked is correctly identified in the Live X-ray images
by the tracking algorithm.
3. Review the translational offsets of the Center Inhale or Center Exhale image in the
Respiratory Model (mm) table.
If the values are close to zero, it is not necessary to move the couch.
If the values are high in one or more axes, you can move the couch to center the range of
respiratory motion. Enter the translational offsets of the Center Inhale/Exhale image into
the Couch Position (mm) textboxes.

4. Click the Move Couch button to move the patient to the respiratory center. For more
information, see “Move Couch Controls” on page 12-23.

5. Re-acquire the Center Inhale or Center Exhale image to verify that the patient is aligned
near the respiratory center.
Image-by-Image Phase Selection

Image-by-Image Phase Selection is the default method used to build a Respiratory Model. With
this method, the Synchrony Respiratory Tracking System controls the timing of image acquisition.
Each image is acquired by clicking the Acquire Image button on the Manual Setup tab.
Timing is controlled so that the model point corresponds to an optimally selected phase in the
respiratory cycle.
This method provides unlimited time to inspect each Live X-ray image to verify target identification,
monitor Offset values, and monitor the Respiratory Model information displayed on the
Respiratory screens. This method is recommended for more difficult breathing patterns or
target motion.
 To build a Respiratory model using Image-by-Image Phase Selection:

1. Click the Manual Setup tab (see Figure 49).
2. Ensure the Phase Selection icon (see below) is selected. If it is disabled, click to re-
enable it. Phase Selection remains enabled until you disable it.
3. Click the Acquire Image button.

Timing of image acquisition is controlled to acquire a model point at an automatically
selected respiratory phase.
NOTE: If an X-ray image at the desired phase cannot be

acquired within 20 seconds, an image is acquired at a random
phase.
The breathing waveform snippet on the right screen shows a dot corresponding to the

phase of the model point (see Figure 50).
Figure 50 Breathing waveform snippet showing

Peak model point
4. Repeat the above step to acquire images throughout the respiratory cycle.
5. Monitor Respiratory modeling as you acquire images:
• Check the Respiratory Phase indicator. As the Peak/Valley and Center Inhale/Exhale
model points are acquired, the Respiratory Phase indicator is updated (see
Figure 51).
Figure 51 Respiratory Phase indicator showing the

required “Four Seasons” model points
At a minimum, the Respiratory model must be valid, containing at least 6 model

points for Linear and Curved Poly models, or 12 model points for Dual Poly models,
and must include the Peak/Valley and the Center Inhale/Exhale model points, before
you can proceed with treatment delivery.
• Review the Respiratory Model (mm) table. See “Respiratory Model Table” on
page 12-44.
• Evaluate the breathing waveforms and the Amplitude indicators in the Tracking
Markers graph. See “Tracking Markers Graph” on page 12-37.
6. After acquiring a Respiratory dataset, you analyze the Respiratory Model. See “Analyzing
the Respiratory Model” on page 12-77.

Verify using Movie Mode (see Table 2 on page 12-17) that the tracking algorithm has
correctly identified the target to be tracked.
User Defined Respiratory Phase Selection

User Defined Respiratory Phase Selection allows you to acquire a single Live X-ray image at a
phase you specify. The Synchrony Respiratory Tracking System controls the timing of image
acquisition to obtain a model point at this phase. After a single model point is acquired, the
Synchrony Respiratory Tracking System reverts to the default Image-by-Image Phase Selection
(see “Image-by-Image Phase Selection” on page 12-67).
User Defined Respiratory Phase Selection can be used to fill in missing model points to obtain all
8 phases, for example, to change from a Sub-optimal model to an Optimal model. It can also be
used during patient alignment to obtain Offset values at the maximum and minimum amplitudes of
the respiratory cycle (the Peak and Valley model points). These values can be used to help center
the range of respiratory motion at the machine center, as described in “Aligning the Patient at the
Respiratory Center” on page 12-66.
being identified and tracked correctly. Otherwise, inaccurate information will be added to
 To build a Respiratory Model with the User Defined Respiratory Phase method:
2. Click a circle in the waveform display to select a phase in the respiratory cycle. (see
Figure 52).
Figure 52 Waveform display for selecting the user-

defined phase of the next model point
A checkmark is displayed to indicate the phase you have selected.

Timing of image acquisition is controlled to acquire a model point at the respiratory phase
you selected. The breathing waveform snippet on the right screen shows a dot
corresponding to the phase of the model point (see Figure 50 on page 12-68).
After image acquisition, the checkmark moves from the waveform display to the Phase
Selection icon (see below), to indicate that Phase Selection is still selected. The default
Image-by-Image Phase Selection will be used for the next image acquisition unless you
select another phase in the waveform display.

Figure 53 Phase Selection icon
4. Repeat Step 2 and Step 3 above to continue to acquire images throughout the respiratory
cycle at phases you select.
Figure 51).
At a minimum, the Respiratory Model must be valid (containing at least 6 model
and must include the Peak/Valley and the Center Inhale/Exhale model points) before
page 12-44.
No Phase Selection
With No Phase Selection, timing is not automatically phase-driven. The Synchrony Respiratory
Tracking System acquires a Live X-ray image as soon as it can after you click the Acquire
Image button, without waiting for a particular phase (see Figure 54). This method is helpful for
patients with irregular breathing patterns, when it can be difficult for the Synchrony Respiratory
Tracking System to acquire a model point at a desired phase using Phase Selection.
NOTE: When Phase Selection is disabled, image acquisition is

not phase-driven and model points may not be evenly distributed
throughout the respiratory cycle.
To build an accurate and robust Respiratory Model with Phase Selection disabled, the model
points should be distributed evenly and cover the whole range of respiration for maximum
coverage. Follow these guidelines:
• Acquire 2 - 4 images spaced evenly throughout the inspiration phase.

• Acquire 2 - 4 images spaced evenly throughout the expiration phase.
Acquire Images Here

End Inspiration
End Expiration
Figure 54 Acquiring model points with No Phase

Selection
 To build a Respiratory Model with Phase Selection disabled:

2. Click the No Phase Selection icon (see below).

The breathing waveform snippet on the right screen shows a dot corresponding to the
phase of the model point (see Figure 50 on page 12-68).
4. Visually compare the Live X-ray and DRR images to ensure that features are similar in
both. Ensure that the fiducials to be tracked are correctly identified in the Live X-ray
images by the tracking algorithm.
5. Repeat Step 2 and Step 3 above to acquire at least 4 model points, including the Peak/
Valley and Center Inhale/Exhale model points.
The following is a recommended methodology for acquiring model points:
• Acquire the first 2 model points at the maximum and minimum amplitudes of the
respiratory cycle (the Peak and Valley model points).
• Acquire the next 2 model points at midpoints of the respiratory cycle (the Center
Inhale and Center Exhale model points).

• Acquire the remaining 4 model points at amplitudes halfway between the above
locations.
The Readiness phase is activated when you have built a valid Respiratory Model
(containing at least 6 model points for Linear and Curved Poly models, or 12 model points
for Dual Poly models, including the Peak/Valley and the Center Inhale/Exhale model
points). The Model State in the Model Information section of the Respiratory
Model (mm) table will be listed as Optimal or Sub-optimal.
Figure 51).
At a minimum, the Respiratory model must be valid (containing at least 6 model
page 12-44.
7. Continue to acquire images to refine the Respiratory Model.
After the Respiratory Model is validated, you can acquire additional images at different
phases of the respiratory cycle to add to the Respiratory dataset, up to a maximum of 15
model points.

Using Automatic Setup (Option)

The Automatic Setup option facilitates building a complete Respiratory Model. Build a
Respiratory Model using this option in two steps:
• Respiratory Alignment: First acquire Peak/Valley images (full inspiration/expiration)
and align the patient at the center of the respiratory cycle.
• Dataset Acquisition: With a single button click, acquire the images needed to
complete the Respiratory dataset, up to 15 model points.
You can also switch to Manual Setup at any time from the Automatic Setup tab. For more
information, see “Using Manual Setup” on page 12-63.
Perform Respiratory Alignment

The Respiratory Alignment step aligns the patient near the center of the respiratory cycle.
This reduces the likelihood of treatment interruptions due to out of bounds errors.
On the Automatic Setup tab, you first click the Acquire Peak and Valley Image button
once. The Synchrony Respiratory Tracking System then automatically acquires both the Peak and
Valley model points. The tracking algorithm then calculates how far the patient is from the center
of respiratory motion. The couch movement required to align the patient at the respiratory center
automatically fills the Respiratory Center (mm) textboxes. You can then move the couch to
this location.
 To align the patient at the center of the respiratory cycle:

1. Click the Automatic Setup tab (see Figure 55).
Figure 55 The Automatic Setup tab

2. Click the Acquire Peak and Valley Image button in the Respiratory
Alignment section.
Two Live X-ray images are taken corresponding to full inspiration/expiration. Images are
displayed on the left screen as they are acquired.
The Peak/Valley icon shows green dots when the Peak and Valley model points of the
respiratory cycle have been acquired
As the model points are acquired:

page 12-44.
If the target is not correctly identified or errors occur, see “Analyzing the Respiratory
Model” on page 12-77.
3. Review the values displayed in the Respiratory Center (mm) text fields.
NOTE: The Respiratory Center (mm) text fields are only

available on the Automatic Setup tab.
Values are the translational difference between the Peak and Valley locations and
indicate how far the patient position is from the respiratory center. (The Couch
Rotation (deg) textboxes are set to zero and remain locked.)
If values are close to zero, it is not necessary to move the couch. If values are high in one
or more axes, you can move the couch to center the range of respiratory motion.
4. Click the Move Couch button to move the patient to the respiratory center.
Values in the textboxes change and approach zero as the desired couch position is
achieved.

5. If you moved the couch, repeat Step 2 to reacquire the Peak/Valley model points.
After Respiratory alignment, the Acquire Dataset button is enabled in the Dataset
Acquisition section (see Figure 56), allowing automatic acquisition of remaining Respiratory
model points.

Acquire a Respiratory Dataset

The goal of the Dataset Acquisition step is to complete the Respiratory Model by filling in
missing model points automatically with one button click. Both the Peak and Valley model points
must exist before you can begin this step. When the Acquire Dataset button is clicked, a burst
of images is acquired rapidly. The first image in the burst is triggered to obtain a model point at a
targeted phase. Then 1 image per second is acquired until the Respiratory Model contains
12 images. The remaining 3 model points are reserved for any missing phases.
NOTE:
 To acquire a Respiratory dataset:

1. Click the Acquire Dataset button in the Dataset Acquisition section of the
Automatic Setup tab to start acquiring the remaining data points for the Respiratory
Acquire
Dataset
Button
Figure 56 Dataset Acquisition button enabled
You only need to click the button once. The 2 Peak and Valley model points must exist to
enable this button.
Live X-ray images are acquired in a rapid burst at 1 second intervals. 3 images are taken
at the end for any missing respiratory phases.
As images are acquired to complete the Respiratory Model, a Wait time in seconds may
be displayed when acquisition is used for extended periods, which is the countdown time
remaining before the Acquire Dataset button is re-enabled for another burst of
imaging (see Figure 57).

Figure 57 Dataset Acquisition section with Wait

time in seconds
2. Monitor Respiratory Modeling as images are acquired:

Figure 51).
At a minimum, the Respiratory Model must be valid (containing at least 6 model
page 12-44.

Analyzing the Respiratory Model
You can analyze the Respiratory Model as follows:

• “Review Images in the Respiratory Cycle.” on page 12-77
• “Evaluate Offset Values” on page 12-77
• “Respond to Errors and Threshold Violations” on page 12-78
• “Move the Couch” on page 12-78
Review Images in the Respiratory Cycle.

To review images in the Respiratory Model, refer to the following sections:
• Respiratory Model (mm) table: Evaluate the Respiratory correlation error,
calculated offsets, and other model information for the current Respiratory dataset. See
“Respiratory Model Table” on page 12-44.
• Movie Mode: Improve target visibility by displaying Live X-ray images in the current
Respiratory Model in respiratory sequence. See Table 2 on page 12-17.
• Image History table: Review additional details for each image in the Respiratory
Model. Sort model points by respiratory phase or age. Evaluate whether to remove or add
back model points. See “Image History Table” on page 12-28.
• Comet graphs: Monitor a virtual view of target motion. See “Comet Graphs” on
page 12-30.
Evaluate Offset Values

Evaluate the calculated Offset values in the Respiratory Model (mm) table. They indicate
couch movement that would be needed to align features in the Live X-ray and DRR images.
An orange box around a row indicates an offset is not within required tolerances (an out-of-bounds
error), or a tracking algorithm threshold violation has occurred.
For Synchrony Fiducial Tracking with Respiratory Modeling mode, use image analysis tools in
Table 2 on page 12-17 to make sure you can visually identify the fiducials to be used for tracking.
Check that fiducials are aligned in the Live X-ray and DRR images. For Synchrony Lung Tracking
with Respiratory Modeling mode, make sure that the tumor has been correctly located, and check
that anatomy in the Live X-ray and DRR images matches.


For example, no rotational offsets are calculated for Synchrony
Fiducial Tracking with Respiratory Modeling mode when fewer
than three fiducials are selected for tracking. For Synchrony
Lung Tracking with Respiratory Modeling mode, rotational
offsets are not calculated during treatment and the rotational
offsets calculated during spine alignment are used.
Respond to Errors and Threshold Violations

When an out-of-bounds error or a threshold violation occurs, you can respond as follows:
1. For Synchrony Fiducial Tracking with Respiratory Modeling mode, verify that the tracking
algorithm has correctly identified the fiducials to be tracked. Verify that the algorithm is
tracking the correct fiducials. Use Offset Mode if necessary.
For Synchrony Lung Tracking with Respiratory Modeling mode, verify that the tracking
algorithm has correctly identified the target tumor. Verify that the algorithm is tracking the
correct tumor. Use Offset Mode if necessary.
For information on Offset Mode, see the following chapters:
“Chapter 9: Synchrony Fiducial Tracking”
“Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”
“Chapter 15: Lung Optimized Treatment (Option)”
2. For Synchrony Fiducial Tracking with Respiratory Modeling mode, enable/disable
fiducials for tracking. For information, see “Chapter 9: Synchrony Fiducial Tracking”.
3. Turn off the model point to remove it from the Respiratory Model. Then reacquire that
model point. See “Image History Table” on page 12-28.
4. You can also adjust algorithm parameters as needed. For more information on adjusting
algorithm parameters, see the following chapters:
“Chapter 9: Synchrony Fiducial Tracking”
“Chapter 10: Synchrony Spine Tracking (Option)”
“Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”
“Chapter 15: Lung Optimized Treatment (Option)”
You can also review a log of parameter values calculated by the tracking algorithm. See
“Acquisition Details Tab” on page 12-35.
Move the Couch

For information on moving the couch, see “Move Couch Controls” on page 12-23 and also

Evaluating Placement of Tracking Markers

After you build a Respiratory correlation model, you should evaluate the placement of the
Synchrony Respiratory External LED Markers on the Synchrony Respiratory Vest. Proper
placement of the Tracking Markers can be evaluated as described below.
Review the breathing waveforms displayed on the Tracking Markers graph display on the
treatment delivery computer (see “Tracking Markers Graph” on page 12-37). Each waveform
represents one of the Tracking Marker LEDs. Watch the waveforms over several breathing cycles.
Ensure that the Tracking Markers stay within view of the LED detectors throughout the breathing
cycle.
It may be necessary to adjust the placement of the Tracking Markers or the Synchrony Respiratory
Camera Array to obtain acceptable breathing waveforms. For information on adjusting the position
of the Synchrony Respiratory Camera Array, see “Adjusting the Synchrony Respiratory Camera
Array” on page 12-56.
The Synchrony Respiratory Tracking System requires at least one Tracking Marker in order to
create a Respiratory Model. It is possible to turn off 1 or 2 Tracking Markers and still build a usable
correlation model. For information on turning off Tracking Markers, see “Image History Table” on
page 12-28.
After building a Respiratory Model, check the correlation error value. This value is displayed in the
Correlation Error text field on the Respiratory tab on the treatment delivery computer. This
text field shows the average radial correlation error (correlation error along the radial R axis) in
millimeters for the three Tracking Markers. This value is determined by the difference between the
actual position of the target, as determined by the Live X-ray images, and the predicted position of
the target, as computed using the Respiratory Model.
The correlation error value should be maintained as close to 0 mm as possible. If the correlation
error exceeds a threshold value of 5 mm, a Soft Stop is triggered. If this occurs, you must rebuild
the Respiratory Model. After rebuilding the model, reevaluate the correlation error to ensure it is
less than 5 mm and as close to 0 mm as possible.

Modeling, a Soft Stop is triggered if the correlation error exceeds
a threshold value of 2.5 mm.
The user can lower the correlation error threshold value so that a Soft Stop is triggered at less than
the default value of 5 mm.
For Synchrony Fiducial Tracking with Respiratory Modeling and for Synchrony Lung Tracking with
Respiratory Modeling, the threshold value can be set between 2.0 mm and 5.0 mm. For Synchrony
Spine Tracking Prone with Respiratory Modeling, the threshold can be decreased from 2.5 mm to
1.5 mm.
If the correlation error is close to the threshold value, consider turning off a Tracking Marker, or
repositioning the Tracking Markers or the Synchrony Respiratory Camera Array. Then rebuild the
Respiratory correlation model and reevaluate the correlation error.
When the Synchrony Respiratory External LED Markers are placed properly and an acceptable
Respiratory correlation model has been built, patient setup is complete and you are ready to start
treatment delivery, as described in “Treatment Delivery” on page 12-81.


Treatment Delivery
• “Starting Synchrony Respiratory Tracking Treatment” on page 12-81
• “Visually Verifying the Target” on page 12-84
• “Displacement Corrections During Treatment” on page 12-84
• “Monitoring Synchrony Respiratory Tracking” on page 12-85
For more information on treatment delivery, see “Chapter 8: Treatment Delivery”.
Starting Synchrony Respiratory Tracking

Treatment
You can begin treatment when the patient is aligned within acceptable bounds and an acceptable
Respiratory correlation model has been established. When these conditions are met, the Start/
Resume button in the Delivery phase on the treatment delivery computer becomes active.
NOTE: The Model Information section on the right screen

of the Delivery phase indicates the current status of the
Respiratory Model, either Optimal, Sub-optimal, or Invalid. The
Start/Resume button is inactive if the Respiratory Model is
Invalid.
 To start treatment delivery:

1. In the Readiness phase, ensure that the patient is located within the Patient Safety
Zone.
2. If the Respiratory Model is Sub-optimal, a Delivery Warning Message occurs. You
can either resolve the warning by acquiring more model points or review and
acknowledge you have read the warning without resolving it by clicking Confirm in the
Delivery Warnings Message panel. You can then proceed with treatment (see
Figure 58).

Figure 58 Unconfirmed Delivery Warning Message for

Respiratory Model containing fewer than 8 model points
3. If there is more than one Delivery Warning Message, review, resolve when
applicable, and confirm all messages as necessary.
When all messages have been confirmed and the Collimation System Status check has
been performed, you can proceed to the Delivery phase.
4. Click the Start button in the Delivery phase to begin treatment delivery, as described
in “Chapter 8: Treatment Delivery”.
WARNING: While treatment is in progress, watch the movement of the treatment robot on
the Closed Circuit TV (CCTV) system for monitoring the patient.

WARNING: During treatment using the Synchrony Respiratory Modeling System, Live X-
ray images are used to verify that the Respiratory Model is still valid for the patient
position. Image frequently enough during treatment to ensure that the Respiratory Model
is still valid.
During treatment delivery, a new model point is added to the Respiratory Model dataset
with each image acquisition, as described in “Overview of Respiratory Modeling” on
page 12-60. When the Respiratory Model contains the maximum of 15 model points and
the oldest model point is discarded before a new model point is acquired, it is possible for
the Model State to change from Optimal to Sub-optimal. With Phase Selection, it is
also possible for the model to change from Optimal to Sub-optimal if the Synchrony
Respiratory Tracking System misses the targeted phase. During treatment delivery
automation, if the Image Burst option is available on your CyberKnife System and
enabled, the Synchrony Respiratory Tracking System will take a burst of 3 images every
60 seconds, which is the default value of the Image Burst Interval parameter. Image Burst
can be disabled in the Readiness phase. The Image Burst Interval can be changed
using the Image Burst Interval (sec) slider bar on the left screen of the Delivery
phase (see “Image Burst Interval Slider Bar (Option)” on page 12-45).
If the Respiratory Model becomes Invalid during treatment delivery, an E-Stop occurs.
You must then rebuild the Respiratory Model to obtain at least a Sub-optimal model state
before you can resume treatment. It is possible for the model to become Invalid if the
model type changes from a Linear or a Curved Poly model to a Dual Poly model, and an
Interlock will occur. In order to proceed with treatment, you must acquire more images for
additional model data points.
If you need to add images to the Respiratory Model during treatment delivery, click the
Pause button to produce a Soft Stop and interrupt treatment at the next convenient
opportunity, or click the Interlock button to trigger an interlock and stop treatment
delivery immediately. For more information on interrupting treatment delivery, see

Visually Verifying the Target
WARNING: Visually verify that the target (fiducials or tumor) is correctly identified
throughout treatment. Make sure that anatomy in the Live X-ray and DRR images matches.
For more information on visually identifying features to be tracked, see “Chapter 8:
It is possible that the tracking algorithm will incorrectly identify the target without returning an error.
In this case, Offset values and the average Respiratory Correlation Error value will still be
displayed on the Offsets window on the treatment delivery computer, However, the markers in
the Live X-ray images will not be positioned over the actual target:
• In Synchrony Fiducial Tracking with Respiratory Modeling mode with the Display
Fiducial Markers checkbox selected, the green circle markers will not be positioned
over the actual fiducials.
• In Synchrony Lung Tracking with Respiratory Modeling mode with the Display Marker
checkbox selected, the tumor outline will not be positioned over the actual tumor.
For more information on adjusting parameters used by the tracking algorithms to correctly identify
the target, see the following:
• “Chapter 8: Treatment Delivery”.
• “Chapter 9: Synchrony Fiducial Tracking”.
• “Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”.
Displacement Corrections During Treatment

During treatments that use Respiratory Modeling, the treatment robot dynamically compensates
for motion of the target due to respiration, based on the Respiratory correlation model between
target motion and motion of the Tracking Markers.
With the Synchrony Respiratory Tracking System, translation of the target will be compensated for
by the treatment robot up to ± 25 mm. Rotational movements will be compensated for by the
treatment robot based on the average rotation from all the Live X-ray images belonging to the
Synchrony model. Rotational corrections depend on the treatment couch:
• With the standard treatment couch, the treatment robot can compensate for patient
rotations up to ±1° of roll (left and right rotations), ±1° of pitch (head up and head down),
and ±3° of yaw (clockwise and counter-clockwise rotation).
• With the optional RoboCouch System, the robot can compensate for roll, pitch, and yaw
up to ±1.5°.
Live X-ray images acquired during treatment delivery are used to update the Respiratory Model.
The oldest model point is discarded after a maximum of 15 model points has been reached (see
“Overview of Respiratory Modeling” on page 12-60).

When an acceptable Respiratory Model has been established, the Synchrony Respiratory
Tracking System assists the Treatment Delivery System to correlate the Live X-ray images with
the DRR images. The Respiratory Model is used to predict the target position based on respiratory
motion and adjust the location of the centroid of the Region of Interest (ROI) around the target
accordingly.
For more information on treatment robot displacement corrections, see “Chapter 8: Treatment
Delivery”.
Monitoring Synchrony Respiratory Tracking

During treatments that use Respiratory Modeling, you should monitor the information displayed on
the treatment delivery computer in the Delivery phase. See “Left and Right Screens of the
Delivery Phase” on page 12-41.
In the Tracking Markers graph, monitor the amplitude and regularity of the breathing
waveforms for the 3 Tracking Markers. If the amplitude decreases or breathing becomes irregular,
consider rebuilding the Respiratory correlation model. Coach the patient on maintaining regular
breathing. See “Tracking Markers Graph” on page 12-37.
In the XYZ vs R correlation graphs, monitor the Respiratory Models for the 3 Tracking Markers.
If a Respiratory Model is changing frequently, consider coaching the patient to breath more
regularly. See “XYZ vs. R Correlation Graphs” on page 12-32.
In the Respiratory Model Standard Error (mm) graph, monitor the Average Standard
Error (mm) and the Maximum Standard Error (mm) for the Respiratory Model. If the Respiratory
Model standard error increases and remains high, consider rebuilding the Respiratory Model. See
“Treatment Monitoring Graphs” on page 12-47.
In the Markers control area, monitor the status of the 3 Tracking Marker LEDs to make sure they
are visible to the Synchrony Respiratory Camera Array. See “Markers Control Area” on
page 12-36.
If treatment is interrupted due to a Soft Stop or E-Stop, or if you click the Interlock button, and
the Respiratory correlation model is still valid, you can click the Start/Resume button to resume
treatment.
For more information on interrupting treatment using an E-Stop button, the Pause button, or the
Interlock button, see “Chapter 8: Treatment Delivery”.
Error Handling
If an error occurs during treatment delivery, an E-Stop occurs and the CyberKnife System is
paused. If the error is recoverable, you can correct the error, reset the E-Stop, and resume
treatment. If the error is unrecoverable, you cannot reset the E-Stop and must exit the treatment.

Patient Realignment
If treatment is interrupted due to a Soft Stop or E-Stop, or if you click the Pause button, you must
confirm alignment of the patient before treatment can resume. For information on patient
realignment after treatment has been paused or an error occurs, see “Chapter 8: Treatment
Delivery”.

Chapter 13: Synchrony Tracking
with InTempo Imaging (Option)
Introduction
This chapter describes how to use the Synchrony Tracking with InTempo Imaging with the
CyberKnife Treatment Delivery System. The Synchrony Tracking with InTempo Imaging is a time-
based motion tracking technology used to compensate for intrafraction motion of the target. It can
be used with Synchrony Skull Tracking, Synchrony Spine Tracking Supine, or Synchrony Fiducial
Tracking. The most common tracking mode used with InTempo is Synchrony Fiducial Tracking
mode. This is the mode referenced throughout this chapter unless otherwise indicated.
• “Overview of the Synchrony Fiducial Tracking with InTempo Imaging” on page 13-2
• “Workflow for Treatments with the InTempo System” on page 13-4
• “InTempo in the Overview Phase” on page 13-4
• “InTempo in the Patient Alignment Phase” on page 13-4
• “InTempo Settings in the Readiness Phase” on page 13-5
• “InTempo in the Treatment Delivery Phase” on page 13-6
This chapter assumes you are familiar with “Chapter 9: Synchrony Fiducial Tracking” and “Chapter
10: Synchrony Spine Tracking (Option)”. For information on Synchrony Skull Tracking mode, see

Overview of the Synchrony Fiducial Tracking

with InTempo Imaging
Before using the Synchrony Fiducial Tracking with InTempo Imaging, it is important to understand
several key system-level concepts, in order to track and compensate for target motion more
accurately. This section covers the following topics:
• “Image Age” on page 13-2
• “Beam Segments” on page 13-2
• “Calculation of Target Offsets” on page 13-3
• “Adaptive Imaging” on page 13-3
Image Age
Image Age is the elapsed time between acquisition of an X-ray image and completion of delivery
of the beam (or beams) that use that image for targeting. The Synchrony Fiducial Tracking with
InTempo Imaging allows the user to specify the maximum allowed Image Age, by adjusting the
Max Image Age parameter. The Max Image Age parameter may be set to any value between 15
and 150 seconds (between 30 and 150 seconds for the Synchrony Spine Tracking Supine mode).
It may be adjusted at any time during treatment without interrupting treatment delivery.
By setting the value of the Max Image Age, the user controls the frequency of X-ray imaging. In
this way, the Synchrony Fiducial Tracking with InTempo Imaging guarantees that no beam is
delivered based on an image that is older than the user-defined value of this parameter. The
Synchrony Fiducial Tracking with InTempo Imaging decides whether to acquire a new image
based on the duration of the upcoming beam, by determining whether delivery of the beam will fit
within the specified value of the Max Image Age parameter.
This decision does not imply that only one beam will be delivered between two image acquisitions.
The Synchrony Fiducial Tracking with InTempo Imaging will always aim to maximize the number
of beams delivered within the duration set by the Max Image Age parameter. This is accomplished
by "splitting" the beams into manageable segments, as described below, and maximizing the
number of segments delivered within the image age specified.
Beam Segments
In order to comply with the desired Max Image Age set by the user, beams generated during
treatment planning are "split" into segments if their duration exceeds the minimum allowed value
of this parameter. A beam with a long beam-on time will therefore be split into and delivered as
several segments. The length (in time) of each segment is optimized so as to always fit within the
minimum allowed value of the Max Image Age parameter (15 seconds; 30 seconds for the
Synchrony Spine Tracking Supine mode).
13-2 | Overview of the Synchrony Fiducial Tracking with InTempo Imaging 1075883-ENG A
Treatment Delivery Manual Chapter 13: Synchrony Tracking with InTempo Imaging (Option)
The beam Sequence ID number is displayed during treatment in the Delivery Progress panel
of the Delivery phase (right screen) and provides a check to ensure that the beam number
generated at the time of treatment planning is maintained. If a beam is split into segments, the
segment number that is currently being delivered is also displayed (see “Starting Treatment” on
page 13-7).
Calculation of Target Offsets

In contrast to all other tracking modes, target motion with the Synchrony Fiducial Tracking with
InTempo Imaging is calculated as a difference in target position between two consecutive X-ray
images. Tracking without the Synchrony Fiducial Tracking with InTempo Imaging correlates the
observed target position with the position recorded in the DRR images, and target offsets are
calculated using the DRR images as a reference.
With the Synchrony Fiducial Tracking with InTempo Imaging, the offset in observed target position
is determined based on the immediately preceding target position. The offset can be expressed
symbolically in the following way:
PX-ray(i) – PDRR = Di
PX-ray(i-1) – PDRR = Di-1
S = Di – Di-1
where
• PX-ray is the position of the tracked target in the X-ray image,
• subscripts i and i-1 refer to the current and previous X-ray images, respectively,
• PDRR is the position of the tracked target in the reference DRR image,
• D is the displacement of the tracked target in the X-ray image relative to its position in the
DRR image, and
• S is the shift in the target position in the current X-ray image relative to its position in the
previous X-ray image.
Adaptive Imaging
With the Synchrony Fiducial Tracking with InTempo Imaging, in the event that observed motion
between two consecutive images is larger than a preset, user-defined threshold, adaptive imaging
is triggered. Adaptive imaging, if enabled, will cause the imaging frequency to be maximized by
automatically setting the Max Image Age parameter to its smallest value. This adjustment occurs
without triggering a treatment interruption, thus allowing treatment delivery to continue.
1075883-ENG A Overview of the Synchrony Fiducial Tracking with InTempo Imaging | 13-3
Workflow for Treatments with the InTempo

System
The workflow for treatments using the InTempo System follows that of the tracking mode of the
treatment plan. The tracking mode options for an InTempo plan are as follows:
• Synchrony Skull Tracking mode
• Synchrony Fiducial Tracking mode
• Synchrony Spine Tracking Supine mode
InTempo cannot be used with Synchrony Respiratory Modeling.
For information on these tracking modes, see the following chapters:
• “Chapter 8: Treatment Delivery”
The following sections describe how the Synchrony Fiducial Tracking with InTempo Imaging
specifically affects each workflow phase. InTempo parameter settings can be adjusted on the left
screen of the Readiness phase and on the left screen of the Delivery phase under the
Treatment Monitoring graphs.
InTempo in the Overview Phase

The Overview phase procedures of a treatment using the InTempo system are the same as those
of the tracking mode selected in the treatment plan. Refer to the appropriate tracking mode chapter
for more information.
InTempo in the Patient Alignment Phase

The Patient Alignment phase procedures of a treatment using the InTempo System are the same
as those of the tracking mode selected in the treatment plan. Refer to the appropriate tracking
mode chapter for more information.
NOTE: For Synchrony Fiducial Tracking mode, when the

Synchrony Fiducial Tracking with InTempo Imaging is selected,
the spatial arrangement of fiducials identified during the
treatment planning process is validated for optimal tracking.
Optimally positioned fiducials that conform to Accuray guidelines
(see “Chapter 6: Patient Preparation”) are identified at that time.
Disabling optimally positioned fiducials during treatment delivery
could lead to excessive soft stops or sub-optimal tracking.
13-4 | Workflow for Treatments with the InTempo System 1075883-ENG A

InTempo Settings in the Readiness Phase

The InTempo Settings panel is displayed on the left screen of the Readiness phase when
the Synchrony Fiducial Tracking with InTempo Imaging is specified in a treatment plan (see
Figure 1). This panel contains the additional parameters described below.
Figure 1 InTempo Settings panel in Readiness

phase (left screen)
Setting the Maximum Allowed Motion of the

Target
Two parameters set the maximum allowable target motion that can occur between two consecutive
X-ray images. If target motion exceeds one or both of these thresholds, the system responds with
the action specified in the InTempo Settings panel (see “Selecting the InTempo Response”
on page 13-6).
• Max positional shift (mm) textbox: Sets the maximum allowed 3D translational
shift of the target position between two consecutive X-ray images.
The 3D translational shift is the overall translational displacement between the target
position in the current image and its position in the previous image. It is defined as the
Root-Sum-Square (RSS) of the displacements along the X, Y, and Z axes as follows:
2 2 2 (1)
RSS = X +Y +Z
• Max rotational shift (deg) textbox: Sets the maximum allowed rotational shift of
the target. If any single rotation (roll, pitch, or yaw) exceeds this threshold, a response is
triggered, as described below.
1075883-ENG A InTempo Settings in the Readiness Phase | 13-5

Selecting the InTempo Response

The Action section of the InTempo Settings panel includes three options that control how
the CyberKnife System responds when target motion exceeds one or both of the thresholds
defined above. One of the following actions can be selected:
• Adapt option: Enables adaptive imaging. The value of the Max Image Age parameter is
automatically set to its minimum allowed value, thus maximizing the X-ray imaging
frequency.
When using InTempo with the Synchrony Fiducial Tracking System and the Synchrony
Skull Tracking System, target motion exceeding the set threshold will trigger the system
to automatically adapt Max Image Age to a minimum allowed value of 15 seconds.
When using InTempo with the Synchrony Spine Supine Tracking System, target motion
exceeding the set threshold will trigger the system to automatically adapt Max Image Age
to a minimum allowed value of 30 seconds.
NOTE: For a particular X-ray imaging technique, the maximum

supported imaging frequency is a discrete number.
• Treatment Soft Stop option: Interrupts treatment delivery by requesting a Soft Stop,
allowing the user to realign the patient if necessary. No automatic changes are made to
algorithm parameter settings. When this option is selected, the Adapt checkbox below
the leftmost Treatment Monitoring graph is disabled (see “Enabling and Disabling
Adaptive Imaging” on page 13-10).
For more information on Soft Stops, see “Chapter 8: Treatment Delivery”.
• No Action option: No response occurs. The Synchrony Fiducial Tracking with InTempo
Imaging will maintain the current Max Image Age setting even if target motion exceeds a
threshold. Treatment delivery continues with no automatic changes to algorithm
parameter settings and without triggering an E-Stop or Soft Stop.
InTempo in the Treatment Delivery Phase

• “Starting Treatment” on page 13-7
• “Pausing Treatment” on page 13-8
For information on treatment delivery procedures, see “Chapter 8: Treatment Delivery”.
NOTE: The InTempo prostate path set does not include image-
blocked nodes.
13-6 | InTempo in the Treatment Delivery Phase 1075883-ENG A

Starting Treatment
If the Start button of the Delivery phase (left screen) is enabled, the CyberKnife System is ready
to start treatment. Follow the treatment instructions for the type of treatment being delivered.
During treatment using the Synchrony Fiducial Tracking with InTempo Imaging, the treatment
robot moves from node to node in the treatment path. At each node where one or more beams will
be delivered, the CyberKnife System does the following:
• Live X-ray images may be acquired and correlated with the previous X-ray image. In the
Images counter at the bottom of the Treatment Delivery screen, the number of images
acquired increases by 2 for each image pair acquired.
• Adjusts the pointing of the LINAC for the next beam, and corrects for target displacement
as described in “Chapter 8: Treatment Delivery”.
• When radiation is being generated, the BEAM ON status indicator is lit on the operator
control panel and the text BEAM is ON is displayed on both the left and right screens.
When no radiation is being generated, the indicator on the operator control panel is off
and the text BEAM is OFF is displayed on both the left and right screens.
• If the next treatment beam has been divided into segments, the first segment of the next
beam is delivered. As many segments as possible that fit within the current Max Image
Age setting are delivered. If all segments fit, all segments will be delivered.
• If the predicted image age of the current image at the end of the next beam delivery
exceeds the value of the Max Image Age parameter, a new image is taken before
delivery of the next beam begins.
• The Beam Delivery and Delivery Progress panels display information on the
radiation dose delivered for the current beam and fraction (see Figure 2).
The elapsed time that treatment has been in progress and the estimated total time for
delivery of the current fraction are updated prior to each beam delivery. For more
information on the Beam Delivery and Delivery Progress panels, see “Chapter 5:
• In the Images counter, the estimated total number of images (labeled Expected) may
change during treatment delivery, because the estimate depends on variable details of
beam delivery timing. At the beginning of a long treatment path, the estimated total time is
not as accurate as at the end of the path, so the estimated total number of images may
not be as accurate.
During treatment delivery, if adaptive imaging is enabled and target motion exceeds one or both of
the thresholds set in the InTempo Settings panel of the Readiness phase, the Max Image
Age (sec) panel below the leftmost Treatment Monitoring graph flashes:
• Flashing aqua: Indicates that the Max Image Age parameter has been set to its minimum
value.
• Flashing orange: Indicates that the Max Image Age parameter was already set at its
minimum value and an excursion has occurred.
1075883-ENG A InTempo in the Treatment Delivery Phase | 13-7


panels of the Beam Data window for Synchrony
Fiducial Tracking with InTempo Imaging treatment
Pausing Treatment
For information on pausing treatment, see “Chapter 8: Treatment Delivery”.
If a Soft Stop or E-Stop occurs, or if you click the Interlock button or the Pause button,
treatment is interrupted. For more information on interrupting treatment and error handling, see
InTempo Controls in Delivery Phase

When the Synchrony Fiducial Tracking with InTempo Imaging is specified in the treatment plan,
the leftmost Treatment Monitoring graph displays the Max Image Age (sec) panel, containing
the controls described below (see Figure 3).

Figure 3 Treatment Monitoring graph (below

Image B in Delivery phase) with Synchrony Fiducial
Tracking with InTempo Imaging
Adjusting the Maximum Image Age

The Max Image Age slider bar at the bottom of the Treatment Monitoring graph adjusts the
maximum allowable image age. If the predicted image age of the current image at the end of the
next beam delivery exceeds this value, a new X-ray image is taken before delivery of the next beam
begins. The current value is displayed in the textbox on the right of the slider bar.
You can change this value dynamically during beam delivery without pausing treatment. The
change is applied immediately (that is, the age of the current X-ray image is compared to the new
value). The range of allowed values is from 15 to 150 seconds (30 to 150 seconds for the
Synchrony Spine Tracking Supine).
As you change the value, the total estimated number of Expected images is updated in the
Images counter (see Figure 3), and the estimated total time for the current fraction to be
delivered is updated in the Delivery Progress panel of the Delivery phase (right screen) (see
Figure 2 on page 13-8).
 To adjust the Max Image Age parameter:
• Move the slider bar to change the value of the Max Image Age parameter. The current
value is displayed in the textbox on the right of the slider bar.
• Alternatively, enter a new value for the Max Image Age in the textbox on the right of the
slider bar. Then press the <Enter> key.
1075883-ENG A InTempo in the Treatment Delivery Phase | 13-9

Enabling and Disabling Adaptive Imaging

The Adapt checkbox at the bottom of the Treatment Monitoring window enables and disables
adaptive imaging. You can enable or disable adaptive imaging during beam delivery without
pausing treatment. The change is applied immediately.
When adaptive imaging is enabled and target motion exceeds a predefined threshold, the Max
Image Age (sec) panel displayed at the bottom of the Treatment Monitoring window flashes
aqua to indicate that the Max Image Age has been set to its minimum value. If the Max Image Age
parameter is already set at its minimum value, the Max Image Age (sec) panel flashes
orange.
 To enable or disable adaptive imaging:
• To enable adaptive imaging, select the Adapt checkbox. The Adapt option in the
InTempo Settings panel of the Readiness phase is simultaneously selected (see
“Selecting the InTempo Response” on page 13-6).
• To disable adaptive imaging, deselect the Adapt checkbox. The No Action option is
simultaneously selected in the InTempo Settings panel of the Readiness phase
(see “Selecting the InTempo Response” on page 13-6).

Chapter 14: Simulation
Application Overview (Option)
Introduction
The Simulation Application provides a workflow for determining which lung tracking mode(s) are
viable for a given patient prior to creating a deliverable treatment plan. This chapter gives an
overview of the Simulation Application user interface and describes the screen controls and image
displays in each simulation phase and can be used as a reference as you perform a simulation.
The chapter also describes the workflow of the Simulation Application. This chapter covers the
following topics:
• “Starting the Simulation Application” on page 14-2
• “Overview of Simulation Application Screen” on page 14-4
• “Automatic Mode User Interface” on page 14-10
• “Manual Mode User Interface” on page 14-53
• “Simulation Application Workflow” on page 14-69
This chapter assumes that the CyberKnife System is powered up and that you are logged into the
treatment delivery computer.
This chapter assumes you are familiar with “Chapter 8: Treatment Delivery”, which describes
procedures for patient alignment, X-ray image acquisition, and error handling.
This chapter also assumes the Synchrony Fiducial Tracking with Respiratory Modeling System is
enabled on your CyberKnife System. You should also be familiar with “Chapter 12: Synchrony
Respiratory Tracking System (Option)”.
This chapter assumes you are familiar with the following chapters and treatment delivery tracking
modes:
• “Chapter 10: Synchrony Spine Tracking (Option)” on page 10-1
• “Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)” on
page 11-1
• “Chapter 15: Lung Optimized Treatment (Option)” on page 15-1

Starting the Simulation Application

To start the Simulation Application, you must log into Simulation mode on the CyberKnife
System Menu.
NOTE: Equipment power must be turned on before you can log

into Simulation mode.
For instructions on logging into the CyberKnife System, see “Chapter 4: System Startup and
Shutdown”. You can add participants to your Simulation Application session, as described in
“Chapter 5: Treatment Delivery System Overview”.
When you click the Simulation button on the CyberKnife System Menu and log in, the
Overview phase (left screen) is displayed).
The Overview phase displays a list of patients with Simulation Plans and allows you to select a
patient for the simulation session. A list of Simulation Plans for the patient is then displayed.
Simulation Plans are not listed until DRR images have been generated on the iDMS Data
Management System.
NOTE: DRR generation will not begin until the Simulation Plan is
closed on the Accuray Precision System.
As you select the patient and Simulation Plan, additional information is displayed. A notification
message may be displayed which you must acknowledge before the simulation can proceed. Text
at the bottom left of the left screen reports status as data is retrieved from the database.
The Overview phase includes the controls listed in Table 1.
Table 1 Controls in the Overview phase
Button Function
Load After you have selected a patient and Simulation Plan and acknowledged
any notification messages, begins downloading patient and simulation data
from the iDMS Data Management System to the treatment delivery
computer.
Refresh Refreshes the Patient and Plan lists with the latest data from the iDMS
Data Management System. New patients and Simulation Plans are added to
the list only after DRR images have been generated on the iDMS Data
Management System. Click this button if a Simulation Plan has been
generated but is not yet displayed in the list.
14-2 | Starting the Simulation Application 1075883-ENG A

Treatment Delivery Manual Chapter 14: Simulation Application Overview (Option)
The Patient section of the Load Patient Data window displays the following information:
• Date of Birth: Date of birth of the patient.
• Gender: Gender of the patient.
The Plan section displays the following information:
• Name: Name of the Simulation Plan.
• Anatomy: Anatomy to be treated.
• Orientation: Patient position as specified in the Simulation Plan.
• Fractions: Selected fraction number to be delivered.
• Message panel: Notification message that is displayed if an OIS is licensed and there
is an inconsistency between OIS information and the iDMS Data Management System.
1075883-ENG A Starting the Simulation Application | 14-3

Overview of Simulation Application Screen

The right screen of the Simulation Application includes the following main components, labeled in
Figure 1 and described further below:
• (1) “Treatment Data Display” on page 14-6
• (2) “Simulation Phase Selection Tabs” on page 14-6
• (3) “Simulation Phase Images and Data” on page 14-7
• (4) “Mode Selection Buttons (Automatic or Manual)” on page 14-7
• (5) “CyberKnife System Device Status Icons” on page 14-8
• (6) “Error Information, E-Stop Status, and Pause Controls” on page 14-9
2 4
Figure 1 Main components of the left screen of the

Simulation Application
The right screen of the Simulation Application displays controls for using the Synchrony tracking
System to build and monitor a Respiratory correlation model. For more information about the
14-4 | Overview of Simulation Application Screen 1075883-ENG A

Figure 2 Respiratory System controls on the right

screen of the Simulation Application
1075883-ENG A Overview of Simulation Application Screen | 14-5

Treatment Data Display

Figure 3 shows the treatment data display at the top of the Simulation Application screen.
Figure 3 Treatment data display
The treatment data display shows general patient and Simulation Plan information, including the
following:
• First Name: First name and middle name of the patient.
• Plan: Name of the Simulation Plan.
• Session Images: Number of images acquired during the current session.
• Plan Images: Total number of images for the plan.
• Estimated Imaging Dose: Displays the estimated imaging dose for the plan and for
the current session in cGy or Gy depending on the iDMS System setting.
• Time: Current date and time as set on the treatment delivery computer.
Simulation Phase Selection Tabs

Figure 4 shows the simulation phase selection tabs which allow you to switch between simulation
phases in the workflow.
Figure 4 Simulation phase selection tabs
Tabs are enabled depending on which phases of the workflow are currently available. The currently
selected phase is highlighted in yellow. The selected tab displays an in-progress indicator when
automatic operations are in progress, for example (see Figure 5):
• Live X-ray image acquisition
• image correlation
• treatment couch movement using the Move Couch button
• treatment couch movement using the Auto Align button

Figure 5 In-progress indicator
In general, when the in-progress indicator is displayed, controls on the screen are disabled except
for the Interlock button.
Simulation Phase Images and Data

Images, data, and screen controls displayed in the central and lower portion of the screen change
depending on the simulation phase, as described later in this chapter.
NOTE: In general, when buttons are selected in the Simulation

Application, they are outlined in green. When they are
deselected, they do not have a green outline. For example, see
Figure 6, which shows the button for Automatic mode selected
and outlined in green.
Mode Selection Buttons (Automatic or Manual)

Figure 6 shows the mode selection buttons that allow you to switch between Automatic mode and
Manual mode, as described in Table 2. The selected button is outlined in green.
Figure 6 Mode selection buttons for Automatic or

Manual mode
You can switch between Automatic and Manual mode. If you have an incomplete simulation
dataset and switch modes, a dialog box is displayed asking you to confirm whether you want to
discard the incomplete dataset. If you click the OK button, the dataset will be discarded. If you have
complete simulation dataset and you switch modes, the dataset will not be discarded. However,
you will no longer be able to review the dataset in the acquired dataset panel in the Offset phase
or Confirmation phase of Automatic mode.
For more information on controls in Automatic mode and Manual mode, see “Automatic Mode User
Interface” on page 14-10 and “Manual Mode User Interface” on page 14-53. For information on the
workflow in these modes, see “Simulation Application Workflow” on page 14-69.

Table 2 Mode selection buttons
Automatic Switches to Automatic mode.

Mode
Manual Mode Switches to Manual mode.
CyberKnife System Device Status Icons

Figure 8 shows the CyberKnife System device status icons at the bottom of the Simulation
Application (left screen).
Figure 7 CyberKnife VSI System device status icons
These icons are displayed on every screen in the Treatment Delivery System, including the
Simulation Application. For information, see “Chapter 5: Treatment Delivery System Overview”.

Error Information, E-Stop Status, and Pause

Controls
Figure 8 shows the Toggle Error Information, E-Stop Status, and Pause controls at the
bottom of the right screen of the Simulation Application screen.
Figure 8 Error information, E-Stop status, and

Pause controls
These controls are displayed on every screen in the Treatment Delivery System, including the
Simulation Application. For information, see “Chapter 5: Treatment Delivery System Overview”.

Automatic Mode User Interface

This section describes the controls and displays in Automatic Mode. It covers the following topics:
• “Spine Phase” on page 14-10
• “Lung Phase” on page 14-24
• “X-ray Phase” on page 14-31
• “Offset Phase” on page 14-34
• “Confirmation Phase” on page 14-43
• “Review Phase” on page 14-48
Spine Phase
This section describes the controls and displays in the Spine phase. It covers the following topics:
• “Image Panels in the Spine Phase” on page 14-11
• “Skip Spine Checkbox” on page 14-16
• “dxAB, drAB, and False Nodes Slider Bars” on page 14-16
• “Image Correlation Parameters Panel” on page 14-17
• “X-ray Parameters Panel” on page 14-19
• “Algorithm Errors Panel” on page 14-20
• “Patient Position Display” on page 14-21
• “Patient Positioning Controls” on page 14-22
For a description of the workflow in the Spine phase using these controls, see “Simulation
Application Workflow” on page 14-69.
14-10 | Automatic Mode User Interface 1075883-ENG A

Image Panels in the Spine Phase

Figure 9 shows an example of the image panels displayed in the Spine phase.
Figure 9 Image panel in Spine phase
The top row corresponds to Camera A of the X-ray imaging system. The bottom row corresponds
to Camera B. The first image in each row is the DRR image. The center image is the most recently
acquired Live X-ray image. The last image in each row is an overlay of the DRR image and the
Live X-ray image. The green human body icon in each image shows the patient orientation relative
to the X-ray source.
Each image panel includes controls which allow you to change the image display, as well as
perform other functions, described below. Some controls are hidden in a row at the bottom of each
image panel (see Figure 10). These controls are described in Table 3.
Figure 10 Controls visible in the Spine phase when the cur-

sor is dragged along the bottom of an image panel
 To view and select the hidden controls:

1. Drag the cursor along the bottom edge of an image panel. The controls fade in and out as
the cursor hovers over the bottom of the image panel.
2. Click an icon to select that control. The color of the icon changes from green to white
when it is selected.
1075883-ENG A Automatic Mode User Interface | 14-11

Table 3 describes the image panel controls available in the Spine phase.
Table 3 Image panel controls in the Spine phase
Control Icon Description
DRR Display Full Content DRR: Displays the unsegmented (full

Modes content) DRR images. For more information on this display
mode, see “Chapter 10: Synchrony Spine Tracking
(Option)”.
Segmented DRR: Displays the segmented DRR images,

in which all image content except the spine is removed
from the DRR images. For more information on this display
(Option)”.
View Full Screen Displays a full screen view of the image. The image is
automatically zoomed to fill the width of the screen. All
cursor modes, including couch cursor mode, are available
in full screen view.
Returns to the default view of image panels. Alternatively,

click the button at the bottom left of the full screen
view.
Live X-ray Image Display Skeletal Mesh: Toggles on or off the display of
Display Modes the skeletal mesh and ROI. For more information on this
display mode, see “Chapter 10: Synchrony Spine Tracking
(Option)”.
Display Align Center: Toggles on or off the display of

markers in the DRR images and Live X-ray images that
correspond to the imaging center selected during
treatment planning. For more information on this display
(Option)”.
View Crosshairs Displays a pair of crosshairs in the image. For information,

see “View Crosshairs” on page 14-13.

Table 3 Image panel controls in the Spine phase
Cursor Modes Window and Level: Allows you to adjust the contrast and
brightness of the image. For information, see “Window and
Level Controls” on page 14-14.
Couch: Allows you to adjust the position of the Live X-ray

image relative to the DRR image by clicking and dragging
in either the Live or Overlay image panel. For
information, see “Couch Cursor Mode” on page 14-15.
Zoom and Pan: Allows you to zoom in and out and pan
the image. For information, see “Zoom and Pan Controls”
on page 14-15.
Pointer: The default cursor mode. In this mode, clicking in

an image displays the following information at the bottom
left corner of the image:
• The (x, y) coordinate of the location clicked, where
(0, 0) is the location of the pixel at the bottom left of the
512 x 512 image data.
• The pixel intensity of the location clicked, as a
percentage of the maximum pixel intensity.
View Crosshairs
Displays a pair of crosshairs in the image to aid in the alignment of DRR and Live X-ray images.
The vertical crosshair is green, and the horizontal crosshair is red.
 To move the crosshairs:
• Click and drag the intersection of the crosshairs to move both crosshairs together.
• Click and drag either the vertical or horizontal crosshair to movie it independently.
Clicking anywhere else in the image produces the behavior of the currently selected cursor mode
(see Table 3).

Window and Level Controls

The window and level controls allow you to adjust the window (contrast) and level (brightness) of
the image. The controls affect the image display only. They do not affect the X-ray image data used
by the tracking algorithm. These controls can help you visually identify anatomical or other features
in the Live X-ray images.
In this cursor mode, a histogram representing the distribution of pixel intensities in the image is
displayed at the bottom of the image (see Figure 11).
Figure 11 Window and level controls showing (top) default

histogram and (bottom) histogram with adjusted window
and level
 To adjust the window (contrast) of the image:

• Click in an image and drag the cursor up and down.
• Alternatively, in the histogram, click and drag the left and right edges of the histogram to
move them towards the center (as shown in Figure 11, bottom). Dragging the left and
right edges of the blue rectangle adjusts both the window and level settings of the image,
thus changing the displayed range of pixel intensities.
 To adjust the level (brightness) of the image:
• Click in an image and drag the cursor left and right.
• Alternatively, inside the histogram, click and drag only the center vertical blue line to the
left and right to adjust the level setting. The window setting remains constant.
 To reset the window and level settings to their defaults:
• Click the icon.
 To invert the image contrast:
• Click the icon to invert the contrast of the image. Inverting the contrast of an image
may make it easier to visually identify anatomical and other features.

 To apply window and level settings to all images in a row:

• Click the icon to apply window and level changes to all images in a row (that is, to all
images corresponding to either Camera A or Camera B of the X-ray imaging system).
• Click the icon to unlock window and level settings so that they do not apply to all
images in a row.
• To set an image back to its default settings, click the icon. If window and level settings
have been locked for all images in a row, clicking this icon applies to all the images.
Couch Cursor Mode

Couch cursor mode allows you to adjust the position of the Live X-ray image relative to the DRR
image by clicking and dragging in either the Live or Overlay image panel. These adjustments
are done separately for Image A and Image B.
As the relative position of the images is adjusted, the target position of the treatment couch in the
textboxes in the patient positioning controls is automatically updated. You can move the treatment
couch to the new target position, as described in “Patient Positioning Controls” on page 14-22.
You can use couch mode to align the Live X-ray images and DRR images so that anatomical or
other features match in the Overlay images. The textboxes in the patient positioning controls
then indicate the target position of the treatment couch at which the currently shown overlay of Live
X-ray images and DRR images would be achieved.
For more information on patient alignment procedures, see “Chapter 8: Treatment Delivery”.
Zoom and Pan Controls

The zoom and pan controls allow you to zoom in and out in the image and pan the image (see
Figure 12).
Figure 12 Zoom and pan controls
 To pan the image:

• Click and drag in the image.
 To zoom in and out:
• Drag the zoom slider bar or click the icon or the icon.
• To reset the zoom, click the icon.

Skip Spine Checkbox

The Skip Spine checkbox below the patient positioning controls allows you to skip the Spine
phase (see Figure 13). Clicking this button enables the Lung phase without requiring spine
alignment. When this checkbox is selected, all controls in the Spine phase except for the
Interlock button are disabled. This checkbox is deselected (cleared) by default.
When the Spine phase is skipped, Spine Supine and 1-View are not available as recommended
tracking modes in the Review phase. For more information on the effects of skipping spine
alignment, see “Simulation Application Workflow” on page 14-69.
Controls for moving the treatment couch in the Lung phase are also modified. For information,
see “Lung Phase” on page 14-24.
Figure 13 Skip Spine checkbox
dxAB, drAB, and False Nodes Slider Bars

The dxAB (mm), drAB (deg), and False Nodes (%) slider bars allow you to monitor the
calculated value of these parameters and change the value of their thresholds (see Figure 14). The
values are updated each time an image is acquired and image correlation is performed. When the
calculated value exceeds the threshold, an image algorithm error occurs and the Algorithm
Errors panel is displayed. For more information, see “Algorithm Errors Panel” on page 14-20.
Figure 14 dxAB, drAB, and False Nodes slider bars

For information on the effect of adjusting these parameters during spine alignment, see “Chapter
10: Synchrony Spine Tracking (Option)”.
The slider bars include the following displays and controls:
• The current value of each parameter (the error value determined by the imaging
algorithm) is displayed under the left end of each slider bar. The border between the red
and green portions of the slider bar also indicates the current value. The more red, the
higher the error value.
threshold trigger an imaging algorithm error. Drag the cursor to change the threshold.
You can also enter a threshold directly in the textbox under the right end of each slider
bar.
• Dragging the threshold cursor across the red/green border of the slider bar and back
automatically displays and hides the Algorithm Errors panel.
• The default value of the threshold is indicated by a dashed line on the slider bar.
 To change the value of an error threshold:
You can change the value of a threshold during spine alignment in response to errors that occur
after image correlation is performed.
1. Click and drag the threshold cursor to adjust the threshold value. Alternatively, enter a
new value in the textbox under the right end of the slider bar and press <Enter>.
Image Correlation Parameters Panel

The following image correlation parameters are input to the tracking algorithm and change image
correlation results:
• Tracking Range (mm)
• ROI Width (mm)
• Contrast
Changing any of these parameters automatically triggers a new image correlation, as described
below. Figure 15 shows controls for adjusting these parameters.
Figure 15 Image correlation parameters in the Spine phase

When you change one of the above parameters, all controls in the Spine phase except the
Interlock button and the other image correlation parameters are disabled. Image correlation
results will be displayed after a time delay. Continued changes to parameters may increase the
delay. Once the correlation results are displayed, all Spine phase controls will be re-enabled.
For more information on the effect of changing these parameters, see “Chapter 10: Synchrony
Tracking Range Slider Bar

The Tracking Range (mm) slider bar includes the following controls:
• The current value (in millimeters) is displayed in the textbox under the slider bar.
• The default value is indicated by a dashed line on the slider bar.
 To change the Tracking Range parameter value:
For more information on the Tracking Range parameter, see “Chapter 10: Synchrony Spine
Tracking (Option)”.
ROI Width Slider Bar

The ROI Width (mm) slider bar includes the following controls:
• The current value is displayed under the right end of the slider bar.
• When the From Planning checkbox is selected, the default value of the ROI Width
parameter specified in the Simulation Plan is used.
 To change the ROI Width parameter from the default value:
1. Clear (deselect) the From Planning checkbox.
The textbox under the slider bar is enabled.
3. When the ROI Width value is changed, a blue box representing the ROI in the DRR
image dynamically changes size without producing another image correlation.
 To return to the default ROI Width value specified in the Simulation Plan:
1. Select the From Planning checkbox. The ROI Width value from the Simulation Plan
is displayed and the textbox is disabled.
For more information on the ROI Width parameter, see “Chapter 10: Synchrony Spine Tracking
(Option)”.

Contrast Textboxes
The Contrast A and Contrast B parameters correspond to Camera A and Camera B of the
imaging system. The range of parameter values is from 1 to 10.
When the Automatic checkbox is selected, Contrast values are determined automatically by
the Target Locating System (TLS). Pixel intensities in the Live X-ray images are adjusted
automatically to match the intensities in the DRR images. This checkbox is selected by default.
You can manually specify values. The manually specified contrast values will be applied the next
time image correlation is performed.
NOTE: Changing the values of the Contrast parameters has an

effect on tracking. Proceed with caution when adjusting these
parameters.
 To change the values of the Contrast parameters:

1. Clear (deselect) the Automatic checkbox.
The A and B textboxes are enabled. Their values are initially set to the most recent
values (as calculated when Automatic was in use).
2. Enter values or use the initial values.
When the next image correlation is performed, the displayed values will be used.
 To return to automatic setting of the Contrast parameters:
1. Select the Automatic checkbox.
The A and B textboxes are disabled.
2. When the next image correlation is performed, the values will be adjusted automatically.
For more information on the Contrast A and Contrast B parameters, see “Chapter 10:
X-ray Parameters Panel

The Spine A and Spine B dropdown lists allow you to modify X-ray parameters for X-ray
source A and X-ray source B in the Spine phase (see Figure 16).
Figure 16 X-ray parameters panel in the Spine phase

Dropdown lists allow you to adjust the following X-ray parameters:

• kV: Voltage (in kilovolts).
• mA: Current (in milliamps).
• ms: Exposure time (in milliseconds).
You can specify one parameter at a time. Values in each dropdown list are preset depending on
your selections in the other dropdown lists.
NOTE: In the Spine phase, images are acquired serially from

Camera A and Camera B of the X-ray imaging system. For more
information on acquiring Live X-ray images in the Spine phase,
see “Patient Position Display” on page 14-21.
The final set of X-ray parameters you select in the Spine phase will become part of the simulation
dataset sent to the iDMS Data Management System at the end of the simulation session. If the
results of this dataset are selected during the Review phase, these X-ray parameters will be used
as the default parameters for spine alignment during treatment delivery.
Algorithm Errors Panel

The Algorithm Errors panel lists any image algorithm errors and provides information to help
resolve them (see Figure 17). This panel is displayed automatically when an image correlation fails
due to an algorithm error. When multiple errors are listed, click the Next button to view the next
imaging algorithm error, or click the Previous button to view a previous error in the list.
Figure 17 Algorithm Errors panel
Toggle buttons allow you to switch between the Overlay images and the Algorithm Errors
panel, as described in Table 4.

Table 4 Toggle buttons in the Spine phase
Image Panel Displays the Overlay images, which are

overlays of the DRR images and current Live X-
ray images corresponding to Camera A and
Camera B of the X-ray imaging system.
Algorithm Displays the Algorithm Errors panel, which

Panel displays any current image algorithm errors.
Patient Position Display

Figure 18 shows the patient position display in the Spine phase. The display includes a diagram
showing the translational and rotational offsets between the DRR and Live X-ray images calculated
Figure 18 Patient position display in the Spine

phase
The 3 values on the left are the translational offsets (in millimeters) in the Inferior(+)/Superior(-),
Left(+)/Right(-), and Anterior(+)/Posterior(-) directions, as indicated by the arrows. The 3 values on
the right are the rotational offsets (in degrees) for Left(+)/Right(-) roll, Head-up(+)/Head-down(-)
pitch, and Counterclockwise(+)/Clockwise(-) yaw, as indicated by the arrows. The arrows point in
the positive direction and do not change. An orange box around values indicates the values are
out of bounds and the patient must be repositioned.
NOTE: The above anatomical coordinate system is based on a

Head First Supine (HFS) patient position.

The values in the patient position display are updated after each Live X-ray image is acquired.
Images are acquired using the Acquire button, as described in Table 5.
Table 5 Buttons in the patient position display
Acquire Acquires a pair of Live X-ray images. In the Spine phase

image correlation is performed automatically to determine
patient translational and rotational offsets.
In the Spine phase, images are acquired serially from
Camera A and Camera B of the X-ray imaging system. For
more information, see “X-ray Parameters Panel” on
page 14-19.
Patient Positioning Controls

Figure 19 shows the automatic patient positioning controls in the Spine phase.
Figure 19 Patient positioning controls in the Spine phase
The controls include a diagram showing the current absolute rotational position of the treatment
couch above a row of textboxes. The 3 non-editable values give rotations (in degrees) for Left(+)/
Right(-) roll, Head-up(+)/Head-down(-) pitch, and Counterclockwise(+)/Clockwise(-) yaw, as
indicated by the arrows. The arrows point in the positive direction and do not change.
NOTE: For the standard treatment couch, the yaw rotation is

locked and cannot be unlocked.
The textboxes underneath the diagram indicate desired motion of the treatment couch relative to
the current couch position. During the next automatic movement of the treatment couch using the
Move Couch button (see Table 6), the couch moves by this amount. As the treatment couch
moves, the values in the textboxes change and approach zero as the desired couch position is
achieved.
NOTE: Because the rotational axes of the standard treatment

couch are located far from the machine center, you may notice
that translational values in the textboxes increase temporarily
during movement to the desired couch position.

The desired motion can also be specified using couch cursor mode which automatically updates
the textboxes, as described in Table 3 on page 14-12.
Each time a successful image correlation is performed, the textboxes are automatically updated
with the position of the treatment couch at the time of image acquisition plus the calculated patient
offsets.
Each rotation axis can be independently "locked" during automatic movement to prevent it from
changing. To lock a rotation axis, click the icon next to a rotation axis. To unlock a rotation, click
the icon. The locks also apply to the Auto Align button (see Table 6).
Table 6 Patient positioning buttons
Couch Move Moves the treatment couch to the target position indicated
by the values entered in the textboxes in the patient
positioning controls.
Auto Align Initiates the following sequence of actions:

• A pair of Live X-ray images is acquired.
• Image correlation is performed to determine the
patient translational and rotational offsets. The
textboxes in the patient positioning controls are
updated to account for these offsets.
• The treatment couch moves to the updated target
position indicated in the textboxes.
This sequence continues until one of the following
conditions is met:
• The translational offsets are less than 2 mm and the
rotational offsets are less than 0.5°.
• A maximum of 6 image pairs (12 images) is acquired.

Lung Phase
This section describes the controls and displays in the Lung phase. It covers the following topics:
• “Image Panels in the Lung Phase” on page 14-24
• “Treatment Couch Position Display” on page 14-27
For a description of the workflow in the Lung phase using these controls, see “Simulation
Image Panels in the Lung Phase

Figure 20 shows an example of the image panels displayed in the Lung phase.
Figure 20 Image panel in Lung phase
Similar to the Spine phase, the top row corresponds to Camera A of the X-ray imaging system.
The bottom row corresponds to Camera B. The first image in each row is the DRR image. The
center image is the most recently acquired Live X-ray image. The last image in each row is an
overlay of the DRR image and the Live X-ray image. The green human body icon in each image
shows the patient orientation relative to the X-ray source.
image panel (see Figure 21).
Figure 21 Controls visible in the Lung phase when the cur-

sor is dragged along the bottom of an image panel

Controls are similar to those in the Spine phase (see Table 3 on page 14-12) except for the DRR
display modes in the top left corner, described in Table 7.
Table 7 DRR display modes in the Lung phase

mode, see “Chapter 11: Synchrony Lung Tracking with
Respiratory Modeling (Options)”.
Segmented DRR: Displays the segmented DRR images.

This option removes the spine and other bony structures
and displays the remaining DRR image content. For more
information on this display mode, see “Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling
(Options)”.
Tumor Region DRR: Displays the tumor region DRR

images. This option removes image content that is not in
the immediate region of the tumor. For more information on
this display mode, see “Chapter 11: Synchrony Lung
Tracking with Respiratory Modeling (Options)”.


The Lung A and Lung B dropdown lists allow you to modify X-ray parameters for X-ray source A
and X-ray source B in the Lung phase (see Figure 22).
Figure 22 X-ray parameters panel in the Lung phase

NOTE: In the Lung phase, images are acquired synchronously

from Camera A and Camera B of the X-ray imaging system.

Treatment Couch Position Display

Table 8 shows the treatment couch position display in the Lung phase. The display includes a
position indicator which shows the treatment couch at one of 4 positions:
• At the spine position: The spine alignment center specified in the Simulation Plan
including the final patient position offsets determined during the Spine phase.
NOTE: If spine alignment is not performed in the Spine phase

(that is, the Skip Spine checkbox was selected), the spine
position is the treatment couch position at the end of the Spine
phase.
• At the lung position: The treatment position specified in the Simulation Plan. The position
is determined by combining the spine position with the alignment-to-treatment offset
provided by the Simulation Plan.
• Between the spine position and the lung position. This position is indicated when the
treatment couch is moving between or paused between these two positions.

not represent actual targeting of the lung tumor. The treatment
couch icon in the display does not "slide" between couch
positions.


In this state, the Go to Spine
button is enabled.

In this state, the Go to Lung
button is enabled.

the lung position.
In this state, both the Go to
Spine and Go to Lung buttons
are enabled.

moving between the spine and
lung positions.
During movement, all controls are
disabled except the Interlock
button.
Treatment couch is paused

positions, for example, if the
Interlock button is clicked during
movement.
In this state, both the Go to
Spine and Go to Lung buttons
are enabled.

Table 9 describes the buttons associated with the treatment couch position display.
Move to Lung Moves the treatment couch to the lung position (treatment
position).
Move to Moves the treatment couch to the spine position

Spine (alignment center).
Move Couch Moves the treatment couch to the target position indicated
This button is enabled when the treatment couch is at or
near the lung position and when the target couch position
in the textboxes does not match the current position. For
information, see “Patient Positioning Controls” on
page 14-30.
Acquire Acquires a pair of Live X-ray images. In the Lung phase,

images are acquired synchronously from Camera A and
Camera B of the X-ray imaging system. Image correlation
is not performed in the Lung phase.
For more information, see “X-ray Parameters Panel” on
page 14-26.


Figure 23 shows the automatic patient positioning controls in the Lung phase. These controls are
similar to those in the Spine phase (see “Patient Positioning Controls” on page 14-22) except that
in the Lung phase, rotations determined during spine alignment are locked. The patient
positioning controls in the Lung phase can be used to perform minor translational adjustments of
the patient position.
Figure 23 Patient positioning controls in the Lung phase
The row of textboxes underneath the diagram allows you to enter a target position for the next
automatic movement of the treatment couch using the Move Couch button described in Table 9.
The target location can also be specified using couch cursor mode which automatically updates
the textboxes, as described in Table 3 on page 14-12.

X-ray Phase
This section describes the controls and displays in the X-ray phase. It covers the following topics:
• “Image Panels in the X-ray Phase” on page 14-31
• “Image Acquisition Controls” on page 14-33
For a description of the workflow in the X-ray phase using these controls, see “Simulation
Image Panels in the X-ray Phase

Figure 24 shows an example of the image panels displayed in the Lung phase.
Figure 24 Image panel in X-ray phase

to Camera B. The first image in each row is the raw (unprocessed) Live X-ray image. The raw
images have not been enhanced for contrast by the tracking algorithm. The center image is also
the Live X-ray image but it has been enhanced for contrast by the tracking algorithm. The last
image in each row is the DRR image.
NOTE: Though the tracking algorithm performs image

enhancement, image correlation is not performed in the X-ray
phase.
A histogram display under each raw image represents the distribution of pixel intensities and
provides an aid during refinement of the X-ray technique (see Figure 24). Increasing the X-ray
technique will generally push the histogram peak to the left. Decreasing the X-ray technique will
generally push the peak to the right. The ideal histogram distribution is spread out (indicating good
contrast) and shifted towards the right.
Each image panel includes controls which allow you to change the image display. Some controls
are hidden in a row at the bottom of each image panel (see Figure 25). A subset of the controls in
the Spine phase is available, described in Table 3 on page 14-12.
Figure 25 Controls visible when the cursor is dragged

along the bottom of an image panel in the X-ray phase

and X-ray source B in the Lung phase (see Figure 26).
NOTE: In the X-ray phase, images are acquired synchronously

from Camera A and Camera B of the X-ray imaging system.

Figure 26 X-ray parameters panel in the X-ray phase
Image Acquisition Controls

Table 10 describes the Acquire button in the X-ray Offset Phase
Table 10 Image acquisition controls in the X-ray phase
Acquire Acquires a pair of Live X-ray images. In the X-ray phase

image correlation is not performed.
In the X-ray phase, images are acquired synchronously
from Camera A and Camera B of the X-ray imaging
system.

Offset Phase
This section describes the controls and displays in the Offset phase. It covers the following topics:
• “Image Panels in the Offset Phase” on page 14-34
• “Dataset Acquisition Controls” on page 14-38
• “Offset Specification Controls” on page 14-40
• “Camera Visibility Controls” on page 14-42
For a description of the workflow in the Offset phase using these controls, see “Simulation
Image Panels in the Offset Phase

The image panels in the Offset phase includes the following main components, labeled in
Figure 27 and described further below:
• (1) “Acquired Dataset Panel” on page 14-35
• (2) “Offset Specification Panel” on page 14-36
• (3) “DRR Images Panel” on page 14-37
• (4) “User-Provided Offsets Panel” on page 14-37
4B
4A
Figure 27 Image panels in Offset phase

Acquired Dataset Panel

A simulation dataset consists of 8 to 12 pairs of Live X-ray images spread throughout the
respiratory cycle. The acquired dataset panel displays an automatically acquired dataset of up to
12 pairs of Live X-ray images in two columns on the left side of the screen. The first column
displays Image B and the second column displays Image A.
As each image pair is acquired, it is displayed in the panel. The panel is filled from top to bottom
in the order the image pairs are acquired.
NOTE: The order in which the image pairs is displayed does not
correspond to their location in the respiratory cycle.
One image at a time can be displayed in the large offset specification panel. The currently
displayed image is outlined in yellow (see Figure 28). You can also use the Up and Down arrow
keys on your keyboard and the scroll wheel on the mouse to scroll through the images and display
them one at a time in the offset specification panel. When you hold down the arrow keys or use the
scroll wheel, the rapid view of the image series may help to identify the tumor.
Figure 28 Acquired dataset panel in Offset phase
An image outlined in blue can be used for an offset specification. To use the image, click on it to
display it in the offset specification panel. An image that is not outlined in blue cannot be used, for
one of the following reasons:
• 2 images in that column have already been used for the offset specification.
• The image is too near the respiratory phase of another image that has already been used
for the offset specification.
For more information on specifying offsets in the Offset phase, see “Simulation Application
Workflow” on page 14-69.

Offset Specification Panel

The upper right corner of the offset specification panel displays the image number and the
respiratory phase during which it was acquired (see Figure 29).
Figure 29 Image number and respiratory phase
The panel also includes controls which allow you to change the image display, as well as perform
other functions, described below. Some controls are hidden in a row at the bottom of each image
panel (see Figure 30).

along the bottom of an image panel in the Offset phase
A subset of the controls in the Spine phase is available (described in Table 3 on page 14-12), as
well as an additional Live X-ray image display mode, described in Table 11
Table 11 Additional image panel controls in the Offset phase
Live X-ray Image (Bottom of image panel) Display Tumor Contour:

Display Modes Displays the tumor contour.
The offset specification panel also includes controls that allow you to specify the visually identified
tumor location. For more information, see “Offset Specification Controls” on page 14-40.

DRR Images Panel

The DRR image panel displays the DRR images for reference. You can click on a DRR image to
view it in the larger offset specification panel, where you can adjust the window and level controls,
if desired.
The DRR image panel also includes controls for selecting DRR display modes in the top left corner
of each image, described in Table 12.
Table 12 DRR display modes in the Offset phase


(Options)”.
Tumor Region DRR: Displays the tumor region DRR

images. This option removes image content that is not in
the immediate region of the tumor. For more information on
this display mode, see “Chapter 11: Synchrony Lung
User-Provided Offsets Panel

The user-provided offsets panel displays the images that have been used to specify offsets. You
can click on an image to view it in the larger offset specification panel. The selected image and the
corresponding image in the acquired dataset panel are both outlined in yellow.

Dataset Acquisition Controls

Table 9 describes the dataset acquisition controls in the Offset phase.
Table 13 Dataset acquisition controls in the Offset phase
Acquire Automatically acquires from 8 to 12 pairs of Live X-ray

Dataset images, as described in “Acquiring Images” on
page 14-39.
Discard Discards the current dataset and allows acquisition of a

Dataset new dataset. For more information, see “Discarding
Datasets” on page 14-39.
Figure 31 shows the respiratory waveform display. This display shows a waveform representing a
respiratory cycle. The waveform contains 8 positions representing the 8 phases of the respiratory
cycle. The position with the highest amplitude represents either full inspiration or full expiration, and
the position with the lowest amplitude represents the opposite. The waveform displays checkmarks
for phases in the respiratory cycle where images have been acquired.
Figure 31 Respiratory waveform display in the

Offset phase

Acquiring Images
When the Acquire Dataset button is clicked, the Synchrony tracking System is used to time
image acquisition so that the images are spread throughout the respiratory cycle. At least 8 image
pairs are acquired before a dataset is considered complete. Images are acquired repetitively until
7 of the 8 respiratory phases are covered, or until a maximum of 12 image pairs are acquired.
Respiratory phases are targeted as follows (see Figure 32): The first two image acquisitions target
the peak and valley of the respiratory waveform (full inspiration and expiration). Next, the midpoints
of inspiration and expiration are targeted. Lastly, the center positions of the respiratory waveform
are targeted.
Taken First
Taken Second
Taken Last
Figure 32 Respiratory phase targeting
As image pairs are acquired, they are displayed in the acquired dataset panel (see “Acquired
Dataset Panel” on page 14-35.
NOTE: The order of the images in the acquired dataset panel

does not correspond to their respiratory phase. For example,
images next to each other in the panel do not necessarily
represent adjacent respiratory phases.
If dataset acquisition is interrupted by an E-Stop, then after the E-Stop is reset, you can click the
Acquire button to continue adding images to the dataset, as long as less than 7 minutes has
elapsed since the first image was acquired.
Discarding Datasets
The following actions will discard acquired datasets in the Offset phase, after a confirmation
dialog box is displayed asking you to confirm that you want to discard the dataset:
• Switching back to a previous phase and changing the X-ray technique.
• Switching back to a previous phase and changing the treatment couch position.
• Allowing too much time to pass while the system is paused (for example, due to errors),
before a dataset is complete.
Datasets that are discarded are not available for later review. Datasets must be completed in the
Confirmation phase in order to be available for review. For information, see “Confirmation
Phase” on page 14-43.

Offset Specification Controls

Offsets can be specified as soon as the first pair of images has been acquired. When an image is
displayed in the offset specification panel, you drag the outline of the tumor over the location of the
tumor that you visually identify in the image. The steps are as follows:
1. Click an image in the acquired dataset panel to display it in the offset specification panel.
A light blue tumor outline is displayed in the image.
2. Move the cursor over the tumor outline.
When the cursor hovers over the outline, the outline color changes to red, indicating that
you can drag the outline.
3. Click and drag the outline over the tumor. Then release the mouse button.
The outline color changes back to light blue.
4. Click the Confirm Selection button to confirm the offset you specified (see Table 14).
The outline color changes to orange. The image fills one of the user-provided offset
panels. The corresponding image in the acquired datasets panel is also labeled to
indicate which offset image it corresponds to (A1, A2, B1, or B2).
Examples showing light blue and orange tumor outlines are shown in Figure 33.
Figure 33 Examples of the tumor outline before desired

placement (light blue, left) and after the specified offset is
confirmed (orange, right)

Table 14 describes the buttons used to confirm or remove a user-provided offset in the offset
specification panel.
Table 14 Offset specification controls
Confirm Confirms the currently specified offset, determined by

Selection dragging the tumor outline over the location of the tumor in
the image. This button is only available when the following
conditions are met:
• When fewer than 2 images for Camera A and 2 images
for Camera B have been selected for user-provided
offsets.
• When the respiratory phase of the currently displayed
image is sufficiently far from the respiratory phase of
the previously selected image (see Figure 34).
Deselect Removes the currently specified offset. This button is

available only after the offset of the currently displayed
image has been confirmed. When the offset is removed,
the image is removed from the user-provided offsets panel.
Offsets can only be specified for images that have at least one respiratory phase position vertically
between them in the respiratory waveform, as shown in Figure 34.
Good Not Allowed
Okay Not Allowed
Figure 34 Allowed respiratory phase positions for

offsets

Camera Visibility Controls

The camera visibility controls allow you to confirm whether the tumor is visible enough in a
particular camera of the X-ray imaging system to allow offsets to be specified, prior to switching to
the Confirmation phase of the simulation workflow. Table 15 describes the buttons for
confirming visibility or non-visibility of the image views from Camera A and Camera B.
Table 15 Camera visibility controls
Tumor A When selected, confirms that the tumor is visible

Visible Camera A of the X-ray imaging system. This button is
selected (outlined in green) by default.
When deselected (no green outline), you can no longer
specify offsets for images from that camera. Offsets
already provided are not discarded but are ignored in later
workflow phases.
Tumor B When selected, confirms that the tumor is visible

Visible Camera B of the X-ray imaging system. This button is
selected (outlined in green) by default.
When deselected (no green outline), you can no longer
specify offsets for images from that camera. Offsets
already provided are not discarded but are ignored in later
workflow phases.
 To specify that the tumor is not visible in one or both cameras:

• Click the A Visible and/or the B Visible button to deselect it.
The green outline disappears, indicating that the button is no longer selected.
When a camera is deselected as described above, the Simulation Application is prevented from
specifying 1-View tracking for that camera as a result. When both cameras are deselected, neither
Lung 1-View with Respiratory nor Lung with Respiratory tracking will be possible results.

Confirmation Phase
This section describes the controls and displays in the Confirmation phase. It covers the
following topics:
• “Image Panels in the Confirmation Phase” on page 14-43
• “Controls for Confirming Correlation Results” on page 14-47
• “Uncertainty and dxAB Bar Graphs” on page 14-48
For a description of the workflow in the Confirmation phase using these controls, see
“Simulation Application Workflow” on page 14-69.
Image Panels in the Confirmation Phase

The image panels in the Confirmation phase include the following main components, labeled
in Figure 35 and described further below:
• (1) “Acquired Dataset Panel” on page 14-44
• (2) “Image A and Image B Panels” on page 14-45
2A 2B
Figure 35 Image panels in Confirmation phase

Acquired Dataset Panel

The acquired dataset panel in the Confirmation phase displays the same dataset of up to 12
X-ray image pairs that was acquired in the Offset phase (see “Offset Phase” on page 14-34). The
image pairs are displayed in the same order as in the Offset phase. The first column displays
Image B and the second column displays Image A.
No new images are taken in the Confirmation phase. Instead, image correlation is performed
automatically for each image pair. Icons are superimposed over each image that indicate
correlation results (see Figure 35). The icons are described in Table 16.
Table 16 Icons indicating correlation results
Icon Description
Image correlation was performed without image algorithm

errors. The Simulation Application is now waiting for the
user to visually evaluate the result and provide feedback
on whether the correlation was successful.
Image correlation failed due to the calculated Uncertainly

value being above the threshold value.
This icon is also displayed for an entire column (Image B or
Image A) if the tumor was specified as not visible in the
corresponding camera in the Offset phase (see “Camera
Visibility Controls” on page 14-42).
The user has confirmed that the results of the image

correlation are successful by clicking the Correlation
Good button (see “Controls for Confirming Correlation
Results” on page 14-47).
The user has indicated that the results of the image

correlation are unsuccessful (a false positive result by the
lung tracking algorithm) by clicking the Correlation Not
Good button (see “Controls for Confirming Correlation
Results” on page 14-47).
The user cannot see the tumor to confirm whether the

correlation was successful or unsuccessful. This has been
indicated by clicking the Correlation Uncertain button
(see “Controls for Confirming Correlation Results” on
page 14-47).

Image pairs are displayed as their correlations are completed. The lung tracking algorithm
automatically selects the 2 image pairs to be correlated first and they may not be the first 2 image
pairs. As a result, the first 2 image pairs to be displayed may appear in lower positions in the
acquired dataset panel.
If the tumor is specified as not visible in both the Camera A and Camera B views in the Offset
phase (that is, the Tumor A Visible and Tumor B Visible buttons are deselected), all
images in the acquired dataset panel have the icon superimposed on them.
If the tumor is specified as visible in one of the camera views in the Offset phase, images in that
view in the acquired dataset panel have the icon superimposed on them in the Confirmation
phase. As the image correlations are performed, it may take time for the images to populate the
panel. The Confirmation tab displays an in-progress indicator as the correlations are
performed.
One image pair at a time can be displayed in the image A and image B panels (see “Image A and
Image B Panels” on page 14-45). The currently displayed images are outlined in yellow. You can
also use the Up and Down arrow keys on your keyboard and the scroll wheel on the mouse to scroll
through the image pairs and display them one at a time in the image panels.
Image A and Image B Panels

The upper right corner of each image panel displays the image number and the respiratory phase
during which it was acquired (see Figure 36).
Figure 36 Respiratory phase
Each panel also includes controls which allow you to change the image display, as well as perform
other functions, described below. Some controls are hidden in a row at the bottom of each image
panel (see Figure 37).

along the bottom of an image panel in the Confirmation
phase

A subset of the controls in the Spine phase is available (described in Table 3 on page 14-12), as
well as an additional Live X-ray image display mode, described in Table 17
Table 17 Additional image panel controls in the Confirmation phase

Table 18 describes the buttons that switch between Image A and Image B viewing options.
Table 18 Image A and Image B viewing options
Image A|B Displays Image B in the left panel and Image A in the right
Panel panel.
This is the default view when both image views are
confirmed to be trackable in the Offset phase (that is,
when the tumor is confirmed to be visible in both Camera A
and Camera B of the X-ray imaging system).
Image A Displays the DRR image corresponding to Image A in the

Panel left panel and Image A in the right panel.
This is the default view when only the Image A view is
when the tumor is confirmed to be visible in only Camera A
Image B Displays the DRR image corresponding to Image B in the

Panel left panel and Image B in the right panel.
This is the default view when only the Image B view is
when the tumor is confirmed to be visible in only Camera B

When a DRR image is displayed in the left image panel, controls for confirming correlation results
are not displayed beneath it (see “Controls for Confirming Correlation Results” on page 14-47).
You can switch between the same DRR display modes as in Offset mode (see Table 12 on
page 14-37).
One purpose of the lung tracking algorithm in the Confirmation phase is to determine
appropriate settings (enabled or disabled) for the Preferred Projection algorithm parameter. The
user has no input in this determination. If this parameter is enabled, it is enabled for the entire
dataset.
For more information on these parameters, see “Review Phase” on page 14-48 and “Chapter 11:
Synchrony Lung Tracking with Respiratory Modeling (Options)”.
Controls for Confirming Correlation Results

Table 19 describes the buttons that allow you to provide feedback based on your visual evaluation
of the correlation results in the Confirmation phase. There is a separate set of buttons for
Image A and Image B. After you click a button to provide feedback, you can still change your
feedback by clicking a different button. When a button is clicked, the icon in the acquired dataset
panel changes to one of the other icons displayed in Table 16 on page 14-44.
Table 19 Controls for confirming correlation results
Correlation A Confirms that the results of the image correlation are

Good and successful.
Correlation B
Good
Correlation A Indicates that the results of the image correlation are

Not Good and unsuccessful (the image correlation has resulted in a false
Correlation B positive result).
Not Good
Correlation A Indicates that you cannot see the tumor to confirm whether
Uncertain and the correlation was successful or unsuccessful.
Correlation B
Uncertain

Uncertainty and dxAB Bar Graphs

The Uncertainty A (%), dxAB (mm), and Uncertainty B (%) bar graphs allow you to
monitor the calculated value of these parameters relative to their threshold values for the correlated
images (see Figure 38). The thresholds are set to their default values and cannot be changed.
Figure 38 Image algorithm results for Uncertainty A, dxAB,

and Uncertainty B
The bar graphs include the following displays:

• The current value of each parameter is displayed under the left end of each bar graph.
The border between the red and green portions of the slider bar also indicates the current
value.
• The value of the threshold is indicated by a dashed line on the bar graph.
Review Phase
Figure 39 shows the main panel of the Review phase in Automatic mode. For a description of the
workflow in the Review phase, see “Simulation Application Workflow” on page 14-69
Figure 39 Main panel of Review phase in Automatic mode

The top portion of the panel displays a table listing results for each simulation dataset in the current
simulation session as well as datasets from previous login sessions. Each dataset corresponds to
one row of the table. If at least one dataset from a previous session exists, you can go straight to
the Review phase after logging into the Simulation Application. Datasets acquired in Automatic
mode are added to the table when the user has provided feedback for every image correlation in
the Confirmation phase (see “Confirmation Phase” on page 14-43). Columns in the table are
described in Table 20.
NOTE: The term "2-View" used in the main panel of the Review
phase is equivalent to Synchrony Lung Tracking with Respiratory
Modeling (Lung with Respiratory).
Table 20 Table columns displayed in the Review phase
Table Column Description
Set # ID number of the simulation dataset. Datasets are numbered in

the order they were acquired but are not time or date stamped.
Datasets are not listed in the table in order of their Set #.
Instead, they are listed from top to bottom in order of the most
preferred result. For example, a dataset with a result of 2-View
(Lung with Respiratory) tracking would be listed above a
dataset with a result of 1-View A or Lung 1-View B.
Type The type of dataset (Automatic mode or Manual mode).
A For Image A, the percentage (%) and number (out of the total
number of images acquired) of false positives identified by the
user.
For example, for a dataset of type Automatic, a value in this
column of 12% (1/8) indicates that 12% of the images (1 out of 8
images) acquired by Camera A in the Offset phase were
identified as false positives by the user in the Confirmation
phase.
B For Image B, the percentage (%) and number (out of the total
number of images acquired) of false positives identified by the
user.

Table 20 Table columns displayed in the Review phase
Table Column Description
1-View A For Image A, the percentage (%) and number (out of the total
number of images acquired) of successful correlations
confirmed by the user.
1-View B For Image B, the percentage (%) and number (out of the total
number of images acquired) of successful correlations
confirmed by the user.
2-View For both Image A and Image B pairs, the percentage (%) and
Lung with number (out of the total number of image pairs acquired) of
Respiratory successful correlations for both images in the pair confirmed by
the user.
1-View A For Image A, the percentage (%) and number (out of the total
number of images acquired) of user-confirmed successful
correlations plus user-indicated uncertain correlations.
1-View B For Image B, the percentage (%) and number (out of the total
number of images acquired) of user-confirmed successful
correlations plus user-indicated uncertain correlations.
2-View Similar to the table column under the icon above in the
Lung with table, except that user-indicated uncertain correlations are
Respiratory counted as if they are successful correlations.
That is, for both Image A and Image B pairs, this column shows
the percentage (%) and number (out of the total number of
image pairs acquired) of user-confirmed successful correlations
plus the number of user-indicated uncertain correlations for
both images in the pair.
Result Tracking mode result of the Simulation Application based on

this simulation dataset.
For information on the criteria used by the Simulation Application for determining a certain tracking
mode result, see “Simulation Application Workflow” on page 14-69.
In the Result column, the selected dataset icon is displayed next to the dataset that is
currently selected by the user to be used as a candidate for treatment planning.
Clicking a row in the table highlights that row in yellow and displays information about the selected
dataset in the lower portion of the panel.

The Spine section displays the following information:

• A X-ray Technique: The X-ray parameters used for X-ray source A in the Spine
phase (see “X-ray Parameters Panel” on page 14-19).
• B X-ray Technique: The X-ray parameters used for X-ray source B in the Spine
• Spine Alignment Successful: Whether spine alignment was performed (Yes) or
skipped (No) (see “Skip Spine Checkbox” on page 14-16).
The Lung section displays the following information:
• A X-ray Technique: The X-ray parameters used for X-ray source A in the Lung
• B X-ray Technique: The X-ray parameters used for X-ray source B in the Lung
• Preferred Projection: Whether Preferred Projection was enabled (Yes) or disabled
(No) for image correlations by the lung tracking algorithm in the Confirmation phase.
When enabled, the preferred projection method is enabled for locating the tumor. For
more information on the preferred projection method, see “Chapter 11: Synchrony Lung
The Respiratory section displays the same respiratory waveform displayed in the Offset
phase (see Figure 31 on page 14-38). The waveform displays checkmarks for phases in the
respiratory cycle where images were acquired in the highlighted dataset.
The Result text field at the bottom of the panel displays the result for the highlighted dataset.
Controls under the text field allow you to perform the actions described in Table 21.
Table 21 Controls in the Review phase
Review Selects the currently highlighted dataset as the most

Select appropriate candidate for treatment planning.
If another dataset has already been selected, that dataset
is automatically deselected.
When a dataset is selected, the result of the dataset will
appear in treatment planning. If the treatment plan then
uses the same tracking mode result, the following settings
will become the defaults for that plan during treatment
delivery:
• The X-ray technique used in the Spine phase.
• The X-ray technique used in the Lung phase.
• The settings (enabled or disabled) for Preferred
Projection.

Table 21 Controls in the Review phase
Review If the currently highlighted dataset was previously selected

Deselect as the most appropriate candidate for treatment planning,
deselects it so that no dataset is marked as the most
appropriate.
Exit Exits the Simulation Application and returns to the

Application CyberKnife System Menu.
When you exit the Simulation Application, simulation data
is sent to the iDMS Data Management System. Datasets
listed in the table in the Review phase will still be listed
the next time you log into the Simulation Application.

Manual Mode User Interface

• “Spine Phase” on page 14-53
• “Lung Phase” on page 14-53
• “X-ray Phase” on page 14-53
• “Respiratory Phase” on page 14-54
• “Review Phase” on page 14-67
Spine Phase
The Spine phase in Manual mode is the same as in Automatic mode. For information, see “Spine
Lung Phase
The Lung phase in Manual mode is the same as in Automatic mode. For information, see “Lung
X-ray Phase
The X-ray phase in Manual mode is the same as in Automatic mode. For information, see “X-ray
1075883-ENG A Manual Mode User Interface | 14-53

Respiratory Phase
This section describes the controls and displays in the Respiratory phase. It covers the
following topics:
• “Image Panels in the Respiratory Phase” on page 14-54
• “Offset Specification Controls” on page 14-56
• “dxAB and Uncertainty Slider Bars” on page 14-57
• “Image Correlation Parameters Panel” on page 14-58
• “Algorithm Errors Panel” on page 14-61
• “Patient Position Display” on page 14-61
• “Respiratory Modeling Controls” on page 14-63
For a description of the workflow in the Respiratory phase using these controls, see “Simulation
Image Panels in the Respiratory Phase

Figure 40 shows an example of the image panels displayed in the Respiratory phase.
Figure 40 Image panel in Respiratory phase
14-54 | Manual Mode User Interface 1075883-ENG A

to Camera B. The first image in each row is the DRR image. The second image is the most recently
acquired Live X-ray image. The last image in each row is an overlay of the DRR image and the
Live X-ray image.
image panel (see Figure 41). These controls are described in Table 3.

along the bottom of an image panel
Controls are similar to those in the Spine phase (see Table 3 on page 14-12) except for those
described in Table 22.
Table 22 Image panel controls in the Respiratory phase


(Options)”.
Tumor Region DRR: (Top left of image panel) Displays

the tumor region DRR images. This option removes image
content that is not in the immediate region of the tumor. For
more information on this display mode, see “Chapter 11:
(Options)”.

Table 22 Image panel controls in the Respiratory phase

Display ITTV Contour: Displays the Internal Target

Tracking Volume (ITTV) contour in the image not used for
image correlation using Lung 1-View tracking with
Respiratory. Applies when the selected image correlation
method is Track 1-View A or Track 1-View B (see
“Respiratory Modeling Controls” on page 14-63).
The upper right corner of each Live X-ray image panel displays the respiratory phase during which
it was acquired (see Figure 42).
Figure 42 Respiratory phase
Offset Specification Controls

In the Respiratory phase you can specify an offset that can be useful when you are able to
visually identify features in the Live X-ray images that the lung tracking algorithm did not
automatically identify. To specify an offset, you drag the tumor outline in the Live X-ray image to
overlay it on the feature you visually identify as the tumor. The tracking algorithm then searches
for the tumor in the location you have specified.
The steps for using offset cursor mode are as follows:
1. If necessary, use the image panel controls to enable Display Tumor Contour in the Live
X-ray image.
When this display mode is enabled, a blue tumor outline is displayed in the Live X-ray
image.
2. Move the cursor over the tumor outline.
When the cursor hovers over the outline, the outline color changes to red, indicating that
you can drag the outline.
3. Click and drag the outline over the tumor.
A red copy of the outline is dragged to the new location. The blue outline remains at the
original location for reference.
4. Then release the mouse button.
The red copy of the outline turns green. An new image correlation is triggered.

5. Wait until the correlation has completed.

When the correlation is successful, the green outline and original blue outline will
disappear and be replaced with a new blue outline that represents the new correlation
result.
You can independently drag the tumor outline in Image A and Image B.
dxAB and Uncertainty Slider Bars

The dxAB (mm) and Uncertainty (%) slider bars allow you to monitor the calculated value
of these parameters and change the value of their thresholds (see Figure 43). The values are
updated each time an image is acquired and image correlation is performed. When the calculated
value exceeds the threshold, an image algorithm error occurs and the Algorithm Errors panel
is displayed, similar to the panel in the Spine phase. For more information, see “Algorithm Errors
Panel” on page 14-20.
Figure 43 dxAB and Uncertainty slider bars in the

Respiratory phase
For information on the effect of adjusting these parameters, see “Chapter 11: Synchrony Lung
The slider bars include the same displays and controls described in “dxAB, drAB, and False Nodes
Slider Bars” on page 14-16.
 To change the value of an error threshold:
You can change the value of a threshold in response to errors that occur after image correlation is
performed.
Click and drag the threshold cursor to adjust the threshold value. Alternatively, enter a new value
in the textbox under the right end of the slider bar and press <Enter>.

Image Correlation Parameters Panel

The following image correlation parameters are input to the tracking algorithm and change image
correlation results:
• Tracking Range (mm)
• Contrast
• Preferred Projection ON
Changing any of these parameters automatically triggers a new image correlation, as described
below. Figure 44 shows controls for adjusting these parameters.
Figure 44 Image correlation parameters in the

Respiratory phase
When you change one of the above parameters, all controls in the Respiratory phase except
the Interlock button and the other image correlation parameters are disabled. Image correlation
results will be displayed after a time delay. Continued changes to parameters may increase the
delay. Once the correlation results are displayed, all Respiratory phase controls will be re-
enabled.
For more information on the effect of changing these parameters, see “Chapter 11: Synchrony
Lung Tracking with Respiratory Modeling (Options)”.

Tracking Range Slider Bar

The Tracking Range (mm) slider bars for the Tracking Range X and Tracking Range Y
parameters includes the following controls:
• The current value (in millimeters) is displayed in the textbox under the slider bar.
• The default value is indicated by a dashed line on the slider bar.
For more information on these parameters, see “Chapter 11: Synchrony Lung Tracking with
 To change the Tracking Range parameter value:
1. Click and drag a slider bar cursor to adjust the value. Alternatively, enter a new value in
Contrast Textboxes
The Contrast A and Contrast B parameters correspond to Camera A and Camera B of the
imaging system. The range of parameter values is from 1 to 10. Values apply to image correlations
in the Respiratory phase.
When the Automatic checkbox is selected, Contrast values are determined automatically by
the Target Locating System (TLS).
These parameter adjustments are similar to those for the Spine phase. For more information, see
“Contrast Textboxes” on page 14-19.
Preferred Projection ON
The Preferred Projection ON checkbox allows you to enable or disable the Preferred
Projection parameter. When enabled, the preferred projection method is enabled for locating the
tumor in the Respiratory phase. For more information on the preferred projection method, see
“Chapter 11: Synchrony Lung Tracking with Respiratory Modeling (Options)”.


and X-ray source B in the Respiratory phase (see Figure 45).
Figure 45 X-ray parameters panel in the Respiratory

phase

NOTE: In the Respiratory phase, images are acquired

synchronously from Camera A and Camera B of the X-ray
imaging system. For more information on acquiring Live X-ray
images in the Respiratory phase, see “Respiratory Modeling
Controls” on page 14-63.
By default, the final X-ray technique used in the Lung phase is used in the Respiratory phase.
Changes made to the X-ray technique in the Respiratory phase are applied to the all other
phases except the Spine phase.

Algorithm Errors Panel

The Algorithm Errors panel lists any image algorithm errors and provides information to help
resolve them. This panel is similar to the panel displayed in the Spine phase. It is displayed
automatically when an image correlation fails due to an algorithm error. Dragging the threshold
cursor across the red/green border of the dxAB or Uncertainty slider bar and back automatically
displays and hides the panel.
Toggle buttons allow you to switch between the Overlay images and the Algorithm Errors
panel. For more information on the Algorithm Errors panel and the toggle buttons, see
“Algorithm Errors Panel” on page 14-20.
Patient Position Display

Figure 46 shows the patient position display in the Respiratory phase. The display includes a
diagram showing the location of the tracking target calculated by the lung tracking algorithm and
the Respiratory correlation error. Rotational offsets are not calculated by the lung tracking
algorithm.
Figure 46 Patient position display in the Respiratory

phase
The 3 values on the left are the tracking target position relative to the machine center (in
millimeters) in the Inferior(+)/Superior(-), Left(+)/Right(-), and Anterior(+)/Posterior(-) directions, as
indicated by the arrows. The arrows point in the positive direction and do not change. An orange
box around values indicates the values are out of bounds and must be adjusted.
NOTE: The above anatomical coordinate system is based on a

Head First Supine (HFS) patient position.
The value on the far right is the Respiratory correlation error (in millimeters).
The values in the patient position display are updated after each Live X-ray image is acquired.
Images are acquired using the Acquire button, as described in “Respiratory Modeling Controls”
on page 14-63.


“Patient positioning controls in the Respiratory phase” on page 14-62 shows the automatic patient
positioning controls in the Respiratory phase. The controls include a diagram showing the
current translational and rotational position of the treatment couch above a row of textboxes. These
controls are similar to those in the Spine phase (see “Patient Positioning Controls” on page 14-22)
except that in the Respiratory phase, treatment couch rotations are locked.
Figure 47 Patient positioning controls in the Respi-

ratory phase
The row of textboxes underneath the diagram allows you to enter a target position for the next
automatic movement of the treatment couch using the Move Couch button described in
Table 23. The target location can also be specified using couch cursor mode which automatically
updates the textboxes, as described in Table 3 on page 14-12.
Each time a successful image correlation is performed, the textboxes are automatically updated
with the position of the treatment couch at the time of image acquisition plus the calculated location
of the tracking target.
Table 23 Patient positioning buttons
Move Couch Moves the treatment couch to the target position indicated

Respiratory Modeling Controls

Table 24 describes the Respiratory modeling controls in the Respiratory phase. Functionality is
similar to that available during treatment delivery, as described below. For more information on
Respiratory modeling during treatment delivery, see “Chapter 12: Synchrony Respiratory Tracking
System (Option)”.
Table 24 Respiratory modeling controls
Control Tool Tip Button Description
Image Acquire Acquires a pair of Live X-ray images. In

Acquisition the Respiratory phase, image
correlation is performed automatically
to determine tracking target location
using one of the image correlation
methods described below in this table.
The timing of image acquisition is
influenced by the selection of
Respiratory modeling method,
described below in this table.
In the Respiratory phase, images
are acquired synchronously from
Camera A and Camera B of the X-ray
imaging system. For more information,
see “X-ray Parameters Panel” on
page 14-60.

Table 24 Respiratory modeling controls (continued)
Modeling User Phase The waveform represents a respiratory

Method Selection cycle with circles representing the 8
phases. A checkmark in a circle
indicates that the corresponding phase
is selected. This phase is targeted for
the next image acquisition.
Click a circle to select it. Only one circle
can be selected at a time. With this
modeling method, Automatic
Phase Selection and No Phase
Selection are deselected.
After a pair of images is acquired using
this method, the method switches to
Automatic Phase Selection.
Automatic The system automatically selects which

Phase respiratory phase to target based on
Selection the current Respiratory model.
A checkmark in the circle indicates this
method is selected. Click the circle to
select it. Only one modeling method
can be selected at a time.
No Phase The Synchrony tracking System is not

Selection guided to target a particular respiratory
phase. When the Acquire button is
clicked, a pair of Live X-ray images is
acquired as soon as possible.
A checkmark in the circle indicates this
method is selected. Click the circle to
select it. Only one modeling method
can be selected at time.

Respiratory Enable Enables Respiratory modeling. This

Enable/Disable Respiratory button is outlined in green) when
selected.
When Respiratory modeling is enabled,
new Live X-ray images are used to
build and update the Respiratory
model. When Respiratory modeling is
disabled, new images do not contribute
to the model.
Discarding Reset Model Discards the current Respiratory model.

Model

Image Track Selects Image A for image correlation.

Correlation 1-View A Image B will not be used. The tumor
Method outline will be displayed over the tumor
in Image A. In Image B, the ITTV will be
displayed and no correlation will be
performed.
Changing the method automatically
triggers a new image correlation
attempt. It also automatically discards
any existing Respiratory model.
Track Selects Image B for image correlation.

1-View B Image A will not be used. The tumor
outline will be displayed over the tumor
in Image B. In Image A, the ITTV will be
displayed and no correlation will be
performed.
Changing the method automatically
triggers a new image correlation
attempt. It also automatically discards
any existing Respiratory model.
Track 2-View Both Image A and Image B are used for

image correlation. The tumor outline is
displayed over the tumor in both
images.
This is the default image correlation
method. Changing the method
automatically triggers a new image
correlation attempt. It also automatically
discards any existing Respiratory
model.

Review Phase
Figure 48 shows the main panel of the Review phase in Manual mode. For a description of the
workflow in the Review phase, see “Simulation Application Workflow” on page 14-69.
Figure 48 Main panel of Review phase in Manual mode
The panel is similar to the Review phase in Automatic mode (see “Review Phase” on page 14-48)
with the following changes:
• In Manual mode, the columns in the table for false positives identified by the user and for
user-confirmed successful correlations plus user-indicated uncertain correlations do not
apply. No values are listed in these columns for datasets acquired in Manual mode.
• In Manual mode, the values listed in the table under the icon for the percentage/
number of successful correlations are not relevant.
• In Manual mode, the Simulation Application does not use an algorithm to determine a
simulation result. Instead, the user selects a tracking mode from the Result dropdown
list at the bottom of the panel to apply to the highlighted dataset (see Figure 49).
Figure 49 Result dropdown menu in the Review phase for Manual mode

The following result options are available:

 Lung with Respiratory
 Lung 1-view A with Respiratory (only when spine alignment
performed)
 Lung 1-View B with Respiratory (only when spine alignment
performed)
 Spine Supine (only when spine alignment performed)
 Not Trackable
 Defer
Defer is the default option, which indicates that a decision on a particular tracking mode
has not yet been made. The decision can be made later from the iDMS Data
Management System.

Simulation Application Workflow

• “Overview of Simulation Workflow” on page 14-69
• “Simulation Using Automatic Mode” on page 14-69
• “Simulation Using Manual Mode” on page 14-74
Overview of Simulation Workflow

There are two workflows for using the Simulation Application:
• “Simulation Using Automatic Mode” on page 14-69: Automatic mode provides an
automated workflow that guides the user through the simulation workflow. Automatic
mode provides guidance on the feasibility of tracking mode(s) that can be used for the
patient.
• “Simulation Using Manual Mode” on page 14-74: Manual mode provides a non-guided
workflow in which the user performs setup operations manually, including building a
Respiratory Model. The user determines the feasibility of tracking mode(s) based on
review of the simulation results.
These two workflows are described in the sections that follow.
Simulation Using Automatic Mode

Figure 50 shows the simulation workflow using Automatic mode.
Set Up Patient Acquire Dataset Review
Acquire
Couch X-ray Confirm
Spine Dataset and Review
Positioning Technique Algorithm
Alignment Specify Dataset
for Lung Refinement Results
Offsets
Figure 50 Simulation workflow for Automatic Mode
1075883-ENG A Simulation Application Workflow | 14-69

The workflow in Automatic mode includes the following general steps, described in the sections
below:
1. Set up the patient so that the Field of View is centered on the respiratory cycle and the X-
ray technique is optimized.
2. Acquire a simulation dataset which contains Live X-ray images and image algorithm
correlation results that sample the whole respiratory cycle. Image correlation is performed
to determine which image views are appropriate for tracking.
3. Review the simulation dataset. Repeat Step 2 until satisfied.
Set Up the Patient

During a simulation session, the patient is brought into the Treatment Room. Follow the
instructions on patient setup for treatment in “Chapter 12: Synchrony Respiratory Tracking System
(Option)”, including:
1. Assist the patient to put on the Respiratory Tracking Vest. The patient should wear the
same Respiratory Tracking Vest that was used during pretreatment scanning and that will
be used during treatment.
2. The same immobilization device used during pretreatment scanning should be used.
3. The patient should be positioned on the treatment couch and instructed to relax and
breathe normally.
4. The 3 Tracking Markers should be connected to the Respiratory Tracking Vest.
For more information on the above steps, see “Chapter 12: Synchrony Respiratory Tracking
System (Option)”.
Load Patient and Simulation Plan Data

The first step to perform a simulation is to select the patient and Simulation Plan.
 To select the patient and Simulation Plan:
1. On the CyberKnife System Menu, click the Simulation button and log in as described
in “Chapter 4: System Startup and Shutdown”. You may also add participants, as
described in “Chapter 5: Treatment Delivery System Overview”.
After a successful login, the Load Patient Data window is displayed. This window lists
patients with Simulation Plans. It may take a moment for data to be retrieved from the
data server of the iDMS Data Management System
populated with the names of Simulation Plans for that patient. Simulation Plans are not
listed until DRR images have been generated on the iDMS Data Management System.
3. To refresh the Patient list with patients that have newly generated Simulation Plans and
the Plan list with Simulation Plans that have newly generated DRR images, click the
Refresh button. It may take a few moments for the lists to be updated.
4. Click to select a Simulation Plan from the Plan list.
Under the lists, the Patient and Plan sections display information about the selected
patient and Simulation Plan as you select them.
14-70 | Simulation Application Workflow 1075883-ENG A

5. Click the Load button to begin downloading patient and Simulation Plan data from the
iDMS Data Management System to the treatment delivery computer. The Spine tab of
the Simulation Application will be displayed.
6. If there is a pre-existing simulation dataset for the patient from a previous simulation
session, you can go directly to the Review phase to view results for this dataset.
Perform Spine Alignment (Spine Phase)

The goal in the Spine phase is to align the patient using spine tracking. The alignment procedure
is similar to Synchrony Spine Supine Tracking alignment. For more information, see “Chapter 10:
Synchrony Spine Tracking (Option)”. The objectives are as follows:
• Determine rotational offsets that will be used in the Lung phase.
• Determine X-ray parameters that will provide optimal Live X-ray images. These
parameters will be used as the defaults in treatment delivery during the spine alignment
phase.
You can proceed to the Lung phase when the currently displayed patient translational offsets are
less than 10 mm and when the rotational offsets are less than the following:
• 1°, 1°, and 3° rotationally (roll, pitch, and yaw, respectively) for the standard treatment
couch.
• 1.5°, 1.5°, and 1.5° rotationally (roll, pitch, and yaw, respectively) for the RoboCouch
System.
You can choose to skip spine alignment if the spine tracking algorithm is unable to track the
patient’s anatomy. You should not skip spine alignment if it is possible to track using the spine
tracking algorithm.
NOTE: Note that skipping spine alignment will disallow Spine

Supine or Lung 1-View with Respiratory as a result in the
Review phase and as tracking modes during treatment
delivery.
By clicking the Skip Spine checkbox, you can switch directly to the Lung phase. Otherwise, the
Lung tab is disabled until spine alignment is performed.
Once spine alignment is complete, click the Lung tab to switch to the Lung phase.
Perform Couch Positioning for Lung (Lung Phase)

The goal in the Lung phase is to move the treatment couch to the lung position and acquire one
pair of Live X-ray images. When you switch to the Lung phase, the treatment couch position
display indicates that the patient is at the spine position, and the Move to Lung button is
enabled. The spine position and lung position are defined as follows, depending on whether spine
alignment was performed in the Spine phase:
• If spine alignment was performed, the spine position is the aligned treatment couch
position from the Spine phase modified by the final patient offsets.

• If spine alignment was not performed, the spine position is the position of the treatment
couch at which the last image was taken in the Spine phase.
• The lung position is the spine position plus the difference between the alignment center
and the ITTV center from treatment planning.
In the Lung phase you first click the Move to Lung button and then wait until the treatment
couch has completed movement to the lung position. You then click the Acquire button to take a
pair of Live X-ray images using the default X-ray parameters. In general, you should defer
changing X-ray parameters until the X-ray phase.
NOTE: Do not attempt to manually align the respiratory target in

the Lung phase. The movement from the spine to the lung
position is intended to center the respiratory motion range of the
target. Manual alignment is unlikely to improve this positioning.
After acquiring a pair of Live X-ray images and determining that there are no unexpected features
or obstructions in the images, click the X-ray tab to switch to the X-ray phase.
Refine X-ray Technique (X-ray Phase)

The goal in the X-ray phase is to refine the X-ray technique to obtain processed Live X-ray images
that match the DRR images reasonably well.
The final X-ray parameters specified in the X-ray phase will be used as the defaults during lung
treatments if this simulation dataset is used to create a treatment plan.
Two methods are available to assist in refining the X-ray technique:
• A histogram-based method in which the user views a histogram display to ensure that the
histogram distribution is reasonably spread out (good contrast) and shifted towards the
right (imaging dose is conserved).
• An image-based method in which the Live X-ray image is visually compared with the DRR
image until it matches reasonably well.
For more information on controls in the X-ray phase, see “X-ray Phase” on page 14-31.
Once you have finished refining the X-ray technique, click the Offset tab to go to the Offset
phase.
Acquire a Simulation Dataset

A dataset in Automatic mode should be sufficient for the Simulation Application to judge the
tracking ability of the CyberKnife System for a given patient position and X-ray technique. An
automatic dataset consists of the following:
• 8 to 12 image pairs spread throughout the respiratory cycle.
• User-provided tumor location specification (offset specification) for 2 images from
Camera A and 2 images from Camera B of the X-ray imaging system.
• Algorithm parameters used for correlation (determined automatically by the lung tracking
algorithm).

• Lung tracking algorithm correlation results for all images.

• User feedback on the success, failure, or uncertainty of algorithm correlation results.
Acquire a Dataset and Specify Offsets (Offset Phase)

When acquiring a simulation dataset in Automatic mode, you start in the Offset phase. You
perform the following steps in the Offset phase:
1. Acquire a dataset using controls described in “Dataset Acquisition Controls” on
page 14-38.
2. Specify target offsets using controls described in “Offset Specification Controls” on
page 14-40.
3. If it is not possible to provide an offset in one or more of the images, indicate that the
tumor is not visible in one or more of the camera views using controls described in
“Camera Visibility Controls” on page 14-42.
If the user indicates that the tumor is not visible in one of the camera views, Lung with
Respiratory and Lung 1-View with Respiratory for the specified view are disallowed as
results by the Simulation Application.
When offsets have been provided for 2 images for Camera A and 2 images for Camera B, or when
offsets have been provided for 2 images for one camera and the other camera view has been
deselected, or when both camera views have been deselected, the user can proceed to the
Confirmation phase.
Confirm Correlation Results (Confirmation Phase)

In the Confirmation phase, the lung tracking algorithm performs image correlations
automatically on all images in the dataset acquired in the Offset phase. No Live X-ray images are
acquired. The correlation results automatically populate the acquired dataset panel. You then
provide feedback on every image correlation for which the lung tracking algorithm returned a
successful result.
For each image with a superimposed the icon, you click on the image to display it in the Image A
or Image B panel. You then visually decide whether the correlation was successful using the
controls for confirming correlation results described in “Controls for Confirming Correlation
Results” on page 14-47. You confirm correlation results one image pair at a time
When results have been confirmed for all image correlations with a superimposed the icon, click
the Review tab to switch to the Review phase.
Review the Simulation Dataset

In the Review phase, you review simulation results and decide whether modifying the setup (for
example, the X-ray technique or treatment couch position) may change the results. Acquiring
another dataset in Automatic mode may also give a different simulation result (for example, if the
patient coughed during acquisition of a previous dataset). You may also decide to switch to Manual
mode.

After reviewing simulation results, you select one dataset as your candidate using the controls
described in “Review the Simulation Dataset” on page 14-73 and then exit the Simulation
Application.
In Automatic mode, the Simulation Application result is chosen for a particular dataset based on
the following criteria:
• If the percentage of successful 2-View correlations is 75% or greater, then the result for
that dataset will be Lung with Respiratory.
• If the percentage of successful 2-View correlations is less than 75% and you have not
skipped spine alignment, then the result will be Spine Supine, Lung 1-View with
Respiratory, or non-trackable.
 If the percentage of successful 1-View A correlations is 75% or greater and spine
alignment was not skipped, then that is the result, Lung 1-View A with Respiratory.
 If the percentage of successful 1-View B correlations is 75% or greater and spine
alignment was not skipped, then that is the result, Lung 1-View B with Respiratory.
 If the percentage of successful 1-View and 2-View correlations are less than 75% and
you have not skipped spine alignment, then the result will be Spine Supine.
• Otherwise, the result will be Not Trackable.
 If in the Confirmation phase, the user specified that the tumor was not visible in
both Camera A and Camera B, the result will be Spine Supine tracking.
Simulation Using Manual Mode

Figure 51 shows the simulation workflow using Manual Mode, which provides an alternative, less
restrictive workflow than Automatic mode.
Set Up Patient Acquire Dataset Review
Couch X-ray Respiratory

Spine Review
Positioning Technique
Alignment Modeling Dataset
for Lung Refinement
Figure 51 Simulation workflow for Manual Mode

Set Up the Patient

The workflow for setting up the patient in Manual mode is the same as for Automatic mode. For
information, see “Set Up the Patient” on page 14-70. The steps for performing spine alignment in
the Spine phase, performing couch repositioning for lung in the Lung phase, and refining the X-
ray technique in the X-ray phase are the same as in Automatic mode.
Acquire a Simulation Dataset

In Manual mode, you acquire a simulation dataset by performing Respiratory modeling in the
Respiratory phase. Respiratory modeling in the Respiratory phase is similar to the methods
available using the Synchrony tracking System during treatment delivery. For more information,
see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
In the Respiratory phase, the goal is to establish a Respiratory model for whichever tracking
mode(s) you choose. It is not possible to establish a model for 2-View tracking (Lung with
Respiratory), you can select one of the Lung 1-View Respiratory tracking image correlation buttons
described in “Respiratory Modeling Controls” on page 14-63 to perform an image correlation in
only Image A or only Image B. For example, if you select the Track 1-View A button, image
correlation will only be performed for Image A and the tumor contour will only be shown in Image
A. No correlation results will be displayed in Image B. Instead, the ITTV contour will be shown.
After establishing a Respiratory model and determining the tracking mode that you believe should
be used, you switch to the Review phase.
Review the Simulation Dataset

The Review phase in Manual mode is similar to that for Automatic mode except that for datasets
acquired in Manual mode, the Simulation Application does not determine a tracking mode result.
Instead, you select a tracking mode from the Results dropdown list, as described in “Review
Phase” on page 14-67. The default result for Manual datasets is Defer.


Chapter 15: Lung Optimized
Treatment (Option)
Introduction
This chapter describes how to use Synchrony Spine Tracking Supine (Spine Supine) and
Synchrony Lung 1-View tracking with Respiratory Modeling (Lung 1-View with Respiratory). It
covers the following topics:
• “Overview of Lung 1-View Tracking with Respiratory Modeling” on page 15-2
• “Qualitative Alignment Check Using the Untracked Image” on page 15-8
• “Workflow for Lung 1-View Tracking with Respiratory Modeling” on page 15-9
• “References” on page 15-36
For information on Synchrony Spine Tracking Supine, see “Chapter 10: Synchrony Spine Tracking
(Option)”.
Lung 1-View with Respiratory enables radiation beam delivery in the lung for tracking without the
need for implanting fiducials, and is used in cases in which the tumor is more clearly visible or
better identified in one Live X-ray image than the other. During treatment delivery, Lung1-View with
Respiratory may be used to track movement of the tumor in the tracking plane due to patient
breathing patterns.
This chapter assumes you are familiar with the following chapters:
• “Chapter 8: Treatment Delivery”
• “Chapter 12: Synchrony Respiratory Tracking System (Option)”

Overview of Lung 1-View Tracking with

This section describes the Lung 1-View Tracking with Respiratory Modeling (Lung 1-View
Tracking) algorithm and its intended use in the CyberKnife System. It covers the following topics:
• “CT Acquisition and Reproducibility” on page 15-2
• “Spine Supine Tracking ITV, Lung 1-View Tracking ITV, ITTV, and PTV” on page 15-3
• “Lung 1-View Tracking with Respiratory Modeling Algorithm” on page 15-6
• “Quality Metrics” on page 15-7
• “Tumor Region DRR Images” on page 15-8
• “Treatment Planning Overview” on page 15-8
Lung 1-View Tracking is intended to track lung tumors that meet the following conditions, without
the use of fiducials in the lung:
• Tumor diameter larger than 15 mm in all directions.
• Tumor is not obstructed by cardiac or skeletal structures in at least one of the two images.
The workflow described in “Chapter 14: Simulation Application Overview (Option)” on page 14-1
will allow the user to verify that the algorithm to able to visualize the lung tumor. Treatment using
1-View with Respiratory includes a treatment planning phase and a treatment delivery phase.
CT Acquisition and Reproducibility

Both Lung 1-View Tracking with Respiratory Modeling and Spine Supine Tracking treatments are
based on the assumption that the position and motion range of the target during treatment with
respect to the spine alignment center are well represented by the CT scans used for treatment
planning. For this reason, it is very important that the CT scans be taken during natural (not forced)
inhalation and exhalation, and that the same immobilization applied to the patient is used for both
CT scanning and treatment delivery. If any compression device is placed on the patient, it is
essential that it be present for both CT scanning and treatment delivery.
15-2 | Overview of Lung 1-View Tracking with Respiratory Modeling 1075883-ENG A

Treatment Delivery Manual Chapter 15: Lung Optimized Treatment (Option)
Spine Supine Tracking ITV, Lung 1-View Tracking

ITV, ITTV, and PTV
This section discusses the -Spine Supine Tracking Internal Target Volume (ITV), Lung 1-View
Tracking ITV, and the Internal Target Tracking Volume (ITTV). It covers the following topics:
• “Spine Supine Tracking ITV” on page 15-3
• “Lung 1-View Tracking with Respiratory Modeling ITV” on page 15-3
• “ITTV” on page 15-5
• “PTV” on page 15-5
Spine Supine Tracking ITV

In the situation that no intra-fraction motion tracking is performed (Spine Supine Tracking), then
the Internal Target Volume (ITV) corresponds with the standard definition of ITV made in ICRU
Report 62 [Ref. 1]. That is, the ITV encompasses the Clinical Target Volume (CTV) and an internal
margin (IM) that accounts for all changes in its position during delivery of the fraction.
NOTE: For an explanation of the accuracy of Synchrony Spine

Tracking Supine, see “Accuracy of Synchrony Spine Tracking”
on page 10-2.
Lung 1-View Tracking with Respiratory Modeling ITV

In the situation that intra-fraction motion tracking is performed using one imaging projection but not
both (Lung 1-View Tracking), the relevant ITV definition is not the same as the ICRU 62 definition.
In this case, the CTV motion along two orthogonal axes is tracked within the Motion Tracking Plane
(see Figure 1 and Figure 2), and therefore the ITV should only be large enough to encompass the
motion of the CTV along the remaining non-tracked axis.
Figure 1 and Figure 2 illustrate the concept of tracked and untracked motion for a case where Lung
1-View Tracking with Respiratory Modeling is selected. The orange circle is the CTV at the two
extremes of respiratory motion. The ITV for Lung 1-View Tracking is different from that for Spine
Supine Tracking. As shown in Figure 1, the Spine Supine Tracking ITV (shown in blue)
encompasses the full range of CTV motion. In the Lung 1-View Tracking scenario, the untracked
motion is perpendicular to the plane of the image being used for tracking, represented in Figure 1
and Figure 2 as the Motion Tracking Plane. For Lung 1-View Tracking, the pink shapes shown in
Figure 2, which include only the untracked component of motion, represent the ITV at each
extreme of the respiratory cycle.
1075883-ENG A Overview of Lung 1-View Tracking with Respiratory Modeling | 15-3

Motion Tracking Plane
This motion is
tracked.
This motion is not tracked. ITV

should be used to compensate.
Figure 1 Tracked and untracked motion for Lung 1-

View Tracking with Respiratory Modeling
Motion Tracking Plane
ITV for this case. Allows for all non-

compensated tumor positions.
Figure 2 The ITV for Lung 1-View Tracking with


ITTV
While the ITV described above is based on the Clinical Target Volume (CTV) and is delineated by
the Physician, the Internal Target Tracking Volume (ITTV) is based on the Target Tracking Volume
(TTV) and is generally delineated by the Physicist or Dosimetrist during creation of a Simulation
plan.
The ITTV represents the expected respiratory excursion of the TTV. The ITTV is defined from the
delineation of the TTV on the two respiratory phases represented by the CT scans used to create
a Simulation plan. The shape and position of the ITTV is independent of the tracking mode
subsequently selected when creating a treatment plan.
During treatment of a case where Lung 1-View Tracking with Respiratory Modeling is selected and
the treatment plan was based on a Simulation plan, the projected overlay of the ITTV is displayed
in the untracked Live X-ray image.
PTV
It is important to recognize that there are additional geometrical uncertainties involved in treatment
delivery which should be combined into a setup margin that is applied to the ITV to form a Planning
Target Volume (PTV) [Ref. 1]. These should include an estimate of the Respiratory modeling
uncertainty in the Motion Tracking Plane with Lung 1-View with Respiratory, together with an
estimate of the uncertainty in the position of the ITV relative to the spine region covered by the
Synchrony Spine Tracking Region of Interest (ROI) in the untracked out-of-plane direction for Lung
1-View Tracking or in all directions for Lung with Respiratory Tracking.

Lung 1-View Tracking with Respiratory Modeling

Algorithm
In Lung 1-View Tracking with Respiratory Modeling, the tracking plane is parallel to the image used
for tracking (that is, perpendicular to the incident X-rays generated by the corresponding X-ray
source) and intersects the machine center. Figure 3 shows the tracking plane for 1-View B Lung
Tracking.
Figure 3 Tracking plane for 1-View B Lung Tracking
The Lung 1-View with Respiratory algorithm searches for and locates the target in either the A or
B image (corresponding to Camera A or Camera B of the X-ray imaging system) during treatment.
The image that is used for tracking (A or B) is specified during treatment planning. Target
localization is performed by image registration between the DRR image and the Live X-ray image
for the specified image. Specifically, the image intensity pattern of the tumor region in the DRR
image is matched to the most similar region in the Live X-ray image. A matching window for the
tumor is defined based on the 2D tumor outline. The matching window is the smallest rectangle
that encompasses the entire tumor. Since typical tumor shapes are not rectangular, the matching
window will also include some of the surrounding region.
Registration is performed by moving the matching window throughout a user-defined search area
(see “Tracking Range X (mm) and Tracking Range Y (mm)” on page 15-30). The region of the
search area with maximum similarity to the corresponding DRR image is considered to be the
target. To assess the quality of the registration, the Synchrony Lung Tracking with Respiratory
Modeling algorithm uses quality metrics (see “Quality Metrics” on page 15-7).

The 1-View with Respiratory algorithm computes three translational components of the target
patient displacement. The rotational components are provided by the roll displacements estimated
by the Synchrony Spine Tracking Supine during patient alignment and are assumed to be constant
throughout the treatment. Successful initial patient alignment using the Synchrony Spine Tracking
Supine is therefore necessary. The treatment robot continually adjusts the position of the LINAC
to correct for translational offsets of the target and applies the constant rotational correction.
1-View with Respiratory is used in conjunction with the Synchrony tracking System to track and
compensate for target respiratory motion in the tracking plane. Treatment delivery uses 1-View
with Respiratory for target localization and the Synchrony tracking System for compensating for
respiratory motion.
Quality Metrics
The 1-View with Respiratory algorithm operates by locating an intensity pattern in the Live X-ray
image that is similar to that in the DRR image. It is possible that more than one such pattern exists
in the search area. The algorithm takes into account several factors to assess the registration
quality:
• The maximum of the similarity measure between the Live X-ray and DRR images.
• The number of other local maxima found within the Tracking Range (for information on
the Tracking Range parameters, see “Tracking Range X (mm) and Tracking Range Y
(mm)” on page 15-30).
• The tumor size and the tumor location relative to the prediction made by the Synchrony
tracking System. For more information on the Synchrony tracking System, see “Chapter
The threshold for detection uncertainty is user-defined (see “Uncertainty (%)” on page 15-29). If
the detection uncertainty is higher than the threshold, treatment delivery is interrupted by a Soft
Stop.
WARNING: It is very important to visually inspect tracking results during treatment

delivery. Otherwise, mistargeting can result. It is possible for intensity patterns similar to
that of the target to exist at locations other than the target position.

Tumor Region DRR Images

Tumor region DRR images remove all structures that are not in the neighborhood of the tumor. In
this way, visibility of the tumor in the DRR images is improved and the 1-View with Respiratory
algorithm is prevented from locking onto a structure that appears to be near the tumor in the DRR
images but is actually located far from it, with a different motion pattern.
Treatment Planning Overview

For information on treatment planning for Lung 1-View Tracking with Respiratory Modeling, see the
Treatment Planning Manual.

Visual evaluation to verify that the lung tumor is tracked correctly in the image used for tracking by
the 1-View with Respiratory algorithm is essential to safe treatment delivery.
1. The Treatment Delivery System user interface provides tools to verify that the Synchrony
Spine Tracking Supine and 1-View with Respiratory are able to register skeletal
structures and lung tumors in the Live X-ray images with those in the DRR images. For
more information, see “Performing Patient Alignment” on page 15-14.
NOTE: Visual inspection during treatment delivery ensures that the

1-View with Respiratory algorithm is tracking correctly. However,
visual inspection alone is not adequate for verifying submillimeter
accuracy.
Qualitative Alignment Check Using the

Untracked Image
When Lung 1-View Tracking with Respiratory Modeling is selected and the treatment plan is based
on a Simulation plan, the projected overlay of the ITTV is displayed in the untracked Live X-ray
image. This overlay displays the excursion of the target in this view, as represented by the CT
scans used in treatment planning. When X-ray images are taken and the treatment target is visible
in the untracked image, it is possible to perform a qualitative check that the position and motion
range of the target still correspond with the position and range from the treatment plan. If the target
appears in a position distal from the ITTV overlay, it is an indication that the position and/or motion
range of the target has changed. We recommend that a qualified person evaluates the degree of
change and determines how to proceed based on the clinical implications for that particular case.
NOTE: When a Lung Optimized Treatment plan is created that is not

based on a Simulation plan, the projected overlay of the ITTV will not
be displayed in the untracked Live X-ray image for Lung 1-View
Tracking with Respiratory Modeling treatments. In this situation, the
qualitative alignment check described above cannot be performed.
15-8 | Requirements for Visual Evaluation 1075883-ENG A

Workflow for Lung 1-View Tracking with

Figure 4 shows the workflow for patient alignment and treatment delivery using Synchrony Lung 1-
View Tracking with Respiratory Modeling.
Figure 4 Workflow for Lung 1-View Tracking with

Two treatment couch positions are used during treatment delivery with 1-View with Respiratory:
• Spine position: The alignment center defined during treatment planning in the Align step
of the Accuray Precision System. This position is used for alignment by the Synchrony
Spine Tracking Supine.
• Lung position: The treatment center automatically determined during treatment planning
during tumor segmentation. This is the spine position plus the alignment-to-treatment
offset from planning. This position is used for tracking by the Synchrony Lung Tracking
The alignment center is typically different from the treatment center. The alignment center is used
during an initial spine alignment procedure using the Synchrony Spine Tracking Supine. The spine
alignment is performed in the Alignment > Align phase. This procedure determines the
rotational alignment corrections that will be used during treatment delivery with Lung 1-View
Tracking with Respiratory Modeling.
After spine alignment is completed, you transition from the Synchrony Spine Tracking Supine to 1-
View with Respiratory. This transition occurs when you move to the Alignment > Lung phase.
You then move the treatment couch to the treatment center.
Treatment delivery using 1-View with Respiratory includes the following general steps:
1. Load patient and treatment plan data in the Overview phase, as described in “Chapter
2. Find the optimal X-ray technique for spine alignment using the Synchrony Spine Tracking
Supine in the first Alignment > Technique phase, as described in “Chapter 10:
3. Position the patient on the treatment couch and move the patient to the alignment center
for initial spine alignment using the Synchrony Spine Tracking Supine in the Alignment
> Align phase, as described in “Chapter 10: Synchrony Spine Tracking (Option)”.
1075883-ENG A Workflow for Lung 1-View Tracking with Respiratory Modeling | 15-9
4. Use Synchrony Spine Tracking Supine to align the patient translationally and rotationally
at the spine position, as described in “Chapter 10: Synchrony Spine Tracking (Option)”.
After this step, the treatment couch is at the Synchrony Spine Tracking alignment center.
5. Switch from the Synchrony Spine Tracking alignment center (the spine position) to the 1-
View with Respiratory treatment center (the lung position) in the Alignment > Lung
phase.
This step involves treatment couch movement. The difference between the alignment
center and the treatment center includes the alignment-to-treatment offset defined from
treatment planning plus any additional offset the user applied during the current or
previous treatment fractions. For more information, see “Transition to Lung 1-View
Tracking with Respiratory Modeling” on page 15-15.
6. Find the optimal X-ray technique for treatment delivery using Lung 1-View Tracking with
Respiratory Modeling in the second Alignment > Technique phase.
7. Use 1-View with Respiratory to translationally align the patient sufficiently for tracking, in
the Alignment > Respiratory phase.
If the Synchrony tracking System is used, establish a Respiratory correlation model for
patient respiratory motion.
NOTE: The user decides whether to enable or disable

Respiratory Modeling during Lung 1-View with Respiratory
treatment. As an example, if the motion of the target due to
respiration is considered to be insignificant, Respiratory
Modeling may be disabled.
8. Start treatment delivery in the Delivery phase.
“Chapter 8: Treatment Delivery”. For information on using the Synchrony Respiratory Tracking
System, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
15-10 | Workflow for Lung 1-View Tracking with Respiratory Modeling 1075883-ENG A


DRR images for use with 1-View with Respiratory are generated using the iDMS Data
Management System as described in “Chapter 8: Treatment Delivery”. Roll angles of the patient
are computed during initial alignment using the Synchrony Spine Tracking Supine by comparing
the Live X-ray images with multiple DRR images.
The following number and types of DRR image pairs are generated:
• Multiple pairs of segmented spine DRR images with optimally distributed orientations, to
simulate different roll angles of the patient. These DRR images are used during patient
alignment with the Synchrony Spine Tracking Supine.
• 1 pair of unsegmented (full content) spine DRR images for automatic contrast adjustment
and visual inspection of image correlation results during patient alignment using the
Synchrony Spine Tracking Supine. These DRR images correspond to the imaging center
(also called the alignment center), which is chosen during treatment planning.
• 1 pair of full content DRR images that correspond to the treatment center for the target
tumor, which is chosen during treatment planning. This pair of DRR images is used for
automatic contrast adjustment and visual inspection of tracking results during treatment
delivery using 1-View with Respiratory.
• 1 pair of segmented DRR images in which the spine and other skeletal structures are
removed. This pair of DRR images is used for image correlation with the Live X-ray
images during treatment delivery.
• 1 pair of tumor region DRR images in which all structures that are not in the neighborhood
of the tumor are removed. For more information on tumor region DRR images, see
“Tumor Region DRR Images” on page 15-8.


transmitted to the TLS computer for use by the Synchrony Spine Tracking algorithm. The
separate pairs of unsegmented (full content) DRR images, soft tissue-only DRR images,
and tumor region DRR images are also transmitted.
• The Synchrony Spine Tracking and Lung 1-View with Respiratory algorithms are
initialized.
For more information on downloading treatment files, see “Chapter 8: Treatment Delivery”.

Figure 5 shows the Alignment > Couch phase (left screen) for Synchrony Spine Tracking
mode after the Live X-ray and DRR images have been visually aligned using Couch Mode. The
unsegmented (full content) DRR images for the Synchrony Spine Tracking Supine are displayed.
Table 3 on page 15-23 describes the image panel controls to aid image analysis and visual
alignment. For more information on this phase, see “Chapter 8: Treatment Delivery”.


chrony Lung Tracking with Respiratory Modeling after
visual alignment using Couch Mode

The goal of the first Alignment > Technique phase for the Synchrony Spine Tracking Supine
is to find the optimal X-ray technique. This X-ray technique will be the default for future treatment
fractions unless it is changed. Start by analyzing the existing image from the Alignment >
Couch phase.
For more information on optimizing the X-ray technique for Synchrony Spine Tracking, see
“Chapter 10: Synchrony Spine Tracking (Option)”.


The goal of patient alignment is to make sure the patient is aligned within acceptable bounds for
treatment using Lung 1-View Tracking with Respiratory Modeling. Patient alignment involves the
following general steps:
1. Initial spine alignment at the spine position using the Synchrony Spine Tracking Supine in
the Alignment > Align phase. For Lung 1-View Tracking with Respiratory Modeling,
the goal of this procedure is to determine the rotational offsets that will be used in the
Align > Lung phase and during treatment delivery.
2. Moving the treatment couch from the spine position to the lung position in the Align >
Lung phase. This step transitions from the Synchrony Spine Tracking Supine to Lung 1-
View Tracking with Respiratory Modeling. The goal of this step is to verify that the move is
successful, with rigid structures aligned in the DRR image and Live X-ray image that is
used for tracking.
3. Finding the optimal X-ray technique for treatment delivery using Lung 1-View Tracking
with Respiratory Modeling in the second Alignment > Technique phase.
4. Alignment for treatment using Lung 1-View tracking and establishment of a Respiratory
correlation model using the Synchrony Respiratory Tracking System, in the Alignment
> Respiratory phase.
5. (Optional) Remote approval of alignment with the TxView application. For information on
the TxView remote approval workflow, see “Requesting Remote Approval of Patient
Alignment (TxView Option)” on page 8-55.
6. (Optional) Use of the Physician Setup Approval button allows a physician to electronically
approve the current patient alignment. For more information on Physician Setup
Approval, see “Physician Setup Approval of Patient Alignment” on page 8-54.
• “Initial Alignment Using Synchrony Spine Tracking” on page 15-14
• “Transition to Lung 1-View Tracking with Respiratory Modeling” on page 15-15
• “Alignment for Treatment Using Lung 1-View Tracking with Respiratory Modeling” on
page 15-20
Initial Alignment Using Synchrony Spine Tracking

Initial alignment using Synchrony Spine Tracking Supine is performed in the Alignment >
Align phase as described in “Chapter 10: Synchrony Spine Tracking (Option)” The goal of this
step for Lung 1-View Tracking with Respiratory Modeling treatments is to determine the rotational
offsets that will be used in the Align > Lung phase and during treatment delivery in the
Delivery phase.
The Alignment > Align phase for a Lung 1-View Tracking with Respiratory Modeling treatment
is similar to that for a Synchrony Spine Tracking treatment, except that the Skip Spine checkbox
is not available (not displayed) for Lung 1-View Tracking with Respiratory Modeling treatments.

After aligning the patient properly within acceptable bounds using the Synchrony Spine Tracking
Supine, you are ready to move to the Alignment > Lung phase.
Transition to Lung 1-View Tracking with

Once alignment has been accomplished using Synchrony Spine Tracking Supine, you click the
Lung tab to transition to alignment using Lung 1-View Tracking with Respiratory Modeling in the
WARNING: Do not reposition the patient or adjust treatment couch rotation after
switching to Lung 1-View with Respiratory. If it is necessary to do this, return to the
Alignment > Align phase and repeat the Synchrony Spine Tracking alignment
procedure, as described in “Chapter 10: Synchrony Spine Tracking (Option)”. Otherwise,
incorrect patient displacement corrections will be used during treatment.
NOTE: If the treatment couch is moved out of the plane of the

image that is used for tracking, for example, using the Hand
Controller, you can click the Move to Couch Lung button in
the treatment couch position display in the
Alignment > Lung phase to return to the Lung 1-View
Tracking treatment center. Otherwise, you need to repeat the
Synchrony Spine Tracking alignment procedure in the
Alignment > Align phase before treatment can proceed.
The goal of this step is to move the treatment couch from the spine position to the lung position.
You then take an image and make sure that rigid structures are aligned in the DRR image and Live
X-ray image that is used for tracking.
NOTE: Do not attempt to manually align the tumor in the

Table 1 shows the treatment couch position display in the Alignment > Lung phase (left
screen, below Image A). The display includes a position indicator which shows the treatment couch
at one of 4 positions:
• At the spine position: The spine position (alignment center) from treatment planning plus
the final offsets from the Alignment > Align phase.
• At the lung position: The treatment position from planning. This is the spine position plus
the alignment-to-treatment offset from planning.
• Between the spine and lung position: The treatment couch is paused between or moving
between these two positions.


not represent actual targeting of the lung tumor.

Lung button is enabled.

Spine button is enabled.

the lung position.
In this state, both the Move
enabled.


paused between or moving
positions.
When paused, both the Move
enabled. During movement, all
controls are disabled except the
Interlock button.
Table 2 describes the buttons associated with the treatment couch position display.
Move Couch Moves the treatment couch to the lung position (treatment
to Lung position).
Move Couch Moves the treatment couch to the spine position

to Spine (alignment center).

system of the CyberKnife System. Visually observe all movement of the couch to prevent
potential collisions.
 To move to the lung position:

1. Click the Move Couch to Lung button. Then wait until the couch has moved to the
lung position.

2. Click the Acquire button to acquire a Live X-ray image. For more information on
acquiring Live X-ray images, see “Chapter 8: Treatment Delivery”.
3. Analyze imaging results to verify that rigid structures are aligned in the Live X-ray and
DRR images. Verify that there are no unexpected features or obstructions in the images.
For more information, see “Analyzing Imaging Results” on page 15-21.
If treatment couch motion is interrupted during the transition between Synchrony Spine Tracking
and Lung 1-View with Respiratory, for example, if an E-Stop button is pressed, you can use the
treatment couch position display to move to the spine or lung position, as described below.
 To move to the spine or lung position after treatment couch motion is interrupted:
• In the Alignment > Lung phase, click the Move to Spine button to move to the
spine position (alignment center). Or, click the Move to Lung position to move to the
lung position (treatment center).
If it is necessary, you can add an offset to the alignment-to-treatment offset from planning, as
described below.
 To add an offset to the lung position from planning:
1. Enter target translation values in the Couch Position (mm) textboxes.
Arrows above the textboxes point in the positive direction. Values indicate target
treatment couch movement relative to its current position.
2. Click the Move Couch button to move the treatment couch. (The couch rotations from
spine alignment are locked in the Alignment > Lung phase.)
The additional offset is automatically saved and will be applied during treatment delivery
for the current fraction and future fractions. (The Apply additional relative offset
checkbox is selected by default.)
3. To remove the additional offset that you generated in Step 2, or to remove the additional
offset that was saved and applied for previous fractions, deselect the Apply
additional relative offset checkbox. Then click the Move to Lung button.
This step returns the couch to the lung position (the treatment position from planning).
The lung position will then be used for the current fraction and future fractions.
After moving the treatment couch to the lung position, taking an image, and verifying that rigid
structures in the DRR image and Live X-ray image that is used for tracking are aligned, you are
ready to move to the second Alignment > Technique phase.


After aligning the patient properly at the lung position, you click the Technique tab to proceed to
the Alignment > Technique phase for lung, where you refine the X-ray technique that will be
used for treatment.
The goal of the second Alignment > Technique phase for Lung 1-View Tracking with
Respiratory Modeling treatments is to find the optimal X-ray technique. This X-ray technique will
be the default for future treatment fractions unless it is changed. You start by analyzing the existing
image from the Alignment > Lung phase.
correctly.
In the Alignment > Technique phase (left screen), a histogram display below each Raw
Image represents the distribution of pixel intensities in the entire image. Table 3 on page 15-23
describes the image panel controls to aid image analysis in this phase, including DRR display
modes.
evaluating image quality and histogram displays of images on the left screen and in the Image
History table.
If you have selected a satisfactory X-ray technique, you can proceed to the
Alignment > Respiratory phase. Otherwise, you can change the X-ray technique as needed
until you are satisfied with the image quality, as described below. For more information on the
Alignment > Technique phase, see “Chapter 8: Treatment Delivery”.

The Live X-ray images should have the same image quality as the DRR images. You can modify
the X-ray parameters to improve the quality of the image. If there is too little detail in the Live X-ray
images, you can try increasing the kV, mA, and ms settings to increase the exposure. If the
image is too dark, try decreasing the kV, mA, and ms settings to decrease the exposure. For
locating the tumor, it is best to maximize the contrast between the tumor and the surrounding
tissue.

Alignment for Treatment Using Lung 1-View

Tracking with Respiratory Modeling
The goal of the Alignment > Respiratory phase for Lung 1-View Tracking with Respiratory
Modeling treatments is to translationally align the patient sufficiently for tracking and to build a
Respiratory correlation model for patient respiratory motion.
Figure 6Figure 6 shows the Alignment > Respiratory phase (left screen) for Lung 1-
View Tracking with Respiratory Modeling after image acquisition, correlation and
respiratory modeling. For more information on the Synchrony Respiratory Tracking
System, see “Chapter 12: Synchrony Respiratory Tracking System (Option)”.
Figure 6 Alignment > Respiratory phase (left screen) for

Lung 1-View Tracking with Respiratory Modeling after
image correlation and respiratory modeling.
The Alignment > Respiratory phase has the following steps, described in the sections
below:
• “Analyzing Imaging Results” on page 15-21: You start by evaluating image correlation
results to determine if you need to move the treatment couch. You also review the Live X-
ray images to verify that the tumor has been correctly located and that anatomy in the
Live X-ray and DRR images matches.
• “Respiratory Alignment and Building a Respiratory Model” on page 15-32: You build a
Respiratory correlation model for respiratory motion.


• “Evaluating Image Correlation Results” on page 15-21
• “Monitoring and Adjusting Imaging Parameters” on page 15-28
Evaluating Image Correlation Results

The Live X-ray image used for tracking (either A or B, as specified during treatment planning) is
correlated with the corresponding reference DRR image to determine patient offsets. Because the
Lung 1-View with Respiratory algorithm does not estimate rotational offsets, only translational
offsets are displayed and updated in the Respiratory Model (mm) table.
If the tumor was successfully detected in the Live X-ray image used for tracking, a graphic overlay
of the tumor outline appears over the detected location of the tumor (see Table 3 on page 15-23).
For Lung 1-View Tracking with Respiratory Modeling, rotational offsets are not calculated during
treatment. The rotational corrections obtained from initial Synchrony Spine Tracking alignment are
used to perform rotation adjustments of the LINAC during treatment delivery. These Alignment
Rotational Correction (deg) values are displayed in the Respiratory Model (mm)
table.
If the calculated offsets are within tolerances required for treatment delivery, and you can verify
that the tumor has been correctly located in the Live X-ray image used for tracking and that
anatomy in the DRR image and Live X-ray image that is used for tracking matches, you are ready
to proceed with building a Respiratory Model. See “Respiratory Alignment and Building a
Respiratory Model” on page 15-32". To reduce offsets, you can move the treatment couch using
the Move Couch button. For more information on moving the couch, see “Chapter 8: Treatment
Delivery”.

If the 1-View with Respiratory algorithm cannot locate the tumor, the displayed tumor outline in the
Live X-ray image will not be aligned with the actual tumor. An out-of-bounds error may also occur,
indicated by an orange box around the row in the Respiratory Model (mm) table that is not
within required tolerances. Also tracking algorithm threshold violations may occur, indicated by an
orange box around the row in the table and around the slider bar for a threshold parameter.
In this situation, you can attempt one or more of the following:
• Make the following adjustments as appropriate:
 Use Offset Mode to drag the tumor outline in the Live X-ray image used for tracking to
determine translational offsets in the tracking plane. For more information, see “Using

 If you are unable to correlate successfully using Offset Mode, you can increase the
Tracking Range X and Tracking Range Y. For more information, see “Tracking
Range X (mm) and Tracking Range Y (mm)” on page 15-30.
• Couch Mode can be used to move the Live X-ray image used for tracking relative to the
corresponding DRR image to determine translational offsets in the tracking plane. For
more information, see Table 3 on page 15-23 and “Chapter 8: Treatment Delivery”.
collisions.
• You can also consider increasing the value of the Uncertainty threshold parameter if you
are confident that the tumor found using a higher value is correctly identified. For more
information, see “Uncertainty (%)” on page 15-29.

continue.
1-View with Respiratory algorithm to incorrectly identify the tumor without generating an
error. You must therefore visually verify that the tumor has been correctly identified in the
image used for tracking throughout the treatment.
For more information on image analysis tools to verify that the tumor is correctly located by the
tracking algorithm, see Table 3 on page 15-23. For information on calculated algorithm
parameters, parameter thresholds, and algorithm input parameters, see “Adjusting Algorithm
Parameters” on page 15-30.


Table 3 describes image panel controls and DRR display modes to aid image analysis.
Control Description

image.
(Lung 1-View Tracking with Respiratory Modeling) You can also use Offset Mode
when the Pointer is turned on. For more information, see “Using Offset Mode” on
page 15-27.


Control Description
clicking and dragging in either the Live X-ray image or DRR image. For more
information, see “Chapter 8: Treatment Delivery”. Depending on the treatment
phase, the following icons are displayed:
unshifted position.

Control Description
ITTV Outline: (Lung 1-View Tracking with Respiratory Modeling only) If the
The ITTV Outline is turned off by default.
Tumor Outline: (Lung 1-View Tracking with Respiratory Modeling; lower right of
image panel) Displays a graphic overlay of the tumor outline (Target Tracking
Volume, TTV) in the DRR images and Live X-ray images that corresponds to the
tumor contour specified during treatment planning. With Lung 1-View Tracking
with Respiratory Modeling, the tumor outline is only displayed in the Live X-ray
image that is used for tracking.
The Tumor Outline is turned on by default.
DRR images.
out automatically.

Control Description
Full Content DRR: (Lung 1-View Tracking with Respiratory Modeling) Displays
the unsegmented (full content) DRR images. See “Display Modes for DRR
Images” on page 15-27.
Spine Removed DRR: (Lung 1-View Tracking with Respiratory Modeling)

Displays the segmented DRR images, in which the spine and other bony
structures are removed and remaining DRR image content is displayed. See
Tumor Region DRR: (Lung 1-View Tracking with Respiratory Modeling; upper
right corner of image panel) Displays the tumor region DRR images, in which all
image content that is not in the immediate region of the tumor is removed. See
image is required.
i Turn on/off ITTV Outline. (Lung 1-View Tracking with


(Lung 1-View Tracking with Respiratory Modeling mode)


You can switch between 3 display modes for the DRR images in the image panels (see Table 3):
• Full Content DRR display mode
• Spine Removed DRR display mode
• Tumor Region DRR display mode
do not affect the results of the 1-View with Respiratory algorithm.
You can select different display modes for each image (corresponding to Camera B and Camera
A of the X-ray imaging system).
NOTE: Use Full Content DRR display mode for visual

evaluation of tracking results. You can switch back and forth
between display modes.
Using Offset Mode

If the Lung 1-View Tracking with Respiratory Modeling algorithm cannot locate the tumor, the
displayed tumor outline in the Live X-ray image will not be aligned with the actual tumor. In this
situation, you can use Offset Mode to assist the tracking algorithm by shifting the tumor outline
manually. You can click and drag the mouse in one of the Live X-ray images to move the tumor
outline and overlay it on the feature you have visually identified as the actual tumor. The
translational offsets determined by manually shifting the tumor outline are used as inputs to the
Lung 1-View Tracking with Respiratory Modeling algorithm.
1. Turn on the Pointer and Tumor Outline in the image panel (see Table 3 on page 15-23).
2. Move the cursor over the blue tumor outline in one of the Live X-ray images. The outline
turns red.
3. Click in the Live X-ray image to grab the tumor outline. Drag the tumor outline in the Live
X-ray image to overlay it on the feature you have visually identified as the actual tumor.
The outline remains red as you drag it. Depending on the movement, the tumor outline in
the opposing image may also move.
4. Let go of the tumor outline. It turns green while both Live X-ray images are automatically
correlated. The Lung 1-View Tracking with Respiratory Modeling algorithm uses the new
location of the tumor outline to search for the tumor.

Upon completion of the automatic correlation, a blue outline indicates the new location of
the tumor in the Live X-ray image. Updated offset values are displayed.

5. Verify that the tumor has been located correctly. Evaluate the updated offsets (see
“Evaluating Image Correlation Results” on page 15-21). You can then move the treatment
couch using the Couch Position (mm) and Couch Rotation (deg) textboxes
and the Move Couch button as needed. For more information on moving the couch,
collisions.
6. Click the AutoCouch button in the Alignment and Tracking window. The Automatic
Patient Positioning window is displayed. You can use the automatic patient positioning
system to move the treatment couch by the amounts indicated in the Couch
Corrections text fields.
For more information on the automatic patient positioning system, see “Chapter 8:
Monitoring and Adjusting Imaging Parameters


You can monitor value of the Uncertainty (%) parameter calculated by the Lung 1-View Tracking
with Respiratory Modeling algorithm. The value is updated when images are acquired or
correlated. The calculated value is displayed on the Acquisition Details tab of the Image
History table (right screen), as shown in Figure 7.

Figure 7 Calculated parameter display for Lung 1-View

Tracking with Respiratory Modeling on the Acquisition
Details tab
NOTE: The dxAB (mm) parameter value is not calculated or

displayed for Lung 1-View Tracking with Respiratory Modeling.
This calculated value is also displayed to the left of slider bar (left screen), where you can adjust
its threshold (see Figure 8). If the parameter value exceeds its threshold, a threshold violation
occurs, and an orange box is displayed around the slider bar. When a threshold violation occurs
the first time you are in the Alignment > Respiratory phase during a treatment fraction, you
cannot move to the next phase until the threshold violation is resolved.
Figure 8 Controls for adjusting algorithm parameters and

thresholds in the Alignment > Respiratory phase (left
screen)
The dxAB (mm) slider bar and the Preferred

Projection (ON) checkbox are disabled for Lung 1-View
Tracking with Respiratory Modeling treatments.
Uncertainty (%)
The Uncertainty (%) parameter gives the calculated detection uncertainty value for the Lung 1-
View Tracking with Respiratory Modeling algorithm. For more information on the detection
uncertainty, see “Quality Metrics” on page 15-7.

The 1-View with Respiratory algorithm calculates a detection uncertainty value for the image
(Image A or B) that is used for tracking. If the calculated value is higher than the Uncertainty
threshold parameter, an Uncertainty error occurs (see “Error Handling” on page 15-35).
you can consider increasing the Uncertainty (%) threshold if you are confident that the tracking
algorithm correctly located the target. For more information, see “Adjusting Algorithm Parameters”
on page 15-30.

continue.
1-View with Respiratory algorithm to incorrectly identify the tumor without generating an
error. You must therefore visually verify that the tumor has been correctly identified
throughout the treatment.

recommended for use. If the 1-View with Respiratory algorithm fails or a threshold violation occurs,
adjusting some of the parameters may allow successful tracking.
• “Tracking Range X (mm) and Tracking Range Y (mm)” on page 15-30
Tracking Range X (mm) and Tracking Range Y (mm)

There are two Tracking Range parameters:
• Tracking Range X (mm)
• Tracking Range Y (mm)
The Tracking Range parameters define the search area within which the 1-View with Respiratory
algorithm searches for the target in the image used for tracking. During image registration, a
matching window is moved throughout this search area to search for the desired intensity pattern.
For more information on the search area and the matching window, see “Lung 1-View Tracking
with Respiratory Modeling Algorithm” on page 15-6.
The default Tracking Range X and Tracking Range Y values are 12.0 mm. The Tracking Range is
the distance from the center of the Live X-ray images that the tracking algorithm will search for the
target. Depending on target location and/or motion, users may find it helpful to increase and/or
decrease this value during treatment.
In most cases, the default value will be sufficient.

page 15-29). Alternatively, enter a new value in the textbox to the right of the slider bar
and press <Enter>.

continue.
default value.
Images are automatically correlated when a Tracking Range parameter is changed.
A slider bar on the left screen allows you to monitor and change the value of the following algorithm
parameter threshold (see Figure 9):
For information on this parameter, see “Calculated Algorithm Parameters” on page 15-28.
Current Default Adjustable Current

Calculated Value of Threshold Threshold
Value Threshold Cursor Value
Figure 9 Uncertainty slider bar

value.

value.

continue.
Lung 1-View with Respiratory algorithm to incorrectly identify the tumor without
generating an error. You must therefore visually verify that the tumor has been correctly
identified.
Respiratory Alignment and Building a Respiratory Model

If the Synchrony tracking System will be used to track respiratory motion, you must also build a
Respiratory correlation model before starting treatment delivery.
The Skip Respiratory checkbox (Figure 6 on page 15-20) is deselected (cleared) by default so
that the Synchrony tracking System is enabled.
Selecting the Skip Respiratory checkbox disables use of the Synchrony tracking System for
treatment delivery and changes the appearance of the left screen of the Respiratory phase. The
Respiratory Model (mm) table is replaced by the Offsets panel displayed in the
Alignment > Align phase. Offset values for only the most recent image are displayed, and
dashes are displayed for the calculated rotations.
For information on building a Respiratory correlation model and using the Synchrony tracking
System during treatment delivery, see “Chapter 12: Synchrony Respiratory Tracking System
(Option)”

Treatment Delivery
• “Visual Inspection During Treatment Delivery” on page 15-34
The Delivery phase (left screen) for 1-View with Respiratory is shown in Figure 10. Controls on
this screen and the right screen allow you to monitor and verify patient alignment and tracking
results, as well as the Respiratory Model, during treatment delivery using 1-View with Respiratory.
Figure 10 Delivery phase (left screen) for Lung 1-

View with Respiratory
Because the 1-View with Respiratory algorithm does not estimate rotational offsets, only
translational offsets are displayed and updated in the Calculated column during treatment.
Dashes are displayed for the calculated rotational offsets. In the Applied column, the rotational
offsets that are displayed and used to perform rotation adjustments of the LINAC during treatment
are the rotational corrections obtained from initial Synchrony Spine Tracking alignment.
information on the Synchrony tracking System, see “Chapter 12: Synchrony Respiratory Tracking
System (Option)”. For information on treatment planning for treatment using 1-View with
Respiratory, see the Treatment Planning Manual.

Visual Inspection During Treatment Delivery
WARNING: Visually compare the DRR and Live X-ray images to ensure that features are
similar in both.
WARNING: During treatment delivery, after acquisition of Live X-ray images, visually
verify the patient position and verify that the tumor is visible in the image used for
tracking. Make sure that anatomy in the Live X-ray and DRR images matches. For more
information on visually identifying features to be tracked, see “Chapter 8: Treatment
Delivery”.

The Treatment Monitoring graph for the 1-View with Respiratory includes a Lung graph display
(Figure 11). This display shows one of the following parameters as a function of time, depending
on whether Lung 1-View A Tracking or Lung 1-View B Tracking is used:
• Uncertainty A (%): The detection uncertainty level in Live X-ray image A, or
• Uncertainty B (%): The detection uncertainty level in Live X-ray image B.
This graph allows you to observe the value of the above parameter during treatment delivery as an
indication of tracking reliability.
Figure 11 Treatment Monitoring graph for 1-View B

Lung Tracking with Respiratory Modeling

Error Handling
The 1-View with Respiratory algorithm may fail for the following reason:
• “Uncertainty Error” on page 15-35
During patient alignment in the Alignment > Align phase, when the calculated value of this
parameter exceeds the value of its threshold, a threshold violation occurs. An orange box is then
displayed around the slider bar for that parameter threshold.
For information on resuming treatment after a Soft Stop, see “Chapter 8: Treatment Delivery”.
Uncertainty Error
An Uncertainty Error occurs when the computed value of the Uncertainty parameter exceeds the
value of the Uncertainty threshold parameter during the Delivery phase. For more information
about the detection uncertainty, see “Uncertainty (%)” on page 15-29.

continue.
WARNING: If you increase the value of the Uncertainty (%) threshold, the 1-View with
Respiratory algorithm may incorrectly identify the tumor without generating an error. You
must therefore visually verify that the tumor has been correctly identified.

Patient Realignment
The same as for patient alignment, patient realignment has two phases:
• Realignment using the Synchrony Spine Tracking Supine.
• Realignment using 1-View with Respiratory.
An example case when this is necessary is when the patient moves during treatment and global
patient rotational alignment needs to be recalculated.
If the Synchrony tracking System is being used and treatment delivery is interrupted by a Soft Stop,
an E-Stop, or a Pause, if the Respiratory correlation model is still valid, you can click the Start/
Resume button to resume treatment.

Alternatively, you can choose to return to Synchrony Spine Tracking alignment.

 To return to Synchrony Spine Tracking alignment:
1. Move back to the Alignment > Lung phase and click the Move to Spine button.
2. Then move to the Alignment > Align phase and perform spine alignment. See “Initial
Alignment Using Synchrony Spine Tracking” on page 15-14.
NOTE: If the treatment couch is moved to the alignment center

for Synchrony Spine Tracking alignment, the Respiratory
correlation model will become invalid. In this case, a new
Respiratory Model must be established before you can resume
treatment delivery using 1-View with Respiratory.
For more information on using resuming treatment after treatment interruption, see “Chapter 8:
References
1. ICRU Report 62 (1999) Prescribing, Recording and Reporting Photon Beam Therapy.
International Commission on Radiation Units and Measurements, Bethesda, MD.
(Supplement to ICRU Report 50.)
15-36 | References 1075883-ENG A

Appendix A: Error Messages
What To Do About Errors

WARNING: Any hardware or software related problems should be recorded in the
appropriate log and reported to Accuray as soon as possible. Failure to do so may result in
injury or death to users or the patient.
The CyberKnife System displays three types of errors: recoverable Emergency Stops (E-Stops),
unrecoverable E-Stops, and Soft Stops. The Error Handling System screen displays information
about E-stop s.
Figure 1 shows an example Error Handling System screen for a recoverable E-Stop. The example
shows the E-Stop that is active and lists the actions you may take to resolve it. If there is more than
one option for resolving an E-Stop, generally, the first item in a list of resolutions is the main cause
of the problem. However, it is important to review the entire list because another item may have
triggered the error. You can correct recoverable errors. If several errors have the same timestamp,
correct the earliest error in the list first, because it may be the cause of the others. The most recent
error is listed at the top of the list.
Some errors can be caused by hardware or software. All software-related errors and hardware
errors can be either recoverable or unrecoverable. An Accuray Service Engineer must correct
unrecoverable errors. An example of an unrecoverable software error is an incorrect data file.
The following types of error messages are described below:
• “Error Handling System Screen Errors” on page A-2
• “Readiness Phase Error Messages” on page A-64
• “Delivery Phase Error Messages” on page A-68
1075883-ENG A What To Do About Errors | A-1

Figure 1
An E-Stop causes termination of treatment couch movement, treatment robot

movement, and radiation delivery. If a recoverable E-Stop occurs and is corrected (see Table 1 on
page A-3), you must reset the CyberKnife System to continue operation. Resetting the CyberKnife
System involves clearing all E-Stops and error detection systems. After the CyberKnife System has
been successfully reset, you can either resume treatment or a makeup fraction can be created. For
more information on resuming treatment, see “Chapter 8: Treatment Delivery”.
The Messages area on the right screen during the Readiness phase of treatment displays
information, warnings, or errors related to treatment setup (Table 2 on page A-64). The messages
are triggered by such conditions as overly high error thresholds, laser alignment check failures, or
patient misalignment.
The Messages area on the right screen during the Delivery phase of treatment displays Soft
Stop, delivery inhibitor, and informational messages (Table 3 on page A-68). Soft Stops are
triggered by imaging errors, such as image algorithm errors, or by patient out-of-bounds errors.
The Messages window also displays information about conditions that inhibit the start or
resumption of treatment delivery.
Error Handling System Screen Errors

Table 1 lists all presently known errors of the CyberKnife System that are displayed in the Error
Handling System screen. Follow the suggested action for correcting the problem. Error numbers
indicate the following:
• Error numbers 1xxxx are notifications that do not require confirmation in order to resume
treatment.
• Error numbers 2xxxx are recoverable errors that require only a confirmation.
• Error numbers 3xxxx are unrecoverable errors that require a confirmation and a power
cycle.
A-2 | What To Do About Errors 1075883-ENG A

Treatment Delivery Manual Appendix A: Error Messages
• Error numbers 4xxxx are unrecoverable errors that require a software recycle and power
cycle.
NOTE: When contacting Accuray Customer Support, include

any log files generated to help clarify the issue.
Table 1 CyberKnife System Error Handling System error messages
No. Description Resolution
10010 Error reading RAID status. Contact Accuray. Contact Accuray Customer Support.
10011 A disk of the RAID array is faulty. Contact Accuray. Contact Accuray Customer Support.
10012 Invalid RAID status. Contact Accuray. Contact Accuray Customer Support.
10013 iDMS Error: Data server RAID status is Critical. See the System Administration
application of the iDMS Data
Management System for more
information.
10014 iDMS Warning: Data server RAID status could not See the System Administration
be determined. application of the iDMS Data
information.
10015 iDMS Error: Unable to determine data server RAID See the System Administration
status. application of the iDMS Data
information.
10016 iDMS Error: Storage Vault RAID status is Critical. See the System Administration
information.
10017 iDMS Warning: Unable to determine Storage Vault See the System Administration
RAID status. application of the iDMS Data
information.
10018 Network teaming interface invalid. Contact Accuray Customer Support.
10020 Error reading power supply status. Contact Contact Accuray Customer Support.
Accuray.

Table 1 CyberKnife System Error Handling System error messages (continued)
10021 At least one computer power supply is unplugged Contact Accuray Customer Support.
or faulty. Contact Accuray.
10022 Invalid power supply status. Contact Accuray. Contact Accuray Customer Support.
10023 iDMS Warning: Storage Vault disk status is See the System Administration
Warning. application of the iDMS Data
information.
10024 iDMS Error: Storage Vault disk status is Failure. See the System Administration
information.
disk status. application of the iDMS Data
information.
10026 iDMS Warning: Storage Vault system status is See the System Administration
Warning. application of the iDMS Data
information.
10027 iDMS Error: Storage Vault system status is Failure. See the System Administration
information.
system status. application of the iDMS Data
information.
10029 Error writing file to disk. Contact Accuray Customer Contact Accuray Customer Support.
Support.
10030 Error reading disk space status. Contact Accuray. Contact Accuray Customer Support.
10031 Warning: The disk is 70% full. Please take action to Contact Accuray Customer Support.
reduce disk usage. Normal operation is allowed
until the disk is 95% full, at which point further
treatment activities will not be allowed.

10036 WARNING: The disk is 95% full! Any ongoing Contact Accuray Customer Support.
patient treatment is allowed, but new patient
treatments will not be allowed until usage is below
95% full (maximum). If the disk becomes
completely full, no system operations will be
allowed.
10037 Invalid disk space status. Contact Accuray. Contact Accuray Customer Support.
10038 Warning: The free space on the disk is low. Please Contact Accuray Customer Support.
take action to reduce disk usage. Syncing data for
service access will resume once the disk space
frees up.
10040 Error determining UPS status. Contact Accuray. Contact Accuray Customer Support.
10041 UPS reports running out of battery power. System Contact Accuray Customer Support.
is shutting down.
10042 Uninterruptible Power Supply (UPS) reports Contact Accuray Customer Support.
system is running on battery power with 15 or more
minutes remaining. If power is not restored, the
system will shutdown automatically.

system is running on battery power with 12 minutes
remaining. If power is not restored the system will
shutdown automatically.
10049 Failed to communicate with Uninterruptible Power Contact Accuray Customer Support.
Supply (UPS). Contact Accuray.
10050 Uninterruptible Power Supply (UPS) reports battery Contact Accuray Customer Support.
fault. Contact Accuray.
10051 Invalid UPS status. Contact Accuray. Contact Accuray Customer Support.
10052 iDMS Warning: The iDMS Uninterruptible Power See the System Administration
Supply (UPS) is now on battery power. application of the iDMS Data
information.

10053 iDMS Error: Unable to determine iDMS See the System Administration
Uninterruptible Power Supply (UPS) status. application of the iDMS Data
information.
10054 iDMS Error: Last backup failed. See the System Administration
information.
10055 iDMS Error: Unknown backup status. See the System Administration
information.
10056 iDMS Error: Minimum disk capacity not available. See the System Administration
information.
10057 iDMS Warning: Minimum disk capacity could not See the System Administration
be calculated. application of the iDMS Data
information.
10058 iDMS Warning: Previous data server shutdown See the System Administration
was unexpected. application of the iDMS Data
information.
10060 Failed to read Security Configuration file. Contact Contact Accuray Customer Support.
Accuray.
10061 Note: System datafile security check is currently Contact Accuray Customer Support.
disabled.
10062 Invalid datafile security status. Contact Accuray. Contact Accuray Customer Support.
10063 System Data Logging is not synchronized with Contact Accuray Customer Support.
iDMS. Contact Accuray.
10064 Failed to read System Data Logging status. Contact Accuray Customer Support.
Contact Accuray.
10065 System Data Logging synchronization status is Contact Accuray Customer Support.
unknown.

10066 Invalid System Data Logging status. Contact Contact Accuray Customer Support.
Accuray.
10070 Error determining iDMS connection status. Contact Contact Accuray Customer Support.
Accuray.
10071 The network connection to iDMS is unavailable. Contact Accuray Customer Support.
The current fraction (if any) and newly generated
make-up fractions will be treatable, but other
treatments will not be possible until the connection
is re-established.
10072 Invalid iDMS connection status. Contact Accuray. Contact Accuray Customer Support.
10073 OIS error: Failed to open appointment from OIS. Check Worklist service.
10074 Unable to send RT plan to OIS. Export to OIS from See the System Administration
iDMS is required. See iDMS System Administration application of the iDMS Data
for more information. Management System for more
information.
10075 Unable to send RT record to OIS. Manual input of See the System Administration
associated records into OIS is required. See iDMS application of the iDMS Data
System Administration for more information. Management System for more
information.
10076 RT plan from OIS does not match CyberKnife See the System Administration
treatment plan. See iDMS System Administration application of the iDMS Data
for more information. Management System for more
information.
10077 OIS error: Failed to send treatment record. Use Plan Administration to resend.
10078 OIS error: OIS general error. Contact Accuray Customer Support.
10080 Failed to read Supplemental Proximity Detection Contact Accuray Customer Support.
Program status. Contact Accuray Customer
Support.
10081 Invalid Supplemental Proximity Detection Program Contact Accuray Customer Support.
status. Contact Accuray Customer Support.
10082 Supplemental Proximity Detection Program is not Contact Accuray Customer Support.
currently functioning.

10084 E-Stop Interlock Control Chassis (ELCC) and If problem persists, contact Accuray
treatment robot show an interlock status mismatch. Customer Support.
treatment couch show an interlock status Customer Support.
mismatch.
LINAC application in Physics mode show an Customer Support.
interlock status mismatch.
Secondary Collimator System show an interlock Customer Support.
status mismatch.
Collision Avoidance System show an interlock Customer Support.
status mismatch.
10089 iDMS Error: The cis log file is too large. See the System Administration
information.
10090 iDMS Warning: The cis log file does not exist. See the System Administration
information.
10091 iDMS Error: Status of the cis log file is unknown. See the System Administration
information.
10092 Master version check is disabled. Contact Accuray Customer Support.
10093 Local version check is disabled. Contact Accuray Customer Support.
10094 Collimator housing ready. You can now move the If problem persists, contact Accuray
treatment robot. Customer Support.
20100 E-Stop button on the LINAC Modulator Control Release E-Stop button on Modulator
Chassis (MCC) is depressed. Control Chassis (MCC) and then
press Fault Reset button on the
MCC.

20101 Software E-Stop detected No corrective action required
20102 One or more E-Stop buttons on the walls are (or Make sure all E-Stop buttons on the
were) depressed. walls are released.
20103 Karel E-Stop detected No corrective action required
20104 Treatment Room door E-Stop detected. Close Treatment Room door.
20105 Cable stretch E-Stop detected Contact Accuray Customer Support.
20106 The E-Stop button on the operator control panel is Make sure the E-Stop button on the
(or was) depressed. operator control panel is released.
20107 LCF E-Stop detected No corrective action required
20108 E-Stop button on the treatment robot Teach Release E-Stop buttons.
Pendant or manipulator controller cabinet is
depressed.
20109 ESCC modulator E-Stop detected No corrective action required
20111 E-Stop has been cleared. Try to reset the system No corrective action required
again.
20112 LINAC driver process communication error If problem persists, contact Accuray
(socket) Customer Support.
20113 LINAC driver process communication error (ping) If problem persists, contact Accuray
Customer Support.
20114 LINAC driver process communication error (CVT) If problem persists, contact Accuray
Customer Support.
20115 LINAC process communication error: LINAC If problem persists, contact Accuray
Control Computer (LCC) to Programmatic Logical Customer Support.
Circuit (PLC).
20116 LINAC process communication error: Treatment If problem persists, contact Accuray
delivery computer to LINAC Control Computer Customer Support.
(LCC)
20117 LINAC leakage is too high. If problem persists, contact Accuray

Customer Support.

20118 LINAC dose measurement channels differ by too If problem persists, contact Accuray
much. Customer Support.
20119 LINAC beam indicator is ON but no dose is If problem persists, contact Accuray
detected. Customer Support.
20120 LINAC outbound dose rate error If problem persists, contact Accuray
Customer Support.
20121 LINAC time limit for beam delivery has been If problem persists, contact Accuray
exceeded. Customer Support.
20122 Error: A local application is running on the LINAC Terminate the local application on
Control Computer (LCC). the LINAC Control Computer (LCC).
20123 LINAC water flow is low. Add water. If problem persists,

20124 LINAC SF6 gas pressure is low. Add SF6 gas. If problem persists,
20127 LINAC reports a hardware fault. If problem persists, contact Accuray

Customer Support.
20128 LINAC reports an unknown hardware fault. If problem persists, contact Accuray
Customer Support.
20129 High Voltage key on the operator control panel is Turn the High Voltage key on the
not in the ON position. operator control panel to the ON
position.
20151 Linac SF6 gas is low Recharge the system with SF6 gas
20152 Linac high voltage error Contact Accuray Customer Support.
20153 Linac water flow error Contact Accuray Customer Support.
20154 Linac Vacuum Fault Select the Reset button to reset

Linac
20155 Linac inverse current error Contact Accuray Customer Support.
20157 Collimator fault Contact Accuray Customer Support.

20158 Magnetron filament UC fault Contact Accuray Customer Support.
20160 GRID power supply fault Contact Accuray Customer Support.
20189 Dose rate A higher than limit Contact Accuray Customer Support.
20190 Dose rate B higher than limit Contact Accuray Customer Support.
20218 Beam status is on but no dose is being delivered. Contact Accuray Customer Support.
20220 No Software E-Stop detected during power up Check that the software E-Stop
sequence. bypass switch is not in maintenance
mode
20223 Dose rate A lower than limit Contact Accuray Customer Support.
20224 Dose rate B lower than limit Contact Accuray Customer Support.
20225 High voltage went off unexpectedly Contact Accuray Customer Support.
20230 LINAC reports hardware fault. If problem persists, contact Accuray

(0: CORE_BIAS_I_FAULT) Customer Support.

(1: MR_LOW_WATER_FLOW_FAULT) Customer Support.

(2: MAG_ION_V_FAULT) Customer Support.

(3: MAG_ION_I_FAULT) Customer Support.

(4: ACCEL_ION_V_FAULT) Customer Support.

(5: ACCEL_ION_I_FAULT) Customer Support.

(6: GD_HTR_I_FAULT) Customer Support.


(7: STRG_X1_I_FAULT) Customer Support.

(8: STRG_Y1_I_FAULT) Customer Support.

(9: STRG_X2_I_FAULT) Customer Support.

(10: STRG_Y2_I_FAULT) Customer Support.

(11: TG_PRF_MON_FAULT) Customer Support.

(12: LPDU_AC_PWR_ON_FAULT) Customer Support.

(13: LPDU_HV_PWR_ON_FAULT) Customer Support.

(14: MD_PFN_GND_RELAY_FAULT) Customer Support.

(15: GD_GRID_BIAS_UNDERVOLTAGE_FAULT) Customer Support.

(16: GD_CATH_OVERVOLTAGE_FAULT) Customer Support.

(17: GD_CATH_OVERCURRENT_FAULT) Customer Support.

(18: MD_HVPS_IL_FAULT) Customer Support.

(19: TG_SET_PRF_FAULT) Customer Support.

(20: MD_MAG_ARC_RATE_FAULT) Customer Support.

(21: FFD_MAG_AVG_I_FAULT) Customer Support.

(22: XH_AIR_TEMP_SENSOR_FAULT) Customer Support.


(23: XH_AFC_POSITION_FAULT) Customer Support.

(24: FFD_PTW_MASTER_FAULT) Customer Support.

(25: FFD_MD_HVPS_SUM_FAULT) Customer Support.

(26: FFD_GD_SUM_FAULT) Customer Support.

(27: FFD_RABBIT_FAULT) Customer Support.

(28: FFD_TG_RABBIT_FAULT) Customer Support.

(29: FFD_VAC_PS1_2_RABBIT_FAULT) Customer Support.

(30: MD_HVPS_LOAD_FAULT) Customer Support.

(31: MD_HVPS_OT_FAULT) Customer Support.

(32: FFD_STRG_PS_XY1_RABBIT_FAULT) Customer Support.

(33: FFD_STRG_PS_XY2_RABBIT_FAULT) Customer Support.

(34: MR_LONG_LOW_WATER_FLOW_FAULT) Customer Support.

(35: MR_SF6_PRESS_SW_FAULT) Customer Support.

(36: MD_HVPS_HV_ON_FAULT) Customer Support.

(37: MD_PFN_CHAS_PNL_FAULT) Customer Support.

(38: MD_CHAS_TEMP_FAULT) Customer Support.


(39: LPDU_MAG_FIL_I_FAULT) Customer Support.

(40: LPDU_SUMMARY_FAULT) Customer Support.

(41: GD_HVPS_OC_FAULT) Customer Support.

(42: GD_HV_ON_FAULT) Customer Support.

(43: LPDU_THY_PWR_FAULT) Customer Support.

(44: LPDU_MAG_PWR_FAULT) Customer Support.

(45: LPDU_MAG_PWR_HV_FAULT) Customer Support.

(46: GD_COVER_IL_FAULT) Customer Support.

(47: GD_BIAS_UV_FAULT) Customer Support.

(48: MD_HV_ON_PRE_FAULT) Customer Support.

(49: HV_OFF_TIME_OUT_FAULT) Customer Support.

(50: CORE_BIAS_I_OV_FAULT) Customer Support.

(51: GD_WARMUP_IND_FAULT) Customer Support.

(52: GD_STANDBY_IND_FAULT) Customer Support.

(53: FFD_SUM_FAULT) Customer Support.

(54: BEAM_TERMINATION_FAULT) Customer Support.


(55: FFD_OC_DOOR_POS_FAULT) Customer Support.

(56: HV_OFF_BUTTON_FAULT) Customer Support.

(57: MD_HVPS_V_FAULT) Customer Support.

(58: PLC_INTERNAL_FAULT) Customer Support.
20300 System E-Stop engaged unexpectedly. Click Continue button. If problem

persists, contact Accuray Customer
Support.
20301 Error Handling System communication error. No corrective action required
20303 System E-Stop is unexpectedly clear. Make sure Software E-Stop is not
bypassed on E-Stop Control
Chassis (ESCC).
20304 Error Handling System timed out attempting to Review prior events in this table. If
clear System E-Stop. necessary, click the Show All button
to view prior events. Resolve all
unresolved errors. Then click
Continue and try again. If problem
Support.
20305 Error Handling System timed out while attempting Make sure Software E-Stop is not
to set System E-Stop. bypassed on E-Stop Control
Chassis (ESCC).
20306 Error Handling System failed attempting to clear Try again. If problem persists,
System E-Stop. contact Accuray Customer Support.
20307 Error Handling System internal queue error. Click Continue button. If problem
Support.
20308 Software E-Stop unexpectedly clear. Make sure Software E-Stop is not
bypassed on E-Stop Control
Chassis (ESCC).

20309 Software E-Stop state is unknown or is If problem persists, contact Accuray

unexpectedly clear. Customer Support.
20310 Equipment is powering down. System E-Stop No corrective action required

status is currently clear but will no0w change to
engaged.
20312 A Secondary Collimator System device fault may If the problem persists, contact
have occurred. Accuray Customer Support. If
another E-Stop occurred first, the
problem is not due to a Secondary
Collimator System device fault.
20315 Treatment couch reports a violation of joint angle If problem persists, contact Accuray
limit(s). Customer Support.
20316 Treatment couch console issued a local interlock/ If problem persists, contact Accuray
E-Stop via the treatment couch. Customer Support.
20317 Secondary Collimator System issued a local If problem persists, contact Accuray
interlock/E-Stop via the treatment couch. Customer Support.
20318 Remote client (TMT adapter) issued a local If problem persists, contact Accuray
interlock/E-Stop via the treatment couch. Customer Support.
20319 A treatment couch client issued a local interlock/E- If problem persists, contact Accuray
Stop. Customer Support.
20320 The key on the treatment couch Teach Pendant is Put the treatment couch Teach
not in External mode. Pendant key in the External mode
position.
20321 E-Stop button on RoboCouch Teach Pendant or Release E-Stop buttons.

RoboCouch controller cabinet is depressed.
20322 E-Stop button on RoboCouch Hand Controller is Release E-Stop button, if button is
depressed, or there is a failure to communicate depressed. Otherwise, continue.
with Hand Controller.
20323 Unexpected RoboCouch Teach Pendant program Turn the key on the RoboCouch
execution mode. Teach Pendant back and forth. If
problem persists, cycle RoboCouch
controller power or contact Accuray
Customer Support.

20324 RoboCouch Axis A4 and/or Axis A5 limit switch is Examine the treatment couch. When
engaged. it is safe to do so, move the
treatment couch away from the limit.
20325 RoboCouch Axis A1 limit switch is engaged. Examine the treatment couch. When
it is safe to do so, move the
20326 RoboCouch forearm or offset bracket collision Examine the treatment couch. When
detection engaged. it is safe to do so, move the
20327 Contact sensor on RoboCouch upper arm has Examine the treatment couch. When
detected a pinch condition. it is safe to do so, move the
treatment couch to relieve the pinch
condition.
20328 RoboCouch contact sensor has detected a pinch Examine the treatment couch. When
condition at the foot of the table. it is safe to do so, move the
treatment couch to relieve the pinch
condition.
20329 RoboCouch contact sensor has detected a pinch Examine the treatment couch. When
condition at the foot of the table or at the offset axis it is safe to do so, move the
(Axis A7). treatment couch to relieve the pinch
condition.
20330 RoboCouch Seat Angle and/or Seat Height Make sure Seat Angle and/or Seat
Adjustment knobs are not latched. Height Adjustment knobs are fully
latched.
20331 Treatment couch received a stop message from If problem persists, contact Accuray
the Supplemental Proximity Detection Program. Customer Support.
20332 Treatment couch interlock is inconsistent with E- If problem persists, recycle power to
Stop Interlock Control Chassis (ELCC). the treatment couch.
20333 Treatment couch E-Stop is inconsistent with E- If problem persists, recycle power to
Stop Interlock Control Chassis (ELCC). the treatment couch.
20335 RoboCouch failed to set joint angle limits. Move the RoboCouch to the treat
position. If problem persists, contact
20336 RoboCouch joint torque limit exceeded. If problem persists, contact Accuray
Customer Support.

20340 Xchange process canceled due to invalid sensor If problem persists, contact Accuray
triggered. Customer Support.
20341 Xchange process canceled due to invalid sensor If problem persists, contact Accuray
readings. Customer Support.
20342 Treatment robot was unable to complete a move If problem persists, contact Accuray
during the Xchange process. Customer Support.
20343 A system error has interrupted the automated If problem persists, contact Accuray
Xchange process. Customer Support.
20344 Background light on Xchange table too high. If problem persists, contact Accuray
Customer Support.
20345 An invalid process is requesting SCS task client If problem persists, contact Accuray
services. Customer Support.
20346 Two or more processes are requesting SCS task If problem persists, contact Accuray
client services. Customer Support.
20347 The request is not valid for the current status of the If problem persists, contact Accuray
collimator housing. Customer Support.
20348 Secondary Collimator System general error. If problem persists, contact Accuray
Customer Support.
20349 Iris collimator information does not match the data Pick up a different housing and then
file. pick up the Iris housing again. If
problem persists, contact Accuray
Customer Support.
20350 Air pressure for housing is too low Contact Accuray Customer Support.
20351 Problem releasing collimator housing. Contact Accuray Customer Support.
20352 Problem engaging collimator housing. Contact Accuray Customer Support.
20353 Xchange table drawer is open. Close the Xchange table drawer.
20354 Iris collimator motion error. Contact Accuray Customer Support.
20355 Iris collimator initialization error. Contact Accuray Customer Support.

20356 Wrong collimator size. Contact Accuray Customer Support.
20357 Treatment robot is not at the designated starting Collimator Change only available
position. from perch.
20358 Problem communicating with the Xchange table. If problem persists, contact Accuray
Customer Support.
20359 XCHANGE general error Contact Accuray Customer Support.
20360 Iris motor stall Contact Accuray Customer Support.
20361 Problem with pneumatics for Iris collimator Contact Accuray Customer Support.
housing.
20362 Invalid collimator cup type (Xchange table Model A Contact Accuray Customer Support.
or Model B).
20363 Invalid command received. If problem persists, contact Accuray

Customer Support.
20364 PTCU Communication error. If problem persists, contact Accuray

Customer Support.
20365 Either a fixed collimator is missing or an If problem persists, contact Accuray

unexpected potentiometer reading has been Customer Support.
detected.
20366 Invalid Xchange configuration file detected. Contact Accuray Customer Support.
20367 Iris aperture change failed. If problem persists, contact Accuray

Customer Support.
20368 Iris aperture changed unexpectedly. If problem persists, contact Accuray

Customer Support.
20369 Problem with Safe-to-Release signal. Contact Accuray Customer Support.
20370 External E-Stop detected. If problem persists, contact Accuray

Customer Support.
20371 DVRT2 reading is not consistent with DVRT1 If problem persists, contact Accuray
reading. Customer Support.

20372 Contact Detection Sensor bypass is in an Contact Accuray Customer Support.

unexpected state.
20373 An invalid process is requesting SCS task client If problem persists, contact Accuray
services. Customer Support.
20375 The request is not valid for the current status of the If problem persists, contact Accuray
collimator housing. Customer Support.
20376 Secondary Collimator System general error. If problem persists, contact Accuray
Customer Support.
20377 ICCU DVRT Signals Latched up. Reset required. Contact Accuray Customer Support.
20378 Either collimator is missing or PTCU potentiometer If problem persists, contact Accuray
signals are latched up. Insert collimator or reset Customer Support.
power.
20379 ICCU Communication error. If problem persists, contact Accuray

Customer Support.
20380 ICCU DMOD Reference voltage operational error. If problem persists, contact Accuray
Customer Support.
20381 Iris Collimator motor brake failure. If problem persists, contact Accuray
Customer Support.
20382 Iris Collimator temperature control system failed, or If problem persists, contact Accuray
temperature out of range. Customer Support.
20383 Iris Collimator middle limit switch failure. If problem persists, contact Accuray
Customer Support.
20384 Collimator housing detection problem occurred. If problem persists, contact Accuray
Customer Support.
20385 Iris motor problem. If problem persists, contact Accuray

Customer Support.
20386 Cannot detect contact sensor. If problem persists, contact Accuray

Customer Support.
20387 Secondary Collimator System device fault. If problem persists, contact Accuray
Customer Support.

20398 Secondary Collimator System device on E-Stop If problem persists, contact Accuray
Interlock Control Chassis (ELCC) is in bypass Customer Support.
state.
20399 Path file and Secondary Collimator System If problem persists, contact Accuray
requests do not match. Customer Support.
20400 Internal logic error: Error Handling System (EHS) If problem persists, call Accuray
to E-Stop Interlock Control Chassis (ELCC) Customer Support.
processing
20401 Treatment delivery computer cannot communicate If problem persists, call Accuray
with E-Stop Interlock Control Chassis (ELCC). Customer Support.
20402 Treatment delivery computer command to E-Stop If problem persists, call Accuray
Interlock Control Chassis (ELCC) failed. Customer Support.
20403 Treatment delivery computer cannot connect to E- If problem persists, call Accuray
Stop Interlock Control Chassis (ELCC). Customer Support.
20404 E-Stop Interlock Control Chassis (ELCC) is not in Turn key on E-Stop Interlock Control
Remote Mode. Chassis (ELCC) to Remote Mode.
20405 E-Stop Interlock Control Chassis (ELCC) Call Accuray Customer Support.
configuration is invalid.
20406 E-Stop Interlock Control Chassis (ELCC) has a If problem persists, call Accuray
fault. Customer Support.
20408 The LINAC E-Stop button is (or was) depressed. Make sure the LINAC E-Stop button
is released.
20415 Unknown E-Stop is engaged. Release E-Stop.
20416 LINAC has set its interlock. If problem persists, call Accuray
Customer Support.
20417 Secondary Collimator System has an interlock. If problem persists, call Accuray
Customer Support.
20418 Treatment robot has set its interlock. If problem persists, call Accuray
Customer Support.

20419 Treatment couch has set its interlock. If problem persists, call Accuray
Customer Support.
20420 Treatment Room door is open. Close Treatment Room Door.
20421 Collision Avoidance System has an interlock. Inspect the Treatment Room and
correct the problem.
20422 Unknown interlock. If problem persists, call Accuray

Customer Support.
20423 Operator control panel has an E-Stop Interlock If problem persists, call Accuray
Control Chassis (ELCC) fault. Customer Support.
20424 LINAC has an E-Stop Interlock Control Chassis If problem persists, call Accuray
(ELCC) fault. Customer Support.
20425 Secondary Collimator System has an E-Stop If problem persists, call Accuray
Interlock Control Chassis (ELCC) fault. Customer Support.
20426 Imaging system has an E-Stop Interlock Control If problem persists, call Accuray
Chassis (ELCC) fault. Customer Support.
20427 Treatment robot has an E-Stop Interlock Control If problem persists, call Accuray
20428 Treatment couch has an E-Stop Interlock Control If problem persists, call Accuray
20429 Wall switch has an E-Stop Interlock Control If problem persists, call Accuray
20430 Treatment Room door has an E-Stop Interlock If problem persists, call Accuray
Control Chassis (ELCC) fault. Customer Support.
20431 Collision Avoidance System has an E-Stop If problem persists, call Accuray
Interlock Control Chassis (ELCC) fault. Customer Support.
20432 Unknown E-Stop Interlock Control Chassis (ELCC) If problem persists, call Accuray
hardware fault. Customer Support.
20433 Actual and commanded interlock configurations If problem persists, call Accuray
differ. Customer Support.
20434 Failure to enable or disable the interlock of the If problem persists, call Accuray
Target Locating System (TLS). Customer Support.

20435 E-Stop Interlock Control Chassis (ELCC) reports Recycle power to the E-Stop
an incorrect mode or status. Interlock Control Chassis (ELCC),
then recycle system power. If
Customer Support.
20436 Logic error: The Error Handling System received a If problem persists, contact Accuray
command that is not allowed in the current state. Customer Support.
20437 Configuring interlocks timed out. If problem persists, contact Accuray

Customer Support.
20441 Treatment robot reports an unknown hardware If problem persists, contact Accuray
20442 Treatment couch reports unknown hardware fault. If problem persists, contact Accuray
Customer Support.
20443 LINAC reports an unknown hardware fault. If problem persists, contact Accuray
Customer Support.
20444 Secondary Collimator System reports an unknown If problem persists, contact Accuray
20445 Collision Avoidance System reports an unknown If problem persists, contact Accuray
20446 Treatment robot communication error If problem persists, contact Accuray

Customer Support.
20447 Couch communication error. If problem persists, contact Accuray

Customer Support.
20448 LINAC communication error. If problem persists, contact Accuray

Customer Support.
20449 Secondary Collimator System communication error If problem persists, contact Accuray
Customer Support.
20450 Collision Avoidance System communication error. If problem persists, contact Accuray
Customer Support.
20451 Collision Avoidance System reported a hardware If problem persists, contact Accuray
20469 Collimator power failure or power filter problem If problem persists, contact Accuray
detected. Customer Support.

20471 Secondary Feedback System status reporting has If problem persists, contact Accuray
timed out. Customer Support.
20472 Error in treatment workflow for Secondary If problem persists, contact Accuray
Feedback System check. Customer Support.
20475 Secondary Feedback System communication If problem persists, contact Accuray

error. Customer Support.
20476 Bridge command timed out. If problem persists, contact Accuray

Customer Support.
20481 Multi-Gain Calibration Object Obstruction Error. If problem persists, contact Accuray
Verify that no object (for example, the treatment Customer Support.
robot or treatment couch) is blocking the image
detectors.
20482 Multi-Gain Calibration Image Intensity Error. Verify If problem persists, contact Accuray
that no objects are blocking the X-ray imaging Customer Support.
system.
20483 Multi-Gain Calibration Image Acquisition Error. If problem persists, contact Accuray
Customer Support.
20484 Multi-Gain Calibration Timeout. Reset and try If problem persists, contact Accuray
again. Customer Support.
20486 Multi-Gain Calibration initialization timed out. Reset If problem persists, contact Accuray
and try again. Customer Support.
20504 Simulation Application failed to move the treatment If problem persists, reset (cycle)
couch. equipment power. If problem still
Support.
20505 Simulation Application failed to acquire an image. If problem persists, reset (cycle)
equipment power. If problem still
Support.
20506 Simulation Application failed to correlate images. If problem persists, reset (cycle)
Support.
20507 Simulation Application failed to save information to If problem persists, contact Accuray
the file system. Customer Support.

20508 Simulation Application failed to change the X-ray If problem persists, reset (cycle)
technique. equipment power. If problem still
Support.
20509 Simulation Application failed to achieve the If problem persists, contact Accuray
requested X-ray technique. Customer Support.
20510 Simulation Application failed to record progress. If problem persists, contact Accuray
Customer Support.
20511 Tracking offsets are not available for all images. Make sure the Respiratory External
LED Markers are visible throughout
the breathing cycle, return to the
Offset phase, and try acquiring
another image set.
20512 Simulation Application cannot move the treatment Try moving the treatment couch a
couch to the desired position because it exceeds smaller distance. If problem persists,
couch limits. contact Accuray Customer Support.
20513 No Tracking Marker LED was visible when image Check LED placement and check for
was acquired. obstacles in the room.
20514 The simulation plan was created using Contact Accuray Customer Support.
configuration or calibration data that differs from
current system configuration or calibration data.
20515 Auto Alignment Failed. If problem persists, reset (cycle)

Support.
20516 Timed out waiting for acknowledgment from the If problem persists, contact Accuray
Respiratory Tracking System. Customer Support.
20570 X-ray source A has a recoverable fault Try again and if problem persists,
call Accuray.
20571 X-ray source B has a recoverable fault Try again and if problem persists,
call Accuray.
20582 TLS not responding to Imaging Xray Parameter Send parameters again. If a timeout
message. occurs again, contact Accuray
Customer Support.

20584 TLSC Xray exposure error Reset can be attempted.
20585 Unable to generate TLS diagnostic X-rays. Check status of E-Stops and
interlocks, and retry.
20605 Wrong Collimator in Linac Move Manipulator away from patient

Replace collimator
20617 Treatment robot failed to set joint angle limit(s). Move the treatment robot to the
perch position. If problem persists,
20618 Treatment robot motion stopped unexpectedly (RSI If problem persists, contact Accuray
motion). Customer Support.
20620 Treatment robot has a local Interlock but the If problem persists, contact Accuray
reason could not be determined. Customer Support.
20621 The key on the treatment robot Teach Pendant is Make sure the key on the treatment
not in External mode. robot Teach Pendant is in External
mode.
20623 A contact detection sensor has detected contact. Contact Accuray Customer Support.
20624 The Respiratory Tracking System generated Check the patient position and, if
signals that indicate the patient is out of bounds. necessary, reset the Respiratory
Model.
20625 Treatment robot EtherRSI module is not able to Contact Accuray Customer Support.
connect with Motion Tracking System (MTS).
20626 Treatment robot has not received the 'Beam On' Contact Accuray Customer Support.
signal.
20627 Treatment robot motion digital output on E-Stop Contact Accuray Customer Support.
Control Chassis (ESCC) is in unexpected state.
20628 Treatment robot received a stop message from the If problem persists, contact Accuray
Supplemental Proximity Detection Program. Customer Support.
20629 Treatment robot interlock is inconsistent with E- If problem persists, recycle power to
Stop Interlock Control Chassis (ELCC). the treatment robot.
20630 Treatment robot E-Stop is inconsistent with E-Stop If problem persists, recycle power to
Interlock Control Chassis (ELCC). the treatment robot.

20631 Fiducial Location Optimization Error Retry correlation. If this fails again,
20632 Fiducial Location Constraint Error: Excessive Retry Acquisition and/or Attempt
fiducial migration detected. Realignment. Consider disregarding
errant fiducial.
20633 Fiducial Extraction Error: Fiducial could not be Retry Acquisition and/or Attempt
found in live image. Realignment. Check X-Ray
parameters and extraction
thresholds.
20634 Fiducial Pairing Error: Corresponding fiducials from Retry Acquisition and/or Attempt
A and B were not found. Realignment. Check X-Ray
thresholds.
20635 Fiducial Identification Error: Could not match Retry Acquisition and/or Attempt
fiducials to reference. Realignment. Check X-Ray
thresholds.
20636 Fiducial extraction confidence level is less than the Retry target acquisition. If problem
required threshold. persists try the following error
resolutions: (1) Ensure that fiducials
are within tracking range (2) Check
Image quality and/or X-ray exposure
parameters (3) Consider reducing
the confidence level threshold
20637 Detection confidence below threshold Retry Acquisition and/or Attempt

Realignment.
20638 Target dxAB Error Retry Acquisition and/or Attempt

Realignment.
20639 The Respiratory Tracking System has generated Contact Accuray Customer Support.
an unspecific error.

20641 The Respiratory Tracking System reports an The Respiratory External LED
excessive target offset estimate. Markers may have moved too far
outside the range covered by
Respiratory model images. Consider
acquiring more images or resetting
the Respiratory model. Verify that
the marker movement is as large as
reasonably possible. For Fiducial or
Lung with Respiratory, place the
markers where they move most, not
necessarily close to the target. For
Spine Prone with Respiratory, place
the markers close to the target.
20642 The Respiratory Tracking System generated Check the patient position and reset
signals that indicate the patient is out of bounds. the Respiratory Model. If problem
Support.
20643 Communication timing between the Respiratory If problem persists, recycle power
Tracking System and treatment robot failed. and/or contact Accuray Customer
Support.
20644 The Respiratory Tracking System reports Check Respiratory External LED
Respiratory External Markers not visible. Marker placement and check for
obstacles in the room.
20645 The Respiratory Tracking System reports a Reset and re-establish the
modeling error. Respiratory Model. If problem
Support.
20646 Imaging subsystems are out of synch. Simultaneous XRS exposure failed.
Reset can be attempted. If problem
Support.
20647 The Respiratory Tracking System was given an If problem persists, contact Accuray
invalid command. Customer Support.
20648 The Respiratory Tracking System is operating in The Respiratory Tracking System is
Demonstration mode. configured for demonstration mode.
A Respiratory Model cannot be built.
If this is unexpected, contact

20649 The Respiratory Tracking System reports a Check Respiratory Camera Array
communication error between the treatment hardware. If problem persists,
delivery computer and optical hardware. contact Accuray Customer Support.
20650 The Respiratory Tracking System reports Check the patient position and, if
excessive change in LED motion pattern. necessary, reset the Respiratory
Model.
20651 The Respiratory Tracking System failed to remove Reset Respiratory Model.
most recent model point.
20652 Target Locating System provided corrections that Re-acquire image. If problem
are outside of the tracking plane. persists, contact Accuray Customer
Support.
20653 IP image out of bounds Realign patient. If this fails again,

20654 IP image brightness error Take another image. If this fails

again, contact Accuray Customer
Support.
20655 IP uframe deltas error Take another image. If this fails

Support.
20656 IP ref img download error Try downloading DRR images

again. If this fails, contact Accuray
Customer Support.
20657 IP dxAB magnitude error: Measured value of dxAB Check patient rotation & attempt
over threshold. realignment.
20658 The Respiratory Tracking System reports The Respiratory Model was reset.
excessive change in LED motion pattern. Check the patient position.
20659 The Respiratory Model expired. The most recent Add images (model points) to the
image (model point) is too old. Respiratory Model. If necessary,
reset the Respiratory Model first.
20660 IP Computation error Reset the Target Locating System

(TLS) computer power. If problem
Support.
20661 Error detected during IP rotational calculations Contact Accuray Customer Support.

20663 Camera gains cannot be adjusted automatically. Contact Accuray Customer Support.
Try to manually adjust the gains and acquire
another image. If the adjustment fails again,
20665 Patient out of alignment Adjust patient position and acquire

new image
20669 Image acquisition timed out. Retry image acquisition. If problem

Support.
20678 TLSC file transfer protocol err Reset can be attempted.
20679 TLSC illegal camera ID error Reset can be attempted.
20680 TLSC illegal Drr index reference Reset can be attempted.
20681 TLSC illegal patient tag error. Reset can be attempted.
20682 TLSC tracking algorithm failure. Re-acquire image. If problem

Support.
20683 TLSC raw to live transform error. Re-acquire image. If problem

Support.
20684 TLSC no target reference error. Attempt to download the DRR

images again. If the error persists,
20685 TLSC image acquisition error Camera failure occured. Reset can
be attempted.
20686 TLSC general communication failure. Restart TLS Computer. Reset can
be attempted.
20687 TLSC illegal command error Reset can be attempted.
20688 TLSC emergency abort error Reset can be attempted.
20689 TLSC power down abort Reset can be attempted.

20690 TLSC has generated an unspecified error Reset can be attempted.
20691 TLSC camera A has a recoverable fault Target Locating System (TLS)
power will be recycled. If problem
Support.
20692 TLSC camera B has a recoverable fault Target Locating System (TLS)
Support.
20693 TLSC system has a recoverable fault Target Locating System (TLS)
Support.
20696 Image Brightness Gradient Error Take another image. If this fails
Support.
20697 Initial dxAB Error Retry Acquisition and/or Attempt

Realignment.
20698 False Nodes Error Retry Acquisition and/or Attempt

Realignment.
20699 Target dxAB Error. Retry Acquisition and/or Attempt

Realignment.
20700 The Respiratory Camera was bumped or moved. Adjust the Respiratory Camera if
The Respiratory model was reset. necessary.
20705 LINAC calibration (LinCal) Beam command failed. If problem persists, contact Accuray
Customer Support.
20706 LINAC calibration (LinCal) High Voltage command If problem persists, contact Accuray
failed. Customer Support.
20711 A treatment robot client issued a local E-Stop. If problem persists, contact Accuray
Customer Support.
20712 Treatment robot console issued a local E-Stop via If problem persists, contact Accuray
the treatment robot. Customer Support.
20713 Remote client (TMT adapter) issued a local E-Stop If problem persists, contact Accuray
via the treatment robot. Customer Support.

20714 Secondary Collimator System issued a local E- If problem persists, contact Accuray
Stop via the treatment robot. Customer Support.
20715 Treatment robot reports violation of wrist angle If problem persists, contact Accuray
20716 Treatment robot reports violation of joint angle If problem persists, contact Accuray
20717 Treatment robot joint torque limit exceeded. If problem persists, contact Accuray
Customer Support.
20732 Treatment robot and/or Secondary Collimator If problem persists, contact Accuray
System not ready to perform Laser Alignment Customer Support.
Check activities.
20735 Laser Alignment Check scan of sensor failed. Make sure laser is visible when
powered on and check for items
blocking the sensor. If problem
Support.
20736 Treatment robot motion was interrupted. Clear Clear interlocks and try again.
interlocks and try again.
20754 PDP manipulator collision If problem persists, contact Accuray

Customer Support.
20755 Couch violates bounding box. Verify that the couch position is
within bounds for the selected path
set.
20767 The Respiratory Tracking System reports the Check the patient position and, if
prediction error exceeds acceptable threshold. necessary, reset the Respiratory
Model.
20775 Laser did not trigger the sensor over the collimator Move the treatment robot to the
retaining nut remover. perch position manually using the
Teach Pendant and try again. If
problem continues, check the
sensor for obstructions or dust.
Change collimators manually and

20776 Laser did not meet minimum intensity threshold for Try again. If problem continues,
the quick-check sensor during exchange. check the sensor for obstructions or
dust. If problem persists, contact
20777 Laser did not meet minimum intensity threshold for Try again. If problem continues,
the quick-check sensor during exchange. check the sensor for obstructions or
dust. Change collimators manually
and if problem persists, contact
20778 Laser did not trigger the sensor over the collimator Enter the Treatment Room,
holder. manually change the fixed
collimator, reattach the collimator
retaining nut, and return the
treatment robot to the perch
20779 Laser did not trigger the sensor in the housing Move the treatment robot to the
receptacle. perch position manually using the
Teach Pendant and try again. If
problem continues, check the
sensor for obstructions or dust. If
Customer Support.
20780 Xchange System detected the incorrect collimator Enter the Treatment Room, install
after completing the exchange. the correct collimator, and verify
placement of collimators on the
table. If the correct collimator was
picked up, contact Accuray
Customer Support.
20781 Xchange table reports that there is an object in the Enter the Treatment Room and
drop-off location. verify that collimators are in their
proper locations. Verify that no other
objects are on the Xchange table.
Move the treatment robot to the
perch position and try again.
20782 Xchange table reports that desired fixed collimator Enter the Treatment Room and
is not located in the proper location on the table. verify that the fixed collimators are in
the proper locations on the Xchange
table prior to performing another
exchange.

20783 The Xchange System was unable to automatically Enter the Treatment Room,
release the fixed collimator from the collimator manually change the fixed
housing. collimator, reattach the collimator
pick up the desired fixed collimator. manually change the fixed
remove the collimator retaining nut. manually change the fixed
20786 The collimator retaining nut may not have been Ensure that the collimator retaining
properly installed after the collimator exchange. nut is in the proper orientation and
attached to the collimator housing.
Return the treatment robot to the
perch position to continue. If
Customer Support.
20787 The Xchange table reports invalid sensor readings Check the Xchange table to ensure
for the desired collimator housing. the collimator housing is located in
the receptacle in the proper
orientation and no foreign objects
are on or in the table. Move the
treatment robot to the perch position
and try again. If problem persists,

20788 The Xchange table reports invalid sensor readings Check the Xchange table to ensure
for the collimator housing drop-off location. there are no foreign objects on or in
the table. Move the treatment robot
to the perch position and try again. If
Customer Support.
20789 Xchange table overtravel sensor was triggered Contact Accuray Customer Support.
before picking up or dropping off the collimator
housing.
20790 Xchange Collimator Tray not in the expected Xchange table recalibration may be
position required. Targeting accuracy check
recommended. If problem persists,
20791 Collimator Retaining Collar could not be removed Xchange Collimator Tray not in the
expected position
20792 Collimator Retaining Collar not present or loose. Make sure that the collimator
retaining collar is present and that its
sensor is engaged.
20793 Collimator arrangement error (Xchange Tray needs Collimators are not in the expected/
resorting) appropriate spot. Please resort the
collimators.
20794 Xchange General Error Contact Accuray Customer Support.
20795 Xchange Communication Error Contact Accuray Customer Support.
20796 Robot not at perch position Collimator Change only available

from perch.
20797 Failed to send motion command to the Treatment Reset the error and try again. If
Robot. problem persists, contact Accuray
Customer Support.
20798 Failed to drop off/pick up the collimator Manually change the collimator and
try again. If problem persists,
20800 Manipulator is not responding to a resume. Reset the error and try again. If
Customer Support.

20801 Equipment readiness check was interrupted. Return the treatment robot to the
perch position before proceeding.
20802 Cannot launch application: Software ESTOP is Make sure Software E-Stop is not
bypassed or its state cannot be determined. bypassed on E-Stop Control
Chassis (ESCC).
20803 Error updating the position for Treat button on the If problem persists, contact Accuray
treatment couch Hand Controller. Default position Customer Support.
will be used.
20804 The center of tumor motion provided by treatment You may proceed with treatment.
planning does not lie in the tracking plane.
Treatment can proceed, but couch movement may
be necessary after entering the Lung phase.
20805 TREATMENT ERROR: Path error list is non- Contact Accuray Customer Support.
existent or all zero. Path calibration is required.
20806 Missing or incomplete error list for path file. Contact Accuray Customer Support.
20807 High Voltage key is not in the ON position. High Voltage key must be in the ON
position to enable treatment
delivery.
20808 Robot cannot move to an imaging node from the Click Resume to resume treatment
current position. delivery automation. An image will
be acquired for the next beam if
needed.
20809 Image was acquired with invalid Respiratory phase When the Respiratory Tracking
selection setting. System is being used, automatic
phase selection must be in effect.
Return to the Respiratory phase to
select automatic phase selection.
20810 Image correlation algorithm inputs are invalid. Try again and if problem persists,
call Accuray.
20811 The Respiratory Tracking System rejected a model Confirm the error and continue. If
point. problem persists, call Accuray
Customer Support.
20812 Image cannot be added to the Respiratory Model. Verify that the Respiratory External
LED Markers are visible and
enabled.

20813 Treatment timed out while downloading path file. If problem persists, reset (cycle)
Support.
20814 Timeout waiting for initialization acknowledgment If problem persists, contact Accuray
from Error Handling System adaptor. Customer Support.
from Image Processing adaptor. Customer Support.
from Respiratory adaptor. Customer Support.
from Data Management Bridge. Customer Support.
from treatment robot adaptor. Customer Support.
from LINAC adaptor. Customer Support.
from treatment couch adaptor. Customer Support.
from collimation adaptor. Customer Support.
20823 Cannot enter the Delivery phase without valid Return to the Alignment phase and
offsets. acquire a new image.
20824 Respiratory Model is not valid for delivery. Return to the Respiratory phase and
establish a valid Respiratory Model.
20825 Cannot enter the Delivery phase because the Return to the Alignment phase and
treatment couch has moved since the most recent acquire a new image.
image acquisition.
current correlation will be discarded. acquire a new image.
current image is blocked. acquire a new image.

20828 Imaging during treatment delivery is disabled and Return to the Readiness phase and
there is no current image. re-enable imaging during treatment
delivery, and/or return to the
Alignment phase and obtain valid
correlation results.
the current image is blocked. re-enable imaging during treatment
the current correlation will be discarded. re-enable imaging during treatment
there are no correlation results. re-enable imaging during treatment
the current correlation results are not valid for re-enable imaging during treatment
treatment delivery. delivery, and/or return to the
the treatment couch has moved since the last re-enable imaging during treatment
image was acquired. delivery, and/or return to the
20834 Timeout waiting to configure Treatment Room door If problem persists, contact Accuray
interlock. Customer Support.
20835 An error occurred during treatment delivery Reset the error and try again. If
automation. problem persists, contact Accuray
Customer Support.
20836 Imaging subsystem reports that it is not ready for If problem persists, contact Accuray
delivery automation. Customer Support.

20837 LINAC reports that it is not ready for delivery If problem persists, contact Accuray
automation. Customer Support.
20838 Timeout waiting for treatment robot subsystem to If problem persists, contact Accuray
be ready. Customer Support.
20839 Treatment robot reports that it is not ready for Return the treatment robot to the
delivery automation. perch position and try again. If
Customer Support.
20840 Secondary Collimator System or Laser Alignment Follow instructions to perform

Check system action was interrupted. manual action and/or to restart
system action.
20841 Secondary Collimator System timed out If problem persists, contact Accuray
Customer Support.
20842 Timeout waiting to launch delivery automation. If problem persists, contact Accuray
Customer Support.
20843 Request to move treatment robot to imaging node If problem persists, contact Accuray
was rejected. Customer Support.
20844 Treatment timed out waiting for acknowledgment If problem persists, contact Accuray
from the Respiratory Tracking System. Customer Support.
20845 Target is not in tracking plane. Go to Lung phase, move the couch
to the lung position, and perform
realignment as needed.
20846 The couch reports an invalid position. Return the couch to the treatment
position using the Teach Pendant.
20847 Treatment couch position has changed during If problem persists, contact Accuray
delivery automation. Customer Support.
20848 Simulation Application failed to move the treatment If problem persists, reset (cycle)
couch. equipment power. If problem still
Support.
20849 Delivery automation timed out waiting for robot If problem persists, contact Accuray
movement to be completed. Customer Support.
20850 Delivery automation timed out waiting for If problem persists, contact Accuray
collimator aperture change. Customer Support.

20851 Delivery automation timed out waiting for response If problem persists, contact Accuray
from the Respiratory Tracking System or received Customer Support.
unexpected response from the Respiratory
Tracking System.
20852 Delivery automation timed out waiting for response If problem persists, contact Accuray
from LINAC susbsystem. Customer Support.
20853 Treatment cannot move the couch to the desired If problem persists, contact Accuray
position because the couch exceeds its limits. You Customer Support.
may retry after adjusting the patient position on the
couch.
20854 Treatment couch position has changed. If problem persists, contact Accuray
Customer Support.
20855 Secondary Collimator System: Unexpected status If problem persists, contact Accuray
reported. Customer Support.
20856 An error occurred while recording Secondary If problem persists, contact Accuray
Feedback System data. Customer Support.
20857 Collimator retaining nut is missing or loose. Attach collimator retaining nut and
ensure retaining nut sensor is
engaged.
20858 Treatment application failed to change the X-ray If problem persists, reset (cycle)
technique. equipment power. If problem still
Support.
20859 Treatment application failed to achieve the If problem persists, contact Accuray
requested X-ray technique. Customer Support.
20860 Treatment application failed to acquire an image. If problem persists, reset (cycle)
Support.
20861 Exit button pressed while collimator action in Press Continue.

progress.
20863 scs_stub has recoverable error see log

20864 Treatment application failed to correlate images. If problem persists, reset (cycle)
Support.
20865 Delivery automation error. Attempted to acquire an If problem persists, contact Accuray
image at a blocked node. Customer Support.
20866 Error starting delivery automation. If problem persists, contact Accuray

Customer Support.
20867 An image burst is not needed. Image bursting is not allowed

because the Respiratory Model
already contains the maximum
number of images.
20868 LINAC Subsystem Control software encountered If problem persists, contact Accuray
an error enabling high voltage. Customer Support.
an error turning high voltage on or off. Customer Support.
an error trying to turn on beam. Customer Support.
an error trying to turn on laser. Customer Support.
20872 LINAC beam directed at insufficient vault shielding. In Treatment mode, you may retry
after adjusting the patient position.
In Physics mode, retry after
adjusting the treatment robot
position.
20873 Communication error in vault shielding check If problem persists, contact Accuray
program. Customer Support.
20874 A Peak/Valley image acquisition is not needed. Peak/Valley image acquisition is not
allowed because the Respiratory
Model already contains Peak and
Valley model points.
20875 LINAC Subsystem Control (LSC) software If problem persists, contact Accuray
encountered an error setting or clearing the beam Customer Support.
table.

20876 Treatment application timed out waiting for an If problem persists, contact Accuray
image acquisition. Customer Support.
20877 Treatment application timed out waiting for a If problem persists, contact Accuray
correlation result. Customer Support.
20878 Time out waiting for couch position update. If problem persists, contact Accuray
Customer Support.
20879 Fixed initialization did not succeed. If problem persists, contact Accuray
Customer Support.
20880 Iris initialization did not succeed. If problem persists, contact Accuray
Customer Support.
20882 Treatment delivery automation could not start If problem persists, contact Accuray
because the Treatment Room door interlock is Customer Support.
unexpectedly bypassed.
because the Error Handling System indicated that Customer Support.
the System E-Stop state is not clear.
because an acknowledgment that treatment is Customer Support.
active was not received from the Respiratory
Tracking System.
20885 Treatment delivery automation could not start. If problem persists, contact Accuray
Customer Support.
20890 Respiratory model is not valid for delivery. Review the Treatment messages in
the Delivery phase. If necessary,
return to the Respiratory phase and
build a valid Respiratory model.
20901 One or both of the E-Stop buttons on the treatment Make sure both E-Stop buttons on
couch are (or were) depressed. either end of the treatment couch
(under the table top) are released.
20902 RoboCouch E-Stop. Please check the following: Please release the treatment couch
- Hand Controller E-Stop button E-Stop button(s).
- Teach Pendant E-Stop button
- Teach Pendant External Mode switch
- RoboCouch contact sensors
- RoboCouch safety limit switches

20903 The treatment couch reports the device interlock is Make sure both E-Stop buttons on
engaged. either end of the treatment couch
(under the table top) are released.
20950 Patient Data Loader encountered an unknown If problem persists, contact Accuray
20951 Patient Data Loader reports unknown startup If problem persists, contact Accuray
information. Customer Support.
20952 Patient Data Loader startup information is stale. If problem persists, contact Accuray
Customer Support.
20954 Patient Data Loader reports unrecognized startup If problem persists, contact Accuray
information. Customer Support.
20955 Patient Data Loader state machine received If problem persists, contact Accuray
unexpected input. Customer Support.
20958 Patient Data Loader state machine in unknown If problem persists, contact Accuray
state. Customer Support.
20960 Data Management Bridge request is stale. If problem persists, contact Accuray
Customer Support.
20961 Patient Data Loader successfully unloaded a If problem persists, contact Accuray
fraction while recovering from a previous error Customer Support.
condition.
20962 Data Management Bridge Error If problem persists, contact Accuray

Customer Support.
20963 iDMS Error If problem persists, contact Accuray

Customer Support.
20964 iDMS Business Rule violation If problem persists, contact Accuray

Customer Support.
20965 iDMS Read Lock Error Close all instances of all

applications that access iDMS, and
try to load patient data again. If
Customer Support.

20966 iDMS Write Lock Error Close all instances of all

applications that access iDMS, and
try to load patient data again. If
Customer Support.
20967 iDMS Exception If problem persists, contact Accuray

Customer Support.
20968 Treatment Data Manager request is stale. If problem persists, contact Accuray
Customer Support.
20969 Treatment Data Manager reported an error during If problem persists, contact Accuray
finalization. Customer Support.
20970 Fraction IDs do not all agree. If problem persists, contact Accuray
Customer Support.
20971 Data Management Bridge reports that TDCS owns If problem persists, contact Accuray
no fraction. Customer Support.
20972 Treatment Data Manager reported inconsistent If problem persists, contact Accuray
fraction. Customer Support.
20973 Dose shift not sent in Delivery phase. Send dose shift in Delivery phase.
20974 Dose shift adjustments not allowed after starting Exit treatment and send dose shift in
treatment delivery. Delivery phase of makeup fraction.
20975 Dose shift sent during treatment delivery Send dose shift in Delivery phase
automation. before treatment automation.
20976 Dose shift adjustments not allowed for Respiratory Contact Accuray Customer Support.
treatment plans.
20977 Dose shift enabled in configuration for VSI system. Dose shift is not supported for this
system, remove or disable the
setting.
20978 Tumor contour generation failed for Skull Tracking. Contact Accuray Customer Support.
20979 Tumor contour generation timed out for Skull Contact Accuray Customer Support.
Tracking.
20999 Pause button pressed by operator Press Continue.

31006 Unknown error Contact Accuray Customer Support.
31008 sproc creation of a process failed error Contact Accuray Customer Support.
31009 msgsnd failed to send Contact Accuray Customer Support.
31011 Comm Port Lock Failed Contact Accuray Customer Support.
31015 Invalid System Configuration Detected Contact Accuray Customer Support.
31016 Failure to connect to TLS PC for configuration Contact Accuray Customer Support.
verification.
31017 Invalid or no license found for current system Contact Accuray Customer Support.
configuration.
31018 Couch Communication error. Contact Accuray Customer Support.
31019 Treatment robot communication error. Contact Accuray Customer Support.
31020 LINAC Communication error. Contact Accuray Customer Support.
31021 Failure to connect to LCC PC for configuration Contact Accuray Customer Support.
verification.
31022 Inconsistency detected in Gantry LINAC Vault type Contact Accuray Customer Support.
key.
31024 Respiratory Tracking System Communications Reset (cycle) equipment power. If

Error problem persists, contact Accuray
Customer Support.
31025 Respiratory Tracking System process died Reset (cycle) equipment power. If
unexpectedly problem persists, contact Accuray
Customer Support.
31026 Respiratory Tracking System communication error Reset the Respiratory Tracking
when reading Tracking Marker data. System (Flashpoint firmware) and
recycle power. If problem persists,

31027 Synchrony RSI communication error. Recycle power. If problem persists,

31030 LINAC adapter process is erroneously disabled. Recycle system power.
31031 LINAC has an inconsistent beam state. Contact Accuray Customer Support.
31032 LINAC delivered dose that is larger than the Contact Accuray Customer Support.
required amount.
31033 LINAC Driver connector is erroneously disabled. Recycle system power.
31034 LINAC Stop counter does not match termination Contact Accuray Customer Support.
requirement.
31035 LINAC beam symmetry error is out of tolerance. Check beam symmetry.
31036 The LINAC high voltage is locally controlled by the Exit from all LINAC Control
LINAC Control Computer (LCC). Computer (LCC) applications.
31037 The LINAC adapter is not supervised by an If problem persists, contact Accuray
appropriate application process. Customer Support.
31038 Linac power failure has been detected. If problem persists, contact Accuray
Customer Support.
31150 Linac power supply error Contact Accuray Customer Support.
31156 Linac computer error Contact Accuray Customer Support.
31159 DOSE/STIF board timeout fault Contact Accuray Customer Support.
31161 LCF warmup not completed in time Contact Accuray Customer Support.
31162 MCC power supply fault Contact Accuray Customer Support.
31163 VME power supply fault Contact Accuray Customer Support.
31164 LCF wrote to registers while beam was on Contact Accuray Customer Support.

31165 Write to dose counters outside diagnostic mode Contact Accuray Customer Support.
31166 communication error from ESCC/MCC Check cable connection between

ESCC/MCC
31167 communication error to ESCC/MCC Check cable connection between

ESCC/MCC
31168 ESCC command fault Check cable connection between

ESCC/MCC
31169 ESCC bus timeout Contact Accuray Customer Support.
31170 MCC command fault Check cable connection between

ESCC/MCC
31171 MCC bus timeout Contact Accuray Customer Support.
31172 Could not turn off the beam Contact Accuray Customer Support.
31173 Linac reset failed Contact Accuray Customer Support.
31174 Overdose for node Contact Accuray Customer Support.
31175 Overdose for path Contact Accuray Customer Support.
31176 Under dose for node detected by LCF Contact Accuray Customer Support.
31177 Attempt to set stop register A failed Contact Accuray Customer Support.
31178 Attempt to set stop register B failed Contact Accuray Customer Support.
31179 Reset kill beam failed; beam on denied Contact Accuray Customer Support.
31180 Robot moving while beam is on Contact Accuray Customer Support.
31181 Reset LCF E-Stop failed Contact Accuray Customer Support.
31182 Reset LCF E-Stop failed Contact Accuray Customer Support.

31183 LCF powerup diagnostics failed Contact Accuray Customer Support.
31184 LCF could not spawn a task Contact Accuray Customer Support.
31185 LCF watchdog timer fault Contact Accuray Customer Support.
31186 Attempt to reset dose while beam is on Contact Accuray Customer Support.
31187 Attempt to resume LCF while E-Stop is on Contact Accuray Customer Support.
31188 Mus from counter A and mus from counter B are Contact Accuray Customer Support.
too far apart
31191 Beam on too long Contact Accuray Customer Support.
31192 Leakage from counter A greater than limit Contact Accuray Customer Support.
31193 Leakage from counter B greater than limit Contact Accuray Customer Support.
31194 Attempt to turn beam on in wrong state Contact Accuray Customer Support.
31195 New stop register setting less than old Contact Accuray Customer Support.
31196 Attempt to set registers while beam on Contact Accuray Customer Support.
31197 Attempt to set registers in wrong mode Contact Accuray Customer Support.
31198 Attempt to reset counter A failed Contact Accuray Customer Support.
31199 Attempt to reset counter B failed Contact Accuray Customer Support.
31200 DoseA greater than stopA and beam is on Contact Accuray Customer Support.
31201 Beam delivery ended because the dose counter B Contact Accuray Customer Support.
reached the stop register B before the dose
counter A reached the stop register A.

31202 Attempt to set diagnostic mode failed Contact Accuray Customer Support.
31203 Attempt to set CPU mode failed Contact Accuray Customer Support.
31204 Fault in overflow comparator A1 Contact Accuray Customer Support.
31205 Fault in overflow comparator B1 Contact Accuray Customer Support.
31206 Start treatment to LCF in wrong state Contact Accuray Customer Support.
31207 Linac controller has detected inconsistent system Contact Accuray Customer Support.
command and system status
31208 A/D dose rate too high Contact Accuray Customer Support.
31209 A/D dose rate too low Contact Accuray Customer Support.
31210 Cumulative under dose detected by LCF Contact Accuray Customer Support.
31211 AFC positive current too high Contact Accuray Customer Support.
31212 AFC positive current too low Contact Accuray Customer Support.
31213 AFC negative current too high Contact Accuray Customer Support.
31214 AFC negative current too low Contact Accuray Customer Support.
31215 New A count is less than old Contact Accuray Customer Support.
31216 New B count is less than old Contact Accuray Customer Support.
31217 Linac lost power Abort and restart
31219 Beam is on during an error state. Contact Accuray Customer Support.

31222 New node information was received before Exit treatment and move the
previous node was completed treatment robot to the Perch position
using the Teach Pendant. Contact
31320 RoboCouch offset axis (Axis A7) clutch has been Contact Accuray Customer Support.
released. RoboCouch mastering is lost. Do not
move the treatment couch or shut down or reboot
the RoboCouch controller. Contact Accuray
Customer Support.
31321 Treatment couch is not mastered. Do not move the Contact Accuray Customer Support.
treatment couch or shut down or reboot the
treatment couch controller.
31322 Treatment couch offset axis (Axis A7) is not Contact Accuray Customer Support.
coupled. Do not move the treatment couch or shut
down or reboot the treatment couch controller.
31323 RoboCouch configuration failed. Contact Accuray Customer Support.
31324 RoboCouch mastering data is inconsistent. Contact Accuray Customer Support.
31325 RoboCouch serial number data is inconsistent. Contact Accuray Customer Support.
31326 RoboCouch controller unrecoverable error. Reset power for the RoboCouch
controller. If problem persists,
31355 Hardware Fault: Iris collimator initialization Contact Accuray Customer Support.
required.
31378 Either collimator is missing or PTCU potentiometer If problem persists, contact Accuray
signals are latched up. Insert collimator or reset Customer Support.
power.
31379 Fixed collimator status check failed. If problem persists, contact Accuray
Customer Support.
31401 Unable to turn on Linac beam Contact Accuray Customer Support.
31402 Excess dose at node detected by software Contact Accuray Customer Support.

31403 Excess cumulative dose detected by software Contact Accuray Customer Support.
31404 Under dose at node detected by software Contact Accuray Customer Support.
31405 Cumulative under dose detected by software Contact Accuray Customer Support.
31406 Can't open path file Contact Accuray Customer Support.
31407 The path file is invalid Contact Accuray Customer Support.
31408 Can't read path file Contact Accuray Customer Support.
31409 Skipped a node Contact Accuray Customer Support.
31410 An unexpected Linac status has been detected. Contact Accuray Customer Support.
31411 A requested treatment robot move is not allowed. Contact Accuray Customer Support.
31412 Unable to open log file Contact Accuray Customer Support.
31413 Total dose does not match sum of doses in Contact Accuray Customer Support.
treatment plan
31415 Prescribed cGy for node returned from LCF does Contact Accuray Customer Support.
not match saved value
31416 Prescribed mus for node returned from LCF does Contact Accuray Customer Support.
31417 Prescribed cumulative cGy returned from LCF Contact Accuray Customer Support.
does not match saved value
31418 Prescribed cumulative mus returned from LCF Contact Accuray Customer Support.
31419 Prescribed A counts at node returned from LCF Contact Accuray Customer Support.
31420 Prescribed B counts at node returned from LCF Contact Accuray Customer Support.

31421 Prescribed A stop count returned from LCF does Contact Accuray Customer Support.
31422 Prescribed B stop count returned from LCF does Contact Accuray Customer Support.
31423 Node not ready for treatment Contact Accuray Customer Support.
31424 Connection to the linac controller can not be Power down the CyberKnife System
established and wait fifteen minutes before
attempting to reconnect.
31426 Incorrect LCF configuration file Contact Accuray Customer Support.
31512 No images are available for correlation. If problem persists, contact Accuray
Customer Support.
31570 X-ray source A status bad Contact Accuray Customer Support.
31571 X-ray source B status bad Contact Accuray Customer Support.
31584 TLSC Xray exposure error If problem persists, contact Accuray

Customer Support.
31602 NCP Control request failed Contact Accuray Customer Support.
31606 Manipulator cannot continue Clear all estops and try to resume
again
31608 Linac power went off unexpectedly Contact Accuray Customer Support.
31609 Manipulator moved while paused. Moving the treatment robot manually
using the Teach Pendant is not
permitted during treatment. If the
treatment robot was not moved
manually, contact Accuray
Customer Support immediately.
31628 Treatment robot is not mastered. Do NOT move Contact Accuray Customer Support.
the treatment robot or shut down or reboot the
treatment robot controller.
31640 Treatment robot configuration failed. Contact Accuray Customer Support.

31641 Treatment robot mastering data is inconsistent. Contact Accuray Customer Support.
31642 Treatment robot serial number data is inconsistent. Contact Accuray Customer Support.
31643 Treatment robot controller unrecoverable error. Reset the treatment robot controller.
If problem persists, contact Accuray
Customer Support.
31656 IP ref img download error Error is unrecoverable. If problem

Support.
31657 IP live image IO (save) error Contact Accuray Customer Support.
31658 IP calibration IO error Contact Accuray Customer Support.
31659 IP uframe deltas zero error Contact Accuray Customer Support.
31662 IP data integrity check error Contact Accuray Customer Support.
31664 Patient out of alignment Adjust patient position and acquire

new image
31668 DRR download taking too long. Retry. If downloading takes too long
again, exit treatment and contact
31669 The ISCAL configuration file is invalid. Contact Accuray Customer Support.
31674 Connection to TLS computer closed unexpectedly Contact Accuray Customer Support.
31677 Software error detected in IP program. Contact Accuray Customer Support.
31678 TLSC file transfer protocol err Contact Accuray Customer Support.
31679 TLSC illegal camera ID error Contact Accuray Customer Support.
31680 TLSC illegal Drr index reference Contact Accuray Customer Support.

31681 TLSC illegal patient tag error. Contact Accuray Customer Support.
31684 TLSC no target reference error. Error is unrecoverable. If problem

Support.
31685 TLSC image acquisition error Camera failure occured. If error

Support.
31686 TLSC general communication failure. Restart Target Locating System

(TLS) Computer. If problem persists,
31687 TLSC illegal command error Contact Accuray Customer Support.
31688 TLSC emergency abort error Contact Accuray Customer Support.
31689 TLSC power down abort Contact Accuray Customer Support.
31690 TLSC has generated an unspecified error Contact Accuray Customer Support.
31691 TLSC camera A has an unrecoverable fault Contact Accuray Customer Support.
31692 TLSC camera B has an unrecoverable fault Contact Accuray Customer Support.
31693 TLSC system has an unrecoverable fault Contact Accuray Customer Support.
31694 Target Locating System Computer (TLSC) has an If problem persists, contact Accuray
unrecoverable fault. Customer Support.
31695 TLSC graphics hardware error. Close unnecessary programs on

computer. Then power cycle the
TLS computer. If problem persists,
31730 Laser Alignment Check application general error. Contact Accuray Customer Support.
31731 Failed to communicate with required subsystems. Contact Accuray Customer Support.
Reset equipment power and try again.

31733 Laser Alignment Check: Failed to communicate Contact Accuray Customer Support.
with treatment robot.
31734 Laser Alignment Check communication error. Contact Accuray Customer Support.
31735 Invalid Laser Alignment Check configuration. Contact Accuray Customer Support.
31736 Laser Alignment Check: Invalid status reported by Contact Accuray Customer Support.
Secondary Collimator System.
31749 TLS communication adaptor task failed to start. If problem persists, contact Accuray
Customer Support.
31750 Equipment Power Status encountered an error If problem persists, contact Accuray
attempting to communicate with the LINAC. Customer Support.
31757 Couch lost power. System will power down if power

cannot be re-established.
31758 Couch not communicating System will attempt to reestablish

communications.
31759 Error reading Couch obstacle files. Contact Accuray Customer Support.
31760 Failure to spawn manipulator communication If problem persists, contact Accuray

adaptor task Customer Support.
31761 Failure to spawn LINAC communication adaptor If problem persists, contact Accuray
task. Customer Support.
31762 Proximity Detection Program (PDP) active Contact Accuray Customer Support.
monitoring of treatment robot position failed
unexpectedly.
31763 Failure to spawn SCS communication adaptor task. If problem persists, contact Accuray
Customer Support.
31765 Failure to communicate with the Proximity Contact Accuray Customer Support.
Detection Program (PDP).
31766 Xchange System communication adaptor task Contact Accuray Customer Support.
failed to start.
31767 The Respiratory Tracking System reports an invalid Contact Accuray Customer Support.
transformation matrix for imaging to robot
coordinates.

31768 Invalid Respiratory Tracking System Configuration Check the configuration files on the
computer
31769 Incorrect Respiratory Tracking System firmware Contact Accuray Customer Support.
version or communication problem.
31770 System time mismatch between the imaging Contact Accuray Customer Support.
computer and treatment delivery computer. The
Time Synchronization Service (SNTP) may not be
running or may be misconfigured.
31771 The Respiratory System reports a data sampling First try recycling system power, or
problem. reboot the treatment delivery
computer. If problem persists,
31790 Xchange Collimator Tray not in the expected System positioning check failed.
position Contact Accuray Customer Support.
31800 Cannot launch application: Image Processing Contact Accuray Customer Support.
adaptor process is stubbed or configured for
calibration.
31802 Cannot launch application: Data Management Contact Accuray Customer Support.
Bridge process is stubbed or configured for
calibration.
31803 Cannot launch application: Treatment robot Contact Accuray Customer Support.
calibration.
31804 Cannot launch application: LINAC adaptor process Contact Accuray Customer Support.
is stubbed or configured for calibration.
31805 Cannot launch application: Treatment couch Contact Accuray Customer Support.
calibration.
31806 Cannot launch application: Collimation adaptor Contact Accuray Customer Support.
process is stubbed or configured for calibration.
31807 Cannot launch application: Respiratory Tracking Contact Accuray Customer Support.
System process is stubbed or configured for
calibration.

31808 Error setting the interlock configuration (timeout). If problem persists, contact Accuray
Customer Support.
31809 Error setting the interlock configuration (mismatch). If problem persists, contact Accuray
Customer Support.
31810 Couch is not responding to status requests Error is unrecoverable. If problem

Support.
31811 Internal logic error. Contact Accuray Customer Support.
31812 Reference DRR file load failed. Contact Accuray Customer Support.
31813 Error loading algorithm parameters. Contact Accuray Customer Support.
31814 Error loading plan data. If problem persists, contact Accuray

Customer Support.
31815 Treatment timed out while downloading path file. If problem persists, contact Accuray
Customer Support.
31816 Cannot launch application: Error Handling System Contact Accuray Customer Support.
process is stubbed or configured for calibration.
31818 The treatment plan requires Respiratory Modeling, If problem persists, contact Accuray
but the Respiratory Tracking System is not Customer Support.
powered on or has a fault.
31819 Treatment application timed out while waiting for If problem persists, contact Accuray
the LINAC status. Customer Support.
31820 No response received from PDP for couch position Error is unrecoverable. If problem
check persists, contact Accuray Customer
Support.
31821 Error loading plan: One or more error list entries is Error is unrecoverable. If problem
missing for path file. persists, contact Accuray Customer
Support.
31822 Error loading plan: Error list file does not have at Error is unrecoverable. If problem
least one non-zero entry for path file. persists, contact Accuray Customer
Support.

31830 Treatment encountered an error while switching Error is unrecoverable. If problem

tracking modes persists, contact Accuray Customer
Support.
31833 Treatment timed out waiting for acknowledgment Error is unrecoverable. If problem
from the automation thread. persists, contact Accuray Customer
Support.
31834 Robot cannot move to an imaging node from the Error is unrecoverable. If problem
current position. persists, contact Accuray Customer
Support.
31835 An error occurred during treatment delivery Error is unrecoverable. If problem

automation. persists, contact Accuray Customer
Support.
31836 Beam on too long Error is unrecoverable. If problem

Support.
31837 LINAC beam turned on unexpectedly. Error is unrecoverable. If problem

Support.
31840 Invalid node alignment state or tracking mode for Contact Accuray Customer Support.
treatment.
31841 An error occurred while recording the dose during If problem persists, contact Accuray
treatment. Customer Support.
31845 Treatment timed out waiting for acknowledgment If problem persists, contact Accuray
from Treatment Data Manager. Customer Support.
31846 Robot moved during beam on. Contact Accuray Customer Support.
31847 Treatment robot moved unexpectedly. Contact Accuray Customer Support.
31851 Secondary Collimator System: General Error Contact Accuray Customer Support.
31852 Secondary Collimator System: Communication Contact Accuray Customer Support.

Error
31853 Secondary Collimator System: Action was not Contact Accuray Customer Support.
completed within timeout period.

31854 Secondary Collimator System: No message Contact Accuray Customer Support.

received within timeout period.
31855 Secondary Collimator System: Unexpected status Contact Accuray Customer Support.
reported.
31856 Xchange table drawer is open. Close the Xchange table drawer.
31857 Collimator retaining nut is missing or loose. Attach collimator retaining nut and
ensure retaining nut sensor is
engaged.
31858 Iris collimator has an accessory attached to Remove the Iris collimator
accessory flange. accessory attached to accessory
flange.
31859 Too many recoverable E-Stops in succession. The Press Continue.

error is now unrecoverable.
31863 scs_stub has unrecoverable error see log
31864 Iris collimator needs to be calibrated. Perform Iris calibration.
31865 Iris collimator information does not match the data Pick up a different housing and then
file. pick up the Iris housing again. If
Customer Support.
31866 The treatment plan was created using configuration Contact Accuray Customer Support.
or calibration data that differs from current system
configuration or calibration data.
31867 Treatment encountered an error while attempting If problem persists, contact Accuray
to turn off high voltage. Customer Support.
an error enabling high voltage. Customer Support.
an error turning high voltage on or off. Customer Support.
an error trying to turn on beam. Customer Support.

an error trying to turn on laser. Customer Support.
31872 Treatment encountered an error storing or If problem persists, contact Accuray

retrieving data. Customer Support.
31873 Communication error in vault shielding check If problem persists, contact Accuray
program. Customer Support.
31874 Configuration error in vault shielding check Contact Accuray Customer Support.
program.
31875 LINAC Subsystem Control (LSC) software If problem persists, contact Accuray
encountered an error setting or clearing the beam Customer Support.
table.
31876 Treatment Data Manager process encountered an If problem persists, contact Accuray
31877 Treatment Data Manager encountered error while If problem persists, contact Accuray
attempting to load current fraction. Customer Support.
31878 Treatment Data Manager had error while storing Contact Accuray Customer Support.
data.
31879 Patient ID reported by Respiratory Tracking Contact Accuray Customer Support.

System does not match Patient ID reported by
Treatment application.
31880 LINAC calibration (LinCal) Beam command failed. If problem persists, contact Accuray
Customer Support.
31881 LINAC communication error. If problem persists, contact Accuray

Customer Support.
31882 LINAC Subsystem Control (LSC) software denied Reset (cycle) equipment power and
control request. try again. If problem persists,
31883 LINAC calibration (LinCal) failed to communicate If problem persists, contact Accuray
with LINAC. Customer Support.
31884 LINAC calibration (LinCal) Beam command timed If problem persists, contact Accuray
out. Customer Support.
failed. Customer Support.

timed out. Customer Support.
31895 Response from LINAC Control Computer timed Contact Accuray Customer Support.
out.
31898 Error setting the Interlock configuration (mismatch). If problem persists, contact Accuray
Customer Support.
31901 Simulation Application experienced an Contact Accuray Customer Support.

unrecoverable error.
31905 Simulation Application experienced an internal If problem persists, contact Accuray

31906 Simulation Application could not save the If problem persists, contact Accuray
appropriate files. Customer Support.
31907 Simulation Application failed to initialize tracking If problem persists, contact Accuray
with the Target Locating System. Customer Support.
31908 Simulation Application failed to initialize the Motion If problem persists, contact Accuray
Tracking System. Customer Support.
31909 Simulation Application has detected an Synchrony Contact Accuray Customer Support.
Lung Tracking algorithm version mismatch.
31997 Hardware configuration check failed. Contact Accuray Customer Support.
31998 Master Process is not responding. Contact Accuray Customer Support.
31999 Hardware communication error. Reset (cycle) equipment power. If

Customer Support.
32001 Dose shift not configured error. Contact Accuray Customer Support.
41007 Unexpected process termination error Contact Accuray Customer Support.
41023 Uninterruptible Power Supply (UPS) is on battery Wait for system shutdown. Contact
power and battery power is running out. System Accuray Customer Support for help
shutdown is imminent. with recovering from power outage.
41434 Command to E-Stop Interlock Control Chassis If problem persists, call Accuray
(ELCC) timed out. Customer Support.

41503 Internal logic error. Contact Accuray Customer Support.
41560 A process not responding to the status request Contact Accuray Customer Support.
41894 LINAC calibration (LinCal) failed to initialize. Contact Accuray Customer Support.
41910 Master version configuration missing from data Contact Accuray Customer Support.
files.
41911 Local version configuration missing from system. Contact Accuray Customer Support.
41912 Version string incorrectly formatted. Contact Accuray Customer Support.
41913 Local version did not match master. Contact Accuray Customer Support.
41953 Patient Data Loader startup information contains If problem persists, contact Accuray
unrecognized work scenario. Customer Support.
41959 Invalid Session ID If problem persists, contact Accuray

Customer Support.
41973 Data Management Bridge reports that download is If problem persists, contact Accuray
in progress. Customer Support.
41974 Data Management Bridge reports that TDCS If problem persists, contact Accuray
currently owns a fraction. Customer Support.
41975 Attempt to create the active fraction file failed. If problem persists, contact Accuray
Customer Support.
41976 An active fraction file already exists. If problem persists, contact Accuray
Customer Support.
41985 Error Handling System communication error Restart software.

(socket).
42000 System configuration error. Restart software. If problem

Support.
42010 Collimator housing action incomplete. Treatment If problem persists, contact Accuray
robot motion inhibited. Customer Support.

Readiness Phase Error Messages

Table 2 describes Warning messages that may appear in the Delivery Warning Messages
panel on the left screen of the Readiness phase. These Warning messages must be reviewed
and acknowledged before treatment delivery can begin. For more information, see “Chapter 8:
The Delivery Warning Messages panel has an upper and lower block of displayed text. In
the following table, the upper block of text is referred to as "Description," the lower block of text as
"Details".
Table 2 Treatment Readiness Error Messages
Description Detail
Imaging has been disabled. Images will NOT automatically be acquired during
treatment delivery. New translation and rotation offsets
will NOT be acquired.
The Respiratory Tracking System has Respiratory motion will NOT be compensated for
been disabled. during treatment delivery.
The Respiratory Model quality is Sub- An Optimal Respiratory Model that contains 15 images
Optimal. is best for treatment.
Robot Rotation Corrections are disabled. Only translation offsets will be applied during beam
delivery. Make sure that the current rotation offsets are
small enough to be safely ignored during beam
delivery without affecting beam pointing accuracy.
Robot Rotational Bounds Checking is Rotation offsets will be measured but not applied. Only
disabled. translation offsets will be applied during beam delivery.
Large rotation offset results will NOT interrupt delivery.
Trigeminal plan: Robot Rotation Robot Rotation Corrections are disabled during
Corrections are disabled. trigeminal treatments. Only translation offsets will be
applied during beam delivery. Make sure that the
current rotation offsets are small enough to be safely
ignored during beam delivery without affecting beam
pointing accuracy.
Spine alignment was skipped. Rotation offsets based on the spine position have not
been measured and will not be applied. Only
translation offsets will be applied during beam delivery.

Table 2 Treatment Readiness Error Messages (continued)
Description Detail
Fewer than three fiducials are selected. Rotation offsets will not be measured. Only translation
offsets will be applied during beam delivery.
Single fiducial tracking Only one fiducial is selected. Rotation offsets will not
be measured. Only translation offsets will be applied
during beam delivery. Use extreme caution! Tracking
with only one fiducial increases the risk of beam
mistargeting.
The Patient Safety Zone has been Verify that patient positioning is correct. Consider
violated. repositioning the treatment couch or selecting a
different Patient Size.
Treatment couch away from planned lung The treatment couch position has been moved away
tracking position. from the planned lung tracking position by %.1f mm in
the %s direction and %.1f mm in the %s direction.
While these values will be corrected for during delivery
there may be a similar magnitude of error in the
untracked axis that will not be corrected for. Continuing
with treatment without evaluating the impact of this
error may result in mistreatment and patient injury. 1)
Re-examine the patient setup and immobilization
devices to ensure that the CT setup has been
reproduced. 2) Carefully evaluate whether the
anatomy in the Live images is properly aligned with the
anatomy in the DRR images. Pay special attention to
the tumor position in the untracked image. 3) If the
treatment plan provides margins that allow for this
magnitude of error in the untracked axis then this
condition may be acceptable. Consult the treatment
planner. Note that repeating patient setup may help
reduce these values.
Laser Alignment Check failed. Laser Alignment Check is not calibrated. Beam
pointing accuracy cannot be verified. Call Accuray
Customer Support to calibrate the Laser Alignment
Check. Exit treatment delivery and perform an AQA
test to verify beam pointing accuracy.

Description Detail
Laser Alignment Check failed. Preparation for the Laser Alignment Check failed.
Beam pointing accuracy cannot be verified. Call
Accuray Customer Support. Exit treatment delivery
and perform an AQA test to verify beam pointing
accuracy.
Laser Alignment Check failed. Beam pointing accuracy cannot be verified. Exit
treatment delivery and perform an AQA test to verify
beam pointing accuracy. If the AQA test passes and
the Laser Alignment Check fails again call Accuray
Customer Support.
Treatment robot not at the perch position. Treatment delivery will resume with the treatment robot
away from the perch position.
Trip test of 'Beam On Too Long' error The LINAC Beam duration limits have been artificially
shortened. The duration limits have been set to
progressively shorter values to ensure that a 'Beam On
Too Long' error will be tripped.
High error threshold for dxAB. The error threshold for %s is set to %.1f%s. This
threshold may be too high to prevent incorrect
High error threshold for Brightness. The error threshold for %s is set to %.1f%s. This
High error threshold for Gradient. The error threshold for %s is set to %.1f%s. This
High error threshold for drAB. The error threshold for %s is set to %.1f%s. This
High error threshold for False Nodes. The error threshold for %s is set to %.1f%s. This

Description Detail
High error threshold for Uncertainty. The error threshold for %s is set to %.1f%s. This
High error threshold for Rigid Body. The error threshold for %s is set to %.1f%s. This
Low error threshold for Spacing. The error threshold for %s is set to %.1f%s. This
threshold may be too low to prevent incorrect
Low error threshold for Collinearity. The error threshold for %s is set to %.1f%s. This
threshold may be too low to prevent incorrect
High error threshold for Uncertainty. The error threshold for %s is set to %.1f%s. This

Delivery Phase Error Messages

Table 3 describes messages that may appear in the Messages panel on the right screen of the
Delivery phase.
The Messages panel has an upper and lower block of displayed text. In the following table, the
upper block of text is referred to as "Description," the lower block of text as "Details":
• Some of these messages are Soft stop (SS) messages, that is, messages that are
displayed to explain the reason that delivery was interrupted by a Soft Stop.
• Some of these messages are Delivery Inhibitor (DI) messages, meaning they explain the
reason why the user is not allowed to press the Start or Resume button to begin or
resume treatment delivery automation
• Some of these messages are informational (I) messages, for example to indicate that
delivery of a treatment fraction has completed or that the user must take an action such
as turning on the High Voltage.
Table 3 Delivery Phase Error Messages
Type
(SS=SoftStop
DI=Delivery
Inhibitor
I=Informational) Description Details
SS Multiple Correlation Errors Several imaging algorithm errors

occurred. It is likely that the source of
this problem is general not directly
related to any of the specific errors
listed. Please check the following before
proceeding. 1) Visually check that the
patient is roughly aligned (within 3cm for
Respiratory Tracking or 1cm for other
tracking methods). 2) Check imaging
quality and X-ray technique. Acquire a
new image if changes are made.
SS Delivery automation was interrupted Delivery automation was interrupted

because one or more algorithm because one or more algorithm
thresholds were violated. Acquire a thresholds were violated. Acquire a new
new image or go to the Align Phase image or go to the Align Phase to
to troubleshoot. troubleshoot.

Table 3 Delivery Phase Error Messages (continued)
Type
(SS=SoftStop
DI=Delivery
Inhibitor

because one or more algorithm because one or more algorithm
thresholds were violated. Acquire a thresholds were violated. Acquire a new
new image or go to the Align phase image or go to the Align phase or
or Respiratory phase to Respiratory phase to troubleshoot.
troubleshoot.
SS Patient position is out of bounds. Patient position is out of bounds.
SS Patient position is out of bounds. Delivery automation was interrupted

because patient position is out of
bounds.

because the Respiratory radial because the Respiratory radial
correlation error is out of bounds. correlation error is out of bounds.
SS Respiratory model invalid Respiratory Tracking System reports

that the Respiratory model is invalid.
Return to the Respiratory phase.
SS Respiratory model incomplete. Delivery automation was interrupted

because the Respiratory model is
incomplete. One or more respiratory
phases is not present.

because image correlation results because image correlation results are
are out of bounds or there are out of bounds or there are threshold
threshold violations. violations.
SS Respiratory Model update error. Delivery automation was interrupted

because image could not be added to
the Respiratory model. Verify that the
Respiratory External LED Markers are
visible and enabled.
SS Respiratory Automatic Modeling Respiratory Automatic Modeling

interrupted by a Soft Stop. interrupted by a Soft Stop.
I Respiratory model not optimal Respiratory model not optimal
SS User pressed soft stop button. User pressed soft stop button.

Type
(SS=SoftStop
DI=Delivery
Inhibitor

because target displacement because target displacement exceeds
exceeds InTempo thresholds. InTempo thresholds.
SS Respiratory External LED Marker Treatment delivery automation cannot

Excursion Error continue because Respiratory Tracking
System reports excessive change in the
Tracking Respiratory External LED
Marker motion pattern. Check the
patient position. If necessary reset the
Respiratory model
DI There is no image currently Treatment delivery automation cannot

available. proceed without a valid image and
DI The current image has been marked Treatment delivery automation cannot
blocked. proceed with a blocked image.
DI The current correlation result has Treatment delivery automation cannot

been designated to be discarded. proceed without valid correlation results.
DI There are currently no correlation Treatment delivery automation cannot

results. proceed without valid correlation results.
DI The current correlation results are Treatment delivery automation cannot

invalid. proceed with invalid correlation results.
DI The current Respiratory model is Treatment delivery automation cannot

invalid. proceed with an invalid Respiratory
model.
DI The X-ray technique has changed. Treatment delivery automation cannot

proceed unless a new image is acquired.
DI The couch position has changed. Treatment delivery automation cannot

proceed unless the couch position
matches its position during the most
recent image acquisition.

Type
(SS=SoftStop
DI=Delivery
Inhibitor
DI There is no spine alignment image. Treatment delivery automation cannot

proceed unless there is a valid spine
alignment image.
DI The couch rotations have changed. Treatment delivery automation cannot

proceed unless the couch rotations are
the same as they were during patient
alignment.
DI A correlation algorithm threshold is Treatment delivery automation cannot

violated. proceed when correlation algorithm
results are not within thresholds.
DI Current corrections are out of Treatment delivery automation cannot

bounds. proceed when corrections are out of
bounds.
DI The lung tumor treatment position Delivery automation cannot proceed

(spine position plus the alignment- when the lung tumor treatment position
to-treatment offset from planning) is (spine position plus the alignment-to-
not in the tracking plane. treatment offset from planning) is not in
the tracking plane.
DI Treatment delivery automation Return to the Alignment phase and

cannot start. ensure that current correlation results
are valid.
DI The treatment robot is not at perch. The treatment robot is not at the perch
position and is not at a position from
which delivery automation can start.
DI The fixed collimator needs to be The %.1fmm collimator is required.

changed
DI The fixed collimator needs to be Return to Readiness Phase to proceed

changed. with changing the fixed collimator.
DI Correlation algorithm parameters Correlation algorithm parameters have

changed. changed since the most recent image
acquisition. A new acquisition is required
prior to launching delivery automation.

Type
(SS=SoftStop
DI=Delivery
Inhibitor
DI Current correlation results are not A new image is required before

based on most recent image. treatment delivery automation can start.
DI Missing spine alignment results. Treatment delivery automation cannot

proceed without valid spine alignment
DI New spine alignment image needed. The current spine alignment results are
not based on the most recent image. A
new spine alignment image is required
before treatment delivery automation
can start.
DI PDP couch check failed. The most recent PDP couch check did
not use the present couch position.
DI Couch position is too far Superior. Couch is too far superior to begin
treatment. This is caused by either:
1)Incorrect placement of the patient on
the couch. 2)Incorrect path selection (i.e.
head path for body treatment)
DI There is no image currently Imaging during treatment delivery

available. automation is disabled and there is no
image currently available. Delivery
automation cannot proceed without a
valid image and correlation results.
DI The current correlation result has Imaging during treatment delivery

been designated to be discarded. automation is disabled and the current
correlation result has been designated to
be discarded. Delivery automation
cannot proceed without a valid image
and correlation results.
DI There are currently no correlation Imaging during treatment delivery

results. automation is disabled and there are no
correlation results. Delivery automation
cannot proceed without a valid image
and correlation results.
DI Door is open. Delivery automation cannot proceed

until the Treatment Room door is closed.

Type
(SS=SoftStop
DI=Delivery
Inhibitor
DI Laser Alignment Check Laser Alignment Check required. Return

to Readiness phase.
DI Collimation Status Secondary Collimator System is not

ready. Please return to Equipment
Readiness phase.
DI Image acquisition and correlation An image acquisition and correlation is

required. required.
DI Respiratory model not valid for Return to the Respiratory phase.

treatment.
DI Respiratory correlation error out of Treatment delivery automation cannot

bounds. proceed when Respiratory correlation
error is out of bounds.
DI Additional image required. Demonstration Mode: The most recent

correlation is out of bounds or violates
algorithm thresholds. A new image with
valid correlation results is required
before proceeding with Demonstration.
DI Rotational corrections disabled. Lung 1-View Tracking with Respiratory is

not allowed with rotational corrections
disabled.
DI User input required. In order to proceed you must choose

whether to continue or abort treatment.
DI Unconfirmed warnings. There are warning messages requiring

acknowledgment. Return to the
Readiness phase.
I The system is ready to turn on High Push the High Voltage ON button.
Voltage.
I Fraction completed. The fraction has been completed.
I High Voltage key is not in the ON High Voltage cannot be enabled until
position. key is in the ON position.

Type
(SS=SoftStop
DI=Delivery
Inhibitor
I LINAC Control Computer (LCC) is High Voltage cannot be enabled until the
not configured for remote control LINAC Control Computer (LCC) is
from the treatment delivery configured for remote control by the
computer. treatment delivery computer.
I User action required to continue Use Teach Pendant to continue

demonstration. demonstration.
I Demonstration completed. The demonstration has been completed.
I You may enter the Treatment Room. You may enter the Treatment Room.
Wait for the 'Fraction Completed'
message before returning to the
CyberKnife System Menu.

Appendix B: Compliance
Classification
The CyberKnife System is classified by the following:
• Protection against electric shock: Class I, permanently connected.
• Applied part: Patient treatment table only, Type B.
• Methods of sterilization or disinfection: Not required.
• Degree of safety in the presence of flammable mixtures: Not suitable for use in the
presence of flammable mixtures.
• Mode of operation:
 Continuous operation (as per 3rd edition of IEC 60601-1 standard).
 Continuous operation with intermittent loading (as per 2nd edition of IEC 60601-1
standard).
Standards Compliance
System certification labels are issued by independent testing organizations. The system is
compliant with the following standards:
• EN/IEC 60601-1
• EN/IEC 60601-1-2
• EN/IEC 60601-1-3
• EN/IEC 60601-1-6
• EN/IEC 60601-2-1
• EN/IEC 60601-2-68
• EN/IEC 60601-2-54
• EN/IEC 60950-1
• EN/IEC 60825
• EN/IEC 62366
• EN/IEC 62304
• CAN/CSA C22.2 No. 60601-1
• AAMI ES 60601-1
1075883-ENG A Classification | B-1

Radiiation Leakage
Per IEC 60601-2-1, Clause 29.4.1, LINAC manufacturers must inform users if leakage radiation in
an area that can be brought into close proximity to the patient during irradiation exceeds 0.5% of
the maximum absorbed dose at 5 cm from the LINAC enclosure surface. All such points are shown
in the following figure. Of these points, the highest is 0.77% of maximum absorbed dose (at 5 cm
from the enclosure surface). In the CyberKnife System, the worst case proximity of this point to the
patient is 16.5 cm, at which distance the leakage is reduced to 0.39%.
% Leakage
System Labels
The CyberKnife System labeling includes several symbols designed to convey safety and usage
information. Table 1 lists the symbols and their description.
Table 1 Equipment symbols
Located on the system label to signify that Accuray

Incorporated declares the equipment complies with the
requirements of the European Union for medical devices.
Located on the system label to indicate the system

generates ionizing radiation. Symbol source: ISO
7010:W003.
B-2 | Radiiation Leakage 1075883-ENG A

Treatment Delivery Manual Appendix B: Compliance
United States and Canada product safety certification

marks (NRTL or ETL approval).
Attention, proceed with caution. This label appears on the

system to indicate that accompanying documents include
related safety information. Symbol source: ISO 7000-
0434B.
WARNING: This x-ray unit may be dangerous to patient

and operator unless safe exposure factors, operating
instructions and maintenance schedules are observed.
X-ray warning.
This label is located in the operator console area. Symbol
source: ISO 710-W001.
CAUTION: Electric shock hazard. This label is affixed to

the LINAC head, the modulator, and the Power
Distribution Unit (PDU). Symbol source: ISO 7000-6042.
These symbols identify the radiation of laser products.

The symbols are affixed to each laser housing inside the
treatment room and are accompanied by the following
text: "Laser light, do not stare into beam." Symbol source:
IEC TR 60878, symbol 5152.
Electrostatic discharge susceptibility. This label is affixed

to the PDU, the modulator and the gun driver, Symbol
source: ISO 7000-5134.
Attention, follow instructions for use. This symbol

indicates that you should consult the accompanying
documents for information related to the labeled item. The
symbol also indicates that the item is mandatory and
safety related. Symbol source:
Follow service instructions. This label is affixed to the

modulator and the chiller.
This symbol indicates that you should consult the

operating instructions for the device. This label is affixed
to the standard treatment couch table top. Symbol
source: ISO 7000-641.
1075883-ENG A System Labels |B-3

CAUTION: Hand crush hazard. This label is affixed to the

RoboCouch® Patient Positioning System. Symbol source:
ISO 7010-W024.
Do not step on equipment. Symbol source: This label is

affixed to X-ray generators of VSI systems. ISO 7010-
P019.
This label is affixed to the Xchange® table Model B of the
Xchange Robotic Collimator Changer.
Do not place unapproved objects on equipment. This

label is affixed to the Model B Xchange table.
Do not push equipment. Symbol source: This label is

affixed to the X-ray generators. ISO 7010-P017. This
label is affixed to the Xchange table Model B of the
Xchange Robotic Collimator Changer.
Do not sit on equipment. This label is affixed to the

standard treatment couch table top. Symbol source: ISO
7010-P018. This label is affixed to the Xchange table
Model B of the Xchange Robotic Collimator Changer.
Located on system labeling to indicate that the patient

contact surface (couch top) is classified as a Type B
Applied Part. Symbol source: ISO 60417:5841.
3 phase alternating current. This label is affixed to the

PDU. Symbol source: ISO 60417:5032-1.
Located on the system and subsystem labels to identify

the model catalogue number associated with the Accuray
system. Symbol source: ISO 7000:2493.
Located on labels to identify the serial number associated

with the Accuray system. Symbol source: ISO 7000:2498.
Located on labels to identify the acceptable range of

voltage supplied to the Accuray system. Symbol source:
ISO 60417:6045.

the date that the Accuray system was manufactured.
Symbol source: ISO 7000-2497.
B-4 | System Labels 1075883-ENG A

Treatment Delivery Manual Appendix B: Compliance

the facility where the Accuray system was manufactured.
Symbol source: ISO 7000-3082.

the location and contact information of Accuray
Incorporated's European Authorized Representative.
Symbol source: EN ISO 15223-1;5.1.2.
CAUTION: Pinch point. This label is affixed to the patient

support system (the standard treatment couch or the
RoboCouch System).
Emergency Power Off. This label is affixed to the

customer interface box and the PDU.
China Restriction of Hazardous Substances (RoHS) 15.

This label is affixed to the computer rack.
CAUTION: Pinch hazard. This label is affixed to the

Synchrony QA tool for motion tracking (also called the
Synchrony motion table).
Safety ground. This label is affixed to the imaging

detectors, the PDU, and the modulator.
Focal point, exterior XRS housing. This label is affixed to

the covers of the X-ray sources.
1075883-ENG A System Labels | B-5

B-6 | System Labels 1075883-ENG A

Appendix C: Glossary
Acronyms and Abbreviations
2D – 2-Dimensional
3D – 3-Dimensional MR (MRI) – Magnetic Resonance Imaging
3DRA – 3D Rotational Angiography MU - Monitor Unit
4D – 4-Dimensional (three spatial dimensions OAR – Off-Axis Ratio or Organ at Risk

plus time)
cGy – Centigray OIS – Oncology Information System
CI – Conformality Index PDD – Percent Depth Dose
CT – Computed Tomography PDP – Proximity Detection Program
CTV – Clinical Target Volume PT (PET) – Positron Emission Tomography
DICOM – Digital Imaging and Communications PTV - Planning Target Volume

in Medicine
DOF – Degree of Freedom ROI – Region of Interest
DRR – Digitally Reconstructed Radiograph RT – Radio Therapy
DVH – Dose Volume Histogram RTDOSE – Radiation Therapy Dose
E2E – End-to-End (as in End-to-End test) RTSSET – Radiation Therapy Structure Set
ESCC – E-Stop Control Chassis SAD – Source-Axis Distance
FCA – Fixed Collimator Accessory SGI – Silicon Graphics Incorporated (refers to

treatment delivery computer for certain systems)
FFP – Feet First Prone SPDP – Supplemental Proximity Detection

Program
FFS – Feet First Supine SRS – Stereotactic Radiosurgery
FOV – Field of View SSD – Source-to-Surface Distance
1075883-ENG A Acronyms and Abbreviations | C-1

FSPB - Finite Size Pencil Beam TDS – Treatment Delivery System
HFP – Head First Prone TLS – Target Locating System
HFS – Head First Supine TPS – Treatment Planning System
IFCC – Interface Control Chassis TTV - Target Tracking Volume
ITV - Internal Target Volume UPS – Uninterruptible Power Supply
ITTV - Internal Target Tracking Volume VOI – Volume of Interest
LINAC – Linear Accelerator XA – X-ray Angiography
MCC – Modulator Control Chassis XRS – X-ray Source
Definitions
A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Y. Z
6 Degrees of freedom
Refers to motion in 3D space defined using a Cartesian coordinate system with 6 parameters
representing translation (X, Y, and Z) and rotation (r for roll, p for pitch, and w for yaw). X, Y, and
Z represent the three Cartesian axes. See Degrees of freedom (DOF).
Accelerator
The portion of the LINAC which accelerates electrons from a gun into a high-energy electron beam.
See LINAC and Waveguide.
Alignment center
The alignment center is a point defined in the IECP (International Electrotechnical Commission
patient) coordinate system by the Accuray Precision System, based on the different requirements
of each tracking mode. During the patient alignment phase of treatment delivery, the alignment
center is aligned with the machine center in the robot frame. See Machine center.
Axial
An axial plane divides the body into upper and lower segments. This is similar to “slicing” the body
like a loaf of bread starting at the top of the head and working down.
C-2 | Definitions 1075883-ENG A

Treatment Delivery Manual Appendix C: Glossary
Ball-cube
The Ball-cube is a QA tool designed by Accuray Incorporated for measuring stereotactic targeting
accuracy. Physically it is an ABS plastic film cassette used for holding two pieces of radiochromic
film. The notched films are placed orthogonally in the Ball-cube. The Ball-cube is 2.5 inches
(6.35 cm) on each side and contains a 1.25 inch (3.175 cm) acrylic ball, which is visible in a CT
image and used as a treatment target.
Beam
The CyberKnife System uses three X-ray beams: the high therapeutic energy (6 MV) radiosurgical
beam emanating from the LINAC and two low diagnostic energy beams used for image generation.
See LINAC, X-ray source (XRS), and Collimator.
Beam position
A beam position is a position of the treatment robot where the LINAC is located at a treatment node
and is pointed at the treatment target. The beam position includes the offset of the LINAC required
for targeting corrections. Where no targeting corrections are required, the beam position is the
same as the node position. See also Node position.
Beam selection
One of the primary algorithms of the Treatment Planning System (TPS). Beams are selected
according to the given lesion size and shape. The selection uses a reachability model of the
treatment robot workspace. Multiple beam directions with a high degree of collimation are used to
accurately target the lesion while sparing normal tissue. See Treatment Planning System (TPS).
Blocked node
A blocked node is a node at which the treatment robot or some other obstruction blocks the X-ray
imaging system and prevents the successful acquisition of new images. See also Node.
Centigray (cGy)
A unit of radiation dose equal to the rad, 1/100 of a Gray. Radiation dose is a measure of radiation
energy deposited per unit mass.
Centroid
The point about which the beams are assumed to move relative the respiration cycle. This point is
only relative for cases using Respiratory Modeling, because it is assumed for cases that do not use
Respiratory Modeling the moving image deforms but does not translate relative to the targeting of
the beams.
1075883-ENG A Definitions | C-3

Cold spot
A region being irradiated which receives an under-dose of radiation.
Collimator
X-rays radiate in all directions when an electron beam strikes the target. Because X-rays cannot
be focused, heavy metal collimators are used to block the unwanted portion of the radiation to
create a narrow beam.
The LINAC has two collimators, a fixed primary collimator and a changeable secondary collimator.
The primary collimator surrounds the X-ray target and limits the X-ray beam to a narrow cone in
the forward direction. Secondary collimators may be attached to the X-ray head to produce
different beam sizes.
12 interchangeable fixed collimators with apertures (in millimeters) of 5, 7.5, 10, 12.5, 15, 20, 25,
30, 35, 40, 50, 60 (defined at a distance of 80 cm from the X-ray source) allow flexibility and
conformability during the treatment planning process. The fixed collimators attach to a secondary
collimator housing which is mounted on the X-ray head. The fixed collimators produce a beam with
a circular cross section. Each fixed collimator has a different length in 1/16 in (1.5875 mm)
increments based on its aperture. The LINAC contains dual independent linear potentiometers to
detect the length of the currently installed fixed collimator. Treatment cannot proceed with the
wrong collimator installed.
The optional Iris Variable Aperture Collimator provides the same 12 apertures as the fixed
collimators. The aperture of the Iris Collimator is adjustable under computer control. It contains 2
stacked hexagonal banks of tungsten segments that together produce a 12-sided aperture (a
regular dodecagon). The Iris Collimator allows consolidation of multiple path sets with multiple
fixed collimators into a single path set. Using the tungsten segments to rapidly adjust the aperture,
the Iris Collimator can deliver multiple-sized beams from each LINAC position.
The optional Multileaf Collimator is a secondary beam collimator composed of two opposing banks
of beam attenuators. Each bank is composed of 41 individual leaves which can be moved
independently. Used to shape the radiation beam to irregular apertures defined during treatment
planning.
A collimator is also used on each of the imaging X-ray sources to minimize patient exposure.
Computed Tomography (CT)

Computed Tomography is an imaging procedure in which many X-rays images are taken from
different angles of a part of the body. These images are combined by a computer to produce cross-
sectional pictures of internal organs. CT images are used by the CyberKnife System for treatment
planning and to produce the reference images (DRRs).
Conformal
The extent to which the radiosurgical treatment dose is restricted to the target volume, sparing
surrounding healthy tissue, which may be critical or sensitive to radiation.
See also Dose.
Coronal
A frontal image of the body. A coronal plane divides the body into front and back segments.

Couch
See Patient treatment table.
Critical region
An important anatomical structure that is especially sensitive to radiation such as the eyes, optic
nerve, or brain stem.
CyberKnife Treatment Delivery System

The CyberKnife System is a radiosurgery device used to treat cancer throughout the body by
focusing many high energy beams precisely to the tumor delivering a very conformal dose. The
CyberKnife System consists of three key components:
• An linear accelerator (LINAC) that is used to produce high energy (6MV) radiation.
• A treatment robot that can point the linear accelerator from a wide variety of angles.
• X-ray image detectors that are combined with powerful software to track patient position.
The X-ray detectors obtain frequent images of the patient during treatment, and use this
information to target the radiation beam emitted by the linear accelerator.
Deformable registration
A registration model that allows for relative internal motion between the two images.
Deformed image
A moving image that is a CT image series that has been transformed using a deformable
registration algorithm so that it aligns with a fixed CT series.
Degrees of freedom (DOF)

The CyberKnife System treatment robot has 6 degrees of freedom: 3 translations (X, Y, and Z) and
3 rotations (yaw, pitch, and roll). See 6 Degrees of freedom.
Digital Imaging and Communications in Medicine (DICOM)

A data standard used to transfer medical image and radiation therapy planning studies from a
medical image scanner or contouring workstation to the CyberKnife System site via a network prior
to treatment planning.
Digitally Reconstructed Radiograph (DRR)

Digitally Reconstructed Radiographs created from the patient CT image data. The DRRs are used
as reference images by the Image Processing System for patient alignment and treatment.
Dmax
The depth at which the radiation dose reaches a maximum in water or water-equivalent material,
such as soft tissue.

Dose
A measure of accumulated radiation exposure.
Dose Calculation
Calculation of Monitor Units (MUs) to be delivered by the LINAC for each beam to irradiate the
tumor with the prescribed dose.
Dose Volume Histogram (DVH)

A graph that displays the dose received by the volume of interest.
Dosimetry system
Dosimeters measure the energy carried by a beam over time. The dosimetry system in the LINAC
uses dual independent dosimeters (named A and B or primary and secondary) at the X-ray source
to measure its output. They are configured in a redundant dose monitoring combination to
safeguard against incorrect dose delivery. Irradiation at a node is terminated by the dosimeter
hardware when the delivered dose at the node is equal to the planned dose. The first dosimeter to
reach the desired dose causes the LINAC to shut off. The software uses the dose from the primary
dosimeter (dosimeter A) as the measure of delivered dose.
EBT type film

A type of radiochromic film for measuring manufactured by Ashland, Inc (http://www.ashland.com).
See also Ball-cube and Gafchromic Film. EBT2 and EBT3 films have been validated for
recommended QA tests that require EBT type films.
Electron gun
See Gun.
Emergency Stop Control Chassis (ESCC)

The central unit responsible for handling emergency stops. See E-Stop.
End-to-End (E2E) test

A Quality Assurance (QA) test for the CyberKnife System that includes all aspects of a typical
treatment: CT scanning, treatment planning, and treatment delivery.
Error recoverable
An error condition that causes an E-Stop or interlock. Treatment can resume once the error
condition is cleared.
Error unrecoverable
An error condition that causes an E-Stop or interlock. Equipment power must be cycled to reset
the E-Stop after the error condition has cleared.

E-Stop
Emergency Stop. Pressing an E-Stop button manually executes an Emergency Stop. An E-Stop
button performs the same function as a software interlock. However, it interacts directly with
CyberKnife System hardware to stop operation. Treatment couch movement, treatment robot
movement, X-ray image acquisition, and radiation delivery are immediately terminated and the
high voltage to the LINAC is turned off.
Feet First Prone (FFP)

A patient position in which the patient is prone with the feet toward the CyberKnife System robot.
Feet First Supine (FFS)

A patient position in which the patient is supine with the feet toward the CyberKnife System robot.
Fiducials
Artificial references (such as gold seeds or stainless steel screws) that are implanted in or near
tissues undergoing radiosurgery treatment. These markers are used as artificial landmarks by the
imaging system.
Fixed image
Primary CT image used for planning and DRR generation. Also referred to as Image A.
Forward planning
Treatment planning for a given beam selection and dosage. The computer finds the dose
distribution. See Treatment Planning System (TPS).
Fractionated radiosurgery
Treatment that has been partitioned into several doses repeated over time (such as several days).
Frame
The coordinate reference frames used to locate the treatment robot, LINAC, and patient. The
coordinate frames used with the CyberKnife System are in general 3D Cartesian coordinate frames
with 6 degrees of freedom: 3 translations (X, Y, and Z) and 3 rotations (yaw, pitch, and roll; or w,
p, and r). See IECP (IEC patient) coordinate system, Robot frame, and Patient coordinate system.
Frameless
Radiosurgery systems such as the Gamma Knife use a frame rigidly attached to the skull to ensure
accurate radiation targeting and delivery. The CyberKnife System is considered frameless since
only a non-intrusive restraint is used. The CyberKnife System targets off of bony landmarks and
fiducials. The imaging system on the CyberKnife System allows the treatment robot to correct for
small movements of the target during treatment delivery.

Function
An operation the user can perform.
Gafchromic Film
A class of self-developing radiochromic film (http://www.ashland.com) commonly used for
measuring ionizing radiation dose. See Ball-cube and EBT type film.
Gray
A unit of radiation dose equal to 100 cGy. Radiation dose is a measure of radiation energy
deposited per unit mass (1 Gray = 1 Joule/Kg). See Centigray (cGy).
Gun
The electron gun in the LINAC that injects a low energy electron beam into the accelerator. The
gun is a vacuum tube that consists of the following:
• Cathode with a filament heater to produce the electrons
• Control grid to turn the electron beam on and off
• Anode to provide initial acceleration for the beam.
The high voltage power supply provides a negative voltage to the cathode.
Head First Prone (HFP)

A patient position in which the patient is prone with the head toward the CyberKnife System
treatment robot.
Head First Supine (HFS)

A patient position in which the patient is supine with the head toward the CyberKnife System
treatment robot. This is the normal patient position for CT scans.
Hot spot
A region being irradiated that receives an abnormally high dose of radiation.

IECP (IEC patient) coordinate system

The IECP is the coordinate system used by the Accuray Precision System. It is a patient-centric
coordinate system, where the coordinates are defined with respect to the patient. The IECP (0, 0, 0)
position in the X, Y, and Z coordinates is arbitrarily defined.
The x axis is the patient left-right orientation, where left is positive x. The y axis the superior-inferior
orientation, where superior is positive y. The z axis is the anterior-posterior orientation, where
anterior is positive z. See Robot frame and Patient coordinate system.
Image registration
Spatial transformation to align images.
Imaging system
The imaging system locates the treatment center by comparing real-time radiographs of the patient
with DRRs.
The imaging system contains two nearly identical X-ray imaging units. Each unit has the following
components:
• Standard medical radiographic X-ray tube
• High-voltage generator
• Tungsten copper X-ray collimator
• X-ray detector
Interface Control Chassis (IFCC)

For the VSI system, the IFCC is a subsystem that performs two functions:
• Performs LINAC on/off control and monitors LINAC status
• Serves as a central hardware registry for all E-Stops.
The LINAC on/off control is performed under commands from the host computer, and the status of
the LINAC and E-Stops are reported back to the host computer.

Inverse planning
In the Accuray Precision System, the user specifies the following constraints when performing
inverse planning:
• Minimum lesion dose (in cGy)
• Maximum lesion dose (in cGy)
• Maximum beam weight (in MU)
The computer uses a linear programming algorithm to find a dose for each beam to satisfy the
constraints. See Treatment Planning System (TPS).
Ionizing radiation
A radiation beam that, when passing into a biological absorbing medium such as body tissue,
transfers some of the energy carried in the beam to the medium sufficiently to ionize the tissue at
the molecular level and therefore to disrupt cellular reproduction processes. The energy
transferred may produce a biological effect in the medium. Use of the word “radiation” in this
document will mean ionizing radiation.
Isocenter
The point in a target where the central axes of treatment beams intersect.
Isocentric planning
Creating treatment plans using isocentric geometry.
Isocrystal
Target located at the tip of the isopost that is used with the laser in the LINAC to perform treatment
robot pointing calibration. Indicates the precise position of the machine center. See Isopost.
Isopost
Calibration tool used to establish the machine center. See Isocrystal.
Key switch
The radiation enable switch in the operator control panel. When turned on, it provides the “high
voltage enable” to the LINAC for treatment delivery, simulation, or calibration.

LINAC
Acronym for linear accelerator. A linear accelerator is a device that uses high frequency
electromagnetic waves to accelerate charged particles such as electrons to high energies through
a linear tube. In the CyberKnife System, the LINAC uses a magnetron to produce X-band
microwaves to accelerate an electron beam to a nominal energy of 6 MeV. The beam strikes a
tungsten target where X-rays are produced. Here the X-ray beam energy is measured by two
dosimeters. The X-rays are reduced to a narrow beam by a fixed primary collimator and then by a
secondary changeable collimator. The entire apparatus is mounted on the end of the treatment
robot arm that aims the X-ray beam at the treatment site in the patient. Radiation is only fired from
the LINAC when the treatment robot is stopped and located at a node.
LINAC safety interlocks

For the VSI system, Table 1 lists LINAC safety interlocks and status information displayed in the
FAULT STATUS section on the front panel of the Modulator Control Chassis (MCC). These safety
interlocks are cleared (the green status indicators are not illuminated) when the conditions
described in the table are not satisfied.
Table 1 LINAC safety interlocks: Conditions when status indicators are illuminated
Interlock Name Description
DOOR INTLK (Door Interlock) All treatment room doors are closed.
WATER FLOW (Water Flow Interlock) Cooling water or air flow is adequate.
MAG FIL (Magnetron Filament) Magnetron filament voltage is acceptable.
HTR DELAY (Heater Delay) CyberKnife System has completed an approximately

10 minute warm-up.
SF6 GAS (Sulfur Hexafluoride Gas) SF6 tank pressure is acceptable.
VACUUM (Vacuum) No vacuum faults in the accelerator waveguide or

magnetron.
DOSE P.S. (Dose Power Supply) Dosimetry high voltage power supplies are operating
properly.
COMPUTER (Computer) LINAC is in computer control mode.
HVOC (High Voltage Over-Current) Excessive current is not being drawn from the high
voltage power supply (to magnetron).
INVERSE I (Inverse Current) No excessive reverse current is returning from

LINAC X-ray head.

Interlock Name Description
MAN OVERRIDE (Manual Override) When the CyberKnife System operates under
computer control this light is illuminated.
GRID PWR SPLY (Grid Power Supply) Accelerator electron gun power supply is working
properly.
E-STOP (E-Stop) E-Stop switch on the MCC is not pressed.
BEAM ON (Beam On) LINAC X-ray beam is on.
AFC/MAN (Automatic Frequency Control/ Magnetron AFC is in automatic.

Manual)
COLLIMATOR (Collimator Interlock) Both collimator sense potentiometers are reading

the same value.
PRF LIMIT (Pulse Rate Frequency Limit Not used.

Interlock)
HV ENABLE (HV Enable) Treatment delivery computer has enabled the high
voltage.
DC PWR (DC Power) Not used.
DIAG MODE (Diagnostic Mode) Not used.
EXT E-STOP (External E-Stop) No E-Stops and fault conditions monitored by the E-
Stop Control Chassis (ESCC) are currently
triggered.
HEAD FANS (X-ray Head Fans) The fans in the LINAC X-ray head are operational. If
the fans are not working this light will extinguish and
a Water Flow Fault will occur.
Machine center
The machine center is a physical reference point chosen during system installation in the center of
the patient treatment area. The origin of the robot frame is located at the machine center.
The machine center provides a reference point for treatment robot calibration. During system
installation, and at other times when system calibration is required, the machine center is used to
provide a precise reference point to correct the computed node file. That is, all beams from the
LINAC are corrected to point at precisely the same point, the machine center. The Laser Alignment
Unit (LAU) is used to perform this calibration. See Robot frame, Alignment center, and Isopost.

Magnetic Resonance Imaging (MRI)

MRI uses magnetic energy and radio waves to create 2D or 3D images of the body. This type of
imaging is particularly useful for discriminating regions within soft tissue. The main component of
most MRI systems is a large tube-shaped or cylindrical magnet.
Magnetron
A magnetron is a vacuum tube device that produces microwaves. It functions as a high-power
oscillator, generating microwave pulses of several microseconds duration and with a repetition rate
of less than 240 pulses per second. The LINAC uses a mechanically tunable magnetron to provide
the energy necessary to accelerate the electron beam. See LINAC.
Makeup fraction
A new treatment fraction created when an executing plan is aborted during treatment delivery. The
makeup fraction contains the remaining dose to be delivered to the patient. It consists of all paths
and beam that were not executed. Monitor Unit fractions are generated at any time after first image
acquisition if the selected treatment plan fraction is not fully treated.
Mass density
The mass per unit volume in units g/cm3.
MeV
One million electron volts, a unit of energy used to specify the energy of particles such as the
electron beam in the LINAC. One electron volt is the energy equivalent of an electron being
accelerated in free space through a field of one volt. The LINAC produces a nominal 6 MeV
electron beam.
Modulator
For the VSI system, contains the pulse power modulator generator for the magnetron and the high
voltage supply for the LINAC gun.
For the S7 and M6 system, contains the pulse power modulator generator for the magnetron.
Modulator Control Chassis (MCC)

A unit subsystem of the LINAC. It contains the control logic, fault logic, and manual controls for the
modulator.
Monitor unit (MU)

The monitor unit (MU) is the measure of charge integrated by two independent dosimeters. The
calibration of MU as a function of dose controls the dose delivery of the CyberKnife System.
The calibration factor (in units of MU/cGy) sets the precise calibration of the CyberKnife System.
Moving image
A medical image used to assist delineation and evaluation of specific Volumes of Interest. Also
referred to as Image B.

MV
A medical radiation term that is a measure of the energy of a spectrum of X-ray photons. See MeV.
Node
One of a set of predefined nominal points where the source of the radiation beam (the LINAC) can
be placed. Node locations are fixed and cannot be altered for individual treatment plans. See
also Node position.
Node position
A position of the treatment robot where the LINAC is located at a node and is pointed at the
machine center. See also Node, Beam position.
Non-isocentric planning
Common in CyberKnife treatment plans, non-isocentric beam geometry utilizes beams aimed at
various points on a target(s). This is useful for dose painting.
Operator control panel

The purpose of the operator control panel is to allow the user to turn the high voltage on or off to
the LINAC. When the high voltage is on, radiation can be generated and delivered.
See also Key switch.
Partial measured Beam Data Import

The import of less than a full set of measured beam data files.
Patient alignment abbreviations
Table 2 Patient alignment abbreviations
POS – ANT: Posterior/Anterior ROLL: Left/Right
SUP – INF: Superior/Inferior PITCH: Head U /Head Down
LFT – RGT: Left/Right YAW: CW/CCW

Patient coordinate system

Used by the treatment couch and the Synchrony Tracking System. The patient coordinate system
is defined for a patient in the Head First Supine (HFS) position. This coordinate system does not
have an absolute origin. For translation:
• X refers to the Inferior/Superior direction (+X corresponds to Inferior).
• Y refers to the Left/Right direction (+Y corresponds to Left).
• Z refers to the Anterior/Posterior direction (+Z corresponds to Anterior).
For rotation:
• r refers to rotation about the X axis.
• p refers to rotation about the Y axis.
• w refers to rotation about the Z axis.
Patient treatment table

The patient treatment table is a radiolucent table that supports the patient during treatment. The
patient treatment table moves as follows:
• Standard treatment couch: 5 DOF (X, Y, Z, roll, pitch)
• RoboCouch System: 6 DOF (X, Y, Z, roll, pitch, yaw)
Penumbra
The edge region surrounding a beam where the energy level drops from 80% to 20% of its
maximum.
Percent Depth Dose (PDD)

A measure of the energy, or the ability of a spectrum of radiation to penetrate a material such as
water or soft tissue.
Perch position
Rest position of the treatment robot.
Phantom
A physical or mathematical substitute for the patient. A 3D photographic film cube is placed in the
phantom in the particular volume. The exposed film shows the dose distribution applied during a
simulation run.
The phantom with film cube is used to perform various QA tests. In an End-to-End test, a CT image
is generated of a dosimetric phantom and a plan is created to treat a specified location in the film
pack. After irradiating the phantom, the film pack is read and a comparison is made of the location
of the planned treatment with the center of the delivered dose. In this way the total system accuracy
is tested. See Ball-cube.

Phantom mode
One of the operational modes of the CyberKnife System, a physical execution of the treatment plan
by the system with a dosimetric phantom instead of a patient. The primary purpose is to check for
the accurate and safe delivery of a patient treatment plan.
Prescription
Dose to be delivered to the tumor.
Proximity Detection Program (PDP)

The PDP is active when the treatment robot is moved from the treatment delivery computer,
typically in Treatment mode. The PDP monitors the distance between the treatment robot and
stationary objects in the treatment room. The PDP uses Treatment Room geometry files and real-
time data from the treatment robot to detect and signal a proximity error when any part of the
treatment robot moves near any stationary object. When a proximity error occurs, treatment robot
motion is stopped. See Supplemental Proximity Detection Program (SPDP).
Rad
A unit of radiation dose, replaced by the centigray (cGy).
Radiosurgery
The treatment of lesions using stereotactically directed convergent beams of external irradiation,
usually in 1 to 5 fractions.
Reference image
The Digitally Reconstructed Radiographs (DRRs). See Digitally Reconstructed Radiograph (DRR).
Reference plan
A plan that is displayed for comparison.
Relative electron density

Electron density value for a given CT number relative to the electron density of water.
Robot frame
(The treatment robot is also referred to as the treatment manipulator.) The origin of the robot frame
is the machine center. Plans created by the Accuray Precision System are saved in path files that
use the robot frame. Its X and Y axes depend on where the base of the robot is with respect to a
patient in the HFS position.
The base of the robot may be at the Left-Superior or the Right-Superior of the patient. The
orientation and rotation of the robot are calibrated during system installation.

If the robot is at the patient's Right-Superior, X is positive to the patient's Left-Inferior (see
Figure 1). This axis is roughly 45° from the patient's Inferior. Y is positive to the patient's Left-
Superior and is roughly 45° from the patient's Left. The actual orientation of the robot relative to the
treatment couch is measured during system installation.
If the robot is at the patient's Left-Superior, X is positive to the patient's Right-Inferior and is roughly
45° from the patient's Right. Y is positive to the patient's Left-Inferior and is roughly 45° from the
patient's Inferior.
The Z axis is positive to the patient's Anterior regardless of where the robot is. See Machine center
and IECP (IEC patient) coordinate system.
A = Anterior
P = Posterior
S = Superior
I = Inferior
R = Right
L = Left
A
L I
S
R
Machine Center
P
Robot Base
at Patient
Right-Superior
Figure 1 Robot frame
Sagittal
A side image of the body. A sagittal plane divides the body into left and right segments.
Seed point
A point placed on the patient images to obtain a starting position for the image registration.
Sequential Optimization
Sequential optimization is an algorithm used to optimize a Accuray Precision System treatment
plan during the planning stage.

Soft Stop
A non-emergency treatment interruption that switches from treatment delivery to patient
realignment without generating an E-Stop.
Source-Axis Distance (SAD)

For the CyberKnife System, SAD is defined as the distance from the LINAC X-ray source to either
a point on the central beam axis or to a plane perpendicular to the beam axis where some aspect
of the radiation beam or geometry is being defined, characterized, or measured. SAD is always
measured along the beam axis.
Source-to-Surface Distance (SSD)

Measured along the central axis of the LINAC radiation beam. The distance from the LINAC X-ray
source to a surface that serves as a reference for describing the geometry and direction of
incidence of the radiation beam. The "surface" may be defined by the entrance skin surface of the
patient or the nearest boundary of a solid phantom, the water surface of a water phantom, or the
build-up around a radiation detector.
Step
A group of functions in the Accuray Precision System organized into a single user interface layout
(screen).
Stereotactic
Any device that accurately guides a surgical tool in space. Adjective form of stereotaxis.
See Stereotaxis.
Stereotaxis
Stereotaxis is a branch of neurosurgery that utilizes spatial information provided by neuroradiologic
studies to treat certain disorders of the central nervous system with great accuracy.
See Stereotactic.
Sulfur Hexafluoride (SF6)

A dielectric gas used to suppress ionization in the LINAC waveguide between the magnetron and
the accelerator. Also referred to as SF6.
Supplemental Proximity Detection Program (SPDP)

The SPDP is active when the treatment robot is moved using the Teach Pendant with the mode
selector switch set to either T2 or Automatic mode, or when the RoboCouch System is moved
using the RoboCouch Hand Controller. The SPDP monitors the distance between the treatment
robot and stationary objects in the Treatment Room. The SPDP uses Treatment Room geometry
files and real-time data from the treatment robot and treatment couch to detect and signal a
proximity error when any part of the treatment robot or treatment couch moves near any stationary
object. When a proximity error occurs, the treatment robot or RoboCouch motion is stopped.
See Proximity Detection Program (PDP).

Synchrony Respiratory Tracking System

The Synchrony Respiratory Tracking System is Accuray Incorporated’s system for delivering
dynamic radiosurgery to tumors that move with respiration. Respiratory Tracking System records
the breathing movements of a patient’s chest and combines that information with sequential X-ray
images of tiny markers inserted inside the tumor to enable precise delivery of radiation during any
point in the respiration cycle.
Target
There are two different targets referred to in the CyberKnife System:
• Inside the LINAC, a 6 MeV electron beam is aimed at a tungsten target to generate 6 MV
X-rays.
• The X-ray beam is aimed at a second target, the tumor in the patient.

The ceiling mounted X-ray sources and floor-embedded detectors that provide a stereotactic frame
of reference for detecting and tracking target movement during treatment. The TLS coordinate
system frame parallels that of the IECP coordinate system, as in the following illustration.
1. TLS Z-Axis runs parallel to IECP Z-Axis

2. TLS Y-Axis is the IECP X-Axis
3. Image center: origin of IECP frame and is
set using isopost tool
4. TLS X-Axis is the IECP Y-Axis
Task
A group of step in the Accuray Precision System. Each task is displayed on a tab.

Teach Pendant
A hand held device used to manually control the treatment robot or to program sequences of
movements for it. In the CyberKnife System, the operator uses the Teach Pendant to position the
treatment robot for calibration or maintenance, and to manually power up components such as
alignment lasers or imaging X-ray sources. Maintenance mode can only be accessed with a
special key. The CyberKnife System is used for patient treatment only when the treatment robot is
under computer control.
Tool frame
One of the coordinate frames used by the CyberKnife System. The tool frame is a Cartesian
coordinate system with 6 degrees of freedom: 3 translations (X, Y, and Z) and 3 rotations (yaw,
pitch, and roll). The tool frame location (X, Y, and Z) is defined relative to the faceplate of the
treatment robot. The faceplate is located at the end of the “wrist” of the treatment robot (Axes A4,
A5, and A6) where the LINAC is mounted.
The Z axis is perpendicular to the faceplate (positive pointing straight out). The origin of the tool
frame is called the tool center point (TCP). The TCP for the CyberKnife System is at the nominal
point of the LINAC X-ray source. Its position moves with the treatment robot and is continually
being recalculated during treatment delivery. Rotations are defined around the axes of the tool
frame, which depend on the particular orientation of the treatment robot at that time. See Robot
frame and World frame.
Treatment Planning System (TPS)

The main functionality of the Accuray Precision Treatment Planning System is to:
• Display the CT image data
• Delineate the tumor and the critical structures
• Generate treatment plans
• Evaluate and fine-tune plans
Treatment path
The path the LINAC would follow in moving through a set or a subset of nodes. All defined nodes
are visited during radiation treatment or simulation. No nodes are skipped even if radiation is not
activated at all nodes. Normally radiation is only activated at a subset of the defined nodes. For the
CyberKnife System, there are single- or 3-path options available.

The UPS is used to maintain power during power interruptions.

Volume of Interest (VOI)

A volume of interest within an image. VOI can be a target or critical structure.
Voxel
A 3-dimensional pixel, an atomic element of a 3D image. An abbreviation for “volume pixel.”
Water cooling system

The LINAC uses a water cooling system to remove heat from the X-ray head. The water is cooled
by a chiller located in the equipment room.
Water phantom
A precise radiation measurement device used for characterization and calibration of the LINAC
beams. Every LINAC is different. In the CyberKnife System, the beam from each collimator is
characterized using a water phantom and the data collected is stored in a system file. This beam
data is used in treatment planning to determine how much dose to deliver.
Waveguide
The structure in the accelerator that develops electric fields necessary to accelerate electrons.
Utilizes microwaves of the appropriate frequency and power to provide the necessary energy.
Workspace
The workspace is the set of configurations that the treatment robot can assume without entering a
forbidden region. A forbidden region is an obstacle plus any buffer around the obstacle. Defined
obstacles in the treatment area include the patient, couch, camera stands (for X-ray image
detectors), floor, and ceiling.
World frame
One of the coordinate frames used by the CyberKnife System. The World frame is a Cartesian
coordinate system (X, Y, and Z expressed in millimeters) whose origin is predefined by the
treatment robot manufacturer for the particular model of treatment robot. For the CyberKnife
System, the origin of the World frame is located at the intersection of the 2 joints (Axis 1 and Axis
2) at the base of the treatment robot. See Tool frame and Robot frame.

X-band
A frequency spectrum in the microwave band. The LINAC magnetron operates in the X-band. X-
band microwaves are used in the CyberKnife System LINAC because it allows for smaller
treatment robot-mounted LINAC components than would a lower frequency band. Conventional
LINAC accelerators typically use the lower-frequency S-band.
X-ray detectors
Amorphous silicon flat panel X-ray image detectors used by the Target Locating System computer
to obtain images of the patient for use in patient alignment and motion tracking.
X-ray head
The portion of the LINAC that is mounted to the end of the treatment robot arm and provides the
radio-surgical X-ray beam.
X-rays
Photons in the energy band above ultraviolet light that have been produced by high energy
particles colliding into a target.
X-ray source (XRS)

X-ray source used by the Target Locating System computer to illuminate the X-ray detector.

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Treatment Delivery Manual

CyberKnife VSI® System

Hardware and Software Maintenance

Use of Third-Party Software

Instructions for Use of the Accuray System

Prescription Device Statement

Chapter 1: Overview ................................................................1-1

Safety Precautions........................................................................... 2-9

Implanted or Body-Worn Electronic Medical Devices .......................... 2-11

Facility Responsibilities ..................................................................2-35

Chapter 3: CyberKnife Treatment Delivery System Overview3-1

X-ray Sources and Generators........................................................................... 3-3

CyberKnife System Options........................................................... 3-12

Synchrony Tracking™ with InTempo Imaging (Option) ........................ 3-13

Chapter 4: System Startup and Shutdown ............................4-1

Error Handling ................................................................................4-10

Post-startup Checklist ....................................................................4-12

Power-on After Power Interruption ................................................ 4-19

Equipment Operating Instructions ................................................. 4-22

Chapter 5: Treatment Delivery System Overview .................5-1

Error Handling System................................................................... 5-10

Equipment Power Status................................................................5-23

Treatment Mode .............................................................................5-39

Demonstration Mode ......................................................................5-60

Phantom Mode .............................................................................. 5-64

Plan QA Mode ............................................................................... 5-65

Chapter 6: Patient Preparation................................................6-1

Pretreatment Scanning Guidelines .................................................. 6-7

Key Identifiers for DICOM Images ........................................................... 6-18

Fiducial Placement .........................................................................6-18

Chapter 7: Treatment Room Operations ................................7-1

Manually Changing Fixed Collimators..............................................7-3

Xchange Robotic Collimator Changer .............................................7-8

Changing Fixed Collimators ............................................................................. 7-17

Patient Immobilization Devices...................................................... 7-23

RoboCouch Patient Positioning System (Option) .......................... 7-31

Treatment Delivery ........................................................................................... 7-52

Chapter 8: Treatment Delivery ................................................8-1

Initial Patient Positioning ................................................................8-10

Visually Aligning the Patient ...........................................................8-15

Optimizing the X-ray Technique .....................................................8-22

Performing Patient Alignment.........................................................8-27

Analyzing Imaging Results ...................................................................... 8-29

Checking Readiness for Treatment Delivery ................................. 8-56

Treatment Delivery ........................................................................ 8-69

Error Handling ................................................................................8-84

Patient Realignment After a Pause or Error ...................................8-91

Plan QA Mode ..............................................................................8-100

Chapter 9: Synchrony Fiducial Tracking ...............................9-1

Workflow for Synchrony Fiducial Tracking Mode............................. 9-4

Performing Patient Alignment .......................................................... 9-8

Checking Readiness for Treatment Delivery ................................. 9-27

Chapter 10: Synchrony Spine Tracking (Option) ..10-1

Requirements for Visual Evaluation............................................... 10-3

Verifying Patient and Treatment Data ............................................10-5

Visually Aligning the Patient ...........................................................10-7

Performing Patient Alignment.......................................................10-11

Checking Readiness for Treatment Delivery................................10-27

Synchrony Spine Tracking Prone with Respiratory Modeling ......10-33

Chapter 11: Synchrony Lung Tracking with Respiratory Model-

Introduction .................................................................................... 11-1

Requirements for Visual Evaluation............................................... 11-5

Visually Aligning the Patient .......................................................... 11-9